Studies on the systemic mycosis in Korea and the special stainings for fungi
[영문]Mycotic infection, which has been neglected for a century, became challenging medical problem in the past decade since the report of oral moniliasis complicating after penicillin administration by Gross in 1949. Since then many authors reported
increasing incidences of fungus infection and tendency toward dissemination fellowing the long term administration of antibiotics, anti-cancerous agents and steroid derivatives. Furthermore, fungus infections of ten complicate on many other
chronic debilitating disorders, such as leukemia, lymphoma, diabetes mellitus, leukopenia and etc.
The systemic mycosis include fourteen kinds; actinomycosis, nocardiosis, crytococcosis, sporotrichosis, histoplasmosis , aspergillosis, penicillosis, maduromycosis, blastomycosis , coccidioidomycosis, chromoblastomycosis, geotrichosis, mucormycosis, and candidiasis. Some of these are found world-wide, while others are fecund in the limitted areas. Some of them are highly pathogenic, whereas others are almost saprophytic. Therefore, it is important to understand the kinds of mycoses present in each locality for the better diagnosis and management
of the patients. Unfortunately no comprehensive study on the systemic mycosis has been made in Korea.
The final identification of fungi should be based on the culture of organism, but in many occasions the chance of culture may be lost, and quite often the demonstration of the fungus in the tissue is mandatory to assure that the lesion is fungus origin. Fortunately several special staining technics have developed recently to demonstrate the fungus in the tissue.
Present study is attempted to investigate kinds and frequency of mycotic infections in Korea with special reference to possible predisposing factors and evaluation of various special stainings for fungi.
The materials consisted of 760 necropsies and 11,631 surgical specimens examinded at the National Medical Center during four and one-half year period. A few cases of fungus infections observed at the Yonsei Medical Center were also added.
Hematoxylin-eosin staining was routinely applied to all cases, and special stainings were applied only to the cases of suspected fungus lesions by microscopic examination of hematoxylin-eosin stained sections. Special stainings included periodic acid Schiff's reaction, alcian blue-PAS, Bauer-Feulgen reaction, Gridley's , methenamine silver, and Shorr's methods .
For the cases proven as fungus infection, clinical data, particularly use of antibiotics, anticancerous drugs, steroid homone, the sex, age, white blond cell count, and the extent of involvement were checked. Results of seven different stainings were compared.
Reeults : A total of 42 cases of fungus infection was observed in the present study. The 42 cases included 9 cases of candidiasis, 6 cases of aspergillosis, 4 cases of actinomycosis, 3 cases of mucormycosis, 2 cases of sporotrichosis, 1 case of chromohlastomycosis and cryptococcosis, and 16 cases of pneumocystosis.
The overall age distribution was from 5 weeks to 54 years of age. But actinomycosis was observed in the 5th decade, candidiasis mostly under the 12 years of age, and pneumocystosis mostly between the 2nd and the 5th month of life.
The overall sex distribution among 26 out of 42 cases excepting pneumocystosis was about 2: 1, male predominating. The ratio of male to female was 3: 1 in actinomycosis, 5:4 in candidiasis, 2:1 in aspergillosis, and 3:0, in mucormycosis. However, only a sin91e case among 16 cases of Pneumocystosis was male.
The white blood cell count was made in 16 cases, and nine of them showed less than 5,000 per cu. mm. The differential count was made in 12 cartes, and six of them skewed less than 25 per cent of granulocytes, and 4 of them showed less than 1 per cent of granulocytes.
Long term administration of antibiotics was observed in 16 instances. Chloramphenicol was given to 9 cases, penicillin to 6 cases, terramycin and streptomycin to 4 cases, erythromycin and neomycin to 2 cases. The mycoses observed in cases treated with antibiotics were candidiasis, aspergillosis, mucormycosis,
Aminopterine was given to 2 cartes and 6-mercaptopurine baa given to 4 cases. All of them were leukemic patients. and the mycoses complicated with them were candidiasis, aspergillosis, mucormycosis, and actinomycosis, one case of each.
Predniaolone was given to 6 cases and ACTH to 1 case. The mycoses observed in these patients were 1 case of actinomycosis, 2 Cases of candidiasis, 2 cases of aspergillosis, find 1 cases of mucormycosis.
The 19 out of 26 cases excepting pneumocystosis from the total of 42 cases were superimposed over other primary diseases. The most important primary disease was 5 cases of acute leukemias. The mycoses which superimposed to other primary diseases were 9 cases of candidiasis, 6 cases of aspergillosis, 2 cases of mucormycosis, and 2 cases of actinomycosis.
The 5 out of 26 cases showed disseminated form : candidiasis, aspergilloais, cryptococcosis, chromoblastomycosis, and mucormycosis, one of each. The actinomycosis involved predominantly neck and nose, the candidiasis mostly esophagus and pharynx, and the aspergillosis mainly lungs.
The outstanding clinical features in 16 cases of pneumocystosis were : infants under the 5 moths of age, all from orphanage, female preponderance(15 out of 16 cases), and suffered from malnutrition.
The results of 7 different stainings were as follows. The hematoxylin-eosin, though net a special staining, gave suggestive or indicative evidence for the presence of fungus in the tissue, but species identification could net be made with hematoxylin-eosin stained section alone. It staind background tissue reaction best than any other stainings. For the overall screening purpose, methenamine silver staining was the beat method of choice, while Shorr's method gave the poorest result. Methenamine silver and Gridley's staining gave better results on the mycelial form of fungi, whereas PAS and alcian blue-PAS stainings gave better
results on the yeast form of fungi. Cryptococcus stained most specifically by alcian blue-PAS method due to the presence of acid mucopolysaccharide in its capsule. Bauer-Feulgen reaction gave positive staining on the mast of fungi, but coloring was neither superior than other method nor specific.
In conclusion : Total eight kinds of mycoses in 42 instances were observed. All of them belonged to the kinds which distribute world-wide, and the majority of them belonged to the kinds which related with modern therapeutics. The best staining method for the demonstration of fungus in tissue was methenamine silver method. and Gridley's staining was good for mycelial form while PAS and alcian blue-PAS were better for yeast from of fungi. The cryptococcus was stained best with alcian blue-PAS method.