Review of the 2005 Mycology Review of the 2005 Mycology QAP Results QAP Results Royal North Shore Hospital, Sydney Royal North Shore Hospital, Sydney Wednesday 28 Wednesday 28 th th June 2006 June 2006 Dispatch 2005:2:7A,B,C Dispatch 2005:2:7A,B,C – – Maria Maria Carino Carino , SDS Pathology , SDS Pathology Dispatch 2005:4:7A,B,C Dispatch 2005:4:7A,B,C – – Kerry Weeks, Kerry Weeks, PaLMS PaLMS Dispatch 2005:6:7A,B,C Dispatch 2005:6:7A,B,C – – Okcha Okcha Lee & Catherine Wu, ICPMR Lee & Catherine Wu, ICPMR Dispatch 2005:8:7A,B,C Dispatch 2005:8:7A,B,C – – Mirka Mirka Rej Rej , , Symbion Symbion Health Health
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Review of the 2005 Mycology Review of the 2005 Mycology QAP ResultsQAP Results
Royal North Shore Hospital, SydneyRoyal North Shore Hospital, Sydney
Culture A was isolated from a CAPD bag from aCulture A was isolated from a CAPD bag from a30 year old man with peritonitis.30 year old man with peritonitis.
Any ideas?Any ideas?
RhodotorulaRhodotorula mucilaginosamucilaginosa
Rhodotorula mucilaginosaRhodotorula mucilaginosaOn Sabourauds dextrose agar cultures are:• fast growing• smooth, glistering or dull• sometimes roughened or soft • moist to mucoid yeast-like in appearance• cream to pink, coral red, orange in colour.
Microscopic morphology:• spherical to elongate budding yeast-like cells or blastoconidia, 2.5-6.5 x 6.5-14.0 um in size.
India ink preparation:• small capsules present.
Culture on Cornmeal and Tween 80 agar:• budding blastoconidia only. No pseudohyphae areformed.
Physiological tests:• germ tube test is negative• hydrolysis of urea is positive• growth on cycloheximide medium is negative• growth at 37ºC is variable.
Fermentation reactions:• negative for Glucose; Sucrose; Lactose; Galactose;Maltose;Trehalose.
Rhodotorula mucilaginosa is the current name for the species formerly known as Rhodotorula rubra.
Final Results 2005Final Results 200593% of laboratories got it correct to the genus level60% of laboratories got it to correct to the species level
• Morphologically the isolate is very distinctive and a presumptive identification can be made.
• Identification systems. (ID32C) • Keeping up to date with name changes.
Case 2:Case 2:Culture B grew from a scalp scraping taken from Culture B grew from a scalp scraping taken from a 12 year old girl who recently arrived from a 12 year old girl who recently arrived from Sudan.Sudan.
Any ideas?Any ideas?
Trichophyton Trichophyton soudanensesoudanense
Trichophyton Trichophyton soudanensesoudanenseOn Sabourauds dextrose agar cultures are:• slow growing• flat to folded, suede-like surface• often there is a broad fringe of submerged growth• surface and reverse pigment are characteristicallya deep apricot-orange in colour.
Microscopy morphology:• hyphae often show reflexive or right-angle branching• pyriform microconidia may occasionally be present• numerous chlamydoconidia are often found in older
cultures
Clinical significance:•T. soudanense is an anthropophilic funguswhich is a frequent cause of tinea capitis inAfrica.
• Invaded hairs show an endothrix infection butdo not fluoresce under Wood’s ultra-violet light.
• Distribution is mainly in Africa with occasional isolates from Europe, Brazil and U.S.A.
Final results 2005Final results 200587% of laboratories got it correct to the genus level57% of laboratories got it correct to the species level
• Follow a schematic key. Process of elimination• Selective media. If available• The absence or the occasional presence of microconidia
• Reflexing hyphae. Bamboo affect• Geographical information
Case 3:Case 3:Culture C was isolated from a subcutaneous Culture C was isolated from a subcutaneous abscess on the forearm in a 29 year old HIV abscess on the forearm in a 29 year old HIV positive patient.positive patient.
Cladophialophora carrioniiCladophialophora carrioniiOn Sabourauds dextrose agar cultures are:• slow growing (reaching 3-4cm in dia. after 1 month• compact suede-like to downy surface• colonies are olivaceous-black in colour and have well defined margins
Microscopy morphology:• elongate conidiophores • producing branched acropetal chains of smooth-walled conidia, 1.5-3.0 x 2.0-7.0 um in size
• maximum growth temperature 35-37ºC
Clinical significance:• Cladophialophora carrionii is a recognised agent of chromoblastomycosis and it has been isolated from soils and fence posts made from Eucalyptus sp.
• Cases of chromoblastomycosis caused byC.carrionii are commonly found in Australia, Venezuela, Madagascar and South America.
Final Results 2005Final Results 200588% of laboratories got it correct to the genus level59% of laboratories got it correct to the species level
• Cladosporium carrionii has been transferred to theCladophialophora genus
• Cladophialophora can be distinguished from Cladosporium by the absence or poorly differentiatedconidiophores, by unpigmented conidial scars and by being unable to liquify gelatin.
• Cladosporium species have occasionally been found as opportunists in humans, having a wide clinical spectrum.
• In contrast, each Cladophialophora species provokes a mycoses which is characteristic for that species. Cladophialophora is related to the black yeast
• Keeping up to date with name changes
• Following a schematic key
• Clinical information
AcknowledgementsAcknowledgements
VoulaVoula Henry Henry -- BiomerieuxBiomerieuxDr Pitman Dr Pitman -- SDS PathologistSDS PathologistDr fungus website Dr fungus website -- ImagesImagesQuality Assurance ProgramQuality Assurance Program
Review of Mycology QAP Review of Mycology QAP Results for 2005:4: 7A, B, CResults for 2005:4: 7A, B, C
A 60 y.o. farmer presented with swelling A 60 y.o. farmer presented with swelling & a dark, blood& a dark, blood--tinged discharge from the tinged discharge from the nose. A biopsy taken from the paranasal nose. A biopsy taken from the paranasal sinus grew culture 4: 7Asinus grew culture 4: 7A
This fungus didn’t survive freeze drying This fungus didn’t survive freeze drying by QAP = most labs failed to isolate thisby QAP = most labs failed to isolate thisfungusfungus
RhinoRhino--facial infections caused by facial infections caused by ConidiobolusConidiobolus
Photos from “Mycology Online”
Infections mainly in tropics- eg. Africa, Asia, Central America, India. Infection not evident until swelling/ deformity occurs.
EpidemiologyEpidemiologyFound in soil & decaying debris (found on bananas, Found in soil & decaying debris (found on bananas, rotten wood & a fruit warehouse etc). Ubiquitousrotten wood & a fruit warehouse etc). Ubiquitous--wide range of areaswide range of areas-- AlsaksaAlsaksa, temperate to tropical , temperate to tropical regions (regions (egeg. PNG soil). PNG soil)Insect pathogen (mosquitoes, termites, aphids)Insect pathogen (mosquitoes, termites, aphids)Infects man (80% cases are males) (typically) Infects man (80% cases are males) (typically) nasal mucosa & paranasal mucosa & para--nasal sinus, (sometimes) nasal sinus, (sometimes) subcutaneous, (rarely) pulmonary & pericardial subcutaneous, (rarely) pulmonary & pericardial infections firm, subcutaneous nodules/polypsinfections firm, subcutaneous nodules/polypsImmuneImmune--competent & immunecompetent & immune--suppressedsuppressed-- emerging emerging opportunist. Occur sporadically but rarely.opportunist. Occur sporadically but rarely.
Route: inhalationRoute: inhalationInfects animalsInfects animals-- horses, sheep, deer, dogs & horses, sheep, deer, dogs & chimpanzees.chimpanzees.Hard to treatHard to treat-- high MIC’s high MIC’s –– ?itraconazole, Amp B + ?itraconazole, Amp B + terbinafine, flucon, keto, iodides, plastic surgeryterbinafine, flucon, keto, iodides, plastic surgery
Item 4: 7BItem 4: 7B
Clinical historyClinical history
This culture was isolated from sputum This culture was isolated from sputum collected from a lung transplant patient collected from a lung transplant patient who presented with a chronic coughwho presented with a chronic cough
Colonies, fast growing (routine agar), white, rough Colonies, fast growing (routine agar), white, rough texture, hairy, creeping, mostly submerged, dry. texture, hairy, creeping, mostly submerged, dry. Fruity odour.Fruity odour.Hyaline hyphae, aerial Hyaline hyphae, aerial hyphaehyphae fragment forming fragment forming arthroconidia (cylindrical, barrel shaped or arthroconidia (cylindrical, barrel shaped or ellipsoidal). ellipsoidal). No blastospores produced. No blastospores produced. No capsules. No capsules. [[TrichosporonTrichosporon spp. produce spp. produce blastosporesblastospores along along pseudohyphaepseudohyphae]]
Differential features of G. candidum:Differential features of G. candidum:Hyphae 12 um wide with dichotomous branching at Hyphae 12 um wide with dichotomous branching at colony margin.colony margin.Assimilation: xylose POS, cellobiose NEGAssimilation: xylose POS, cellobiose NEGNG at 40C.NG at 40C.
Colonial morphologyColonial morphology
G. candidumSabs agar
(28C 4 days)
MicroscopyMicroscopy
Photo from “Mycology Online”
Geotrichum candidum- Course true hyphae (no pseudohyphae) that segment into arthoconidia. main & lateral branches with arthroconidia. Dichotomously branching.
Similar species to Similar species to GeotrichumGeotrichumTrichosporonTrichosporon spsp-- blastoconidiablastoconidia & & pseudohyphaepseudohyphae (not seen in (not seen in Geotrichum Geotrichum has has true hyphae)true hyphae)ScytalidiumScytalidium spsp-- dematiacousdematiacous arthroconidiaarthroconidia(hyaline (hyaline arthosarthos in in GeotrichumGeotrichum))ArthrographisArthrographis & & OidiodendronOidiodendron spsp-- have have condiophorescondiophores (which (which GeotrichumGeotrichum lacks)lacks)MalbrancheaMalbranchea spsp-- arthroconidaarthroconida release by release by disjunctordisjunctor cells (cells (GeotrichumGeotrichum produces produces arthrosarthrosby fission)by fission)Coccidioides Coccidioides spsp-- arthrosarthros alternate with alternate with empty cells (empty cells (GeotrichumGeotrichum-- consecutive)consecutive)
Differentiating between Differentiating between GeotrichumGeotrichum speciesspecies
PosPosPosPosVVGrowth at 37CGrowth at 37C
PosPosNegNegNegNegArbutinArbutin
NegNegNegNegPosPosVitamin freeVitamin free
PosPosNegNegNegNegSalicinSalicin
NegNegNegNegPosPosDD--xylosexylose
PosPosNegNegNegNegCellobioseCellobiose
G. clavatumG. clavatumG. capitaumG. capitaumG. candidumG. candidum
[Ref: deHoog, Guarro et al. “Atlas of Clinical Fungi” p. 227]
4:7:B QAP results4:7:B QAP results
Geotrichum candidum
Geotrichum sp. G. pennicill- atum
G. captatum G. klebahni Candida kefyr
Unable to ID
82 labs (73.2%)
16 (14.3%)
7 (6.3%)
1 (0.9%)
1 (0.9%)
1 (0.9%)
4 (3.6%)
96% labs correct to genus level73% correct to species level
Results obtained from Microbiology QAP
EpidemiologyEpidemiologyG. G. candidumcandidum found worldwide (tundra, temperate, tropical found worldwide (tundra, temperate, tropical climates) in soil, marine habitats, water, air, sewage, plants,,climates) in soil, marine habitats, water, air, sewage, plants,,freq dairy, cereals (freq dairy, cereals (eg.frozeneg.frozen fruit cake, bread), tomatoes, fruit cake, bread), tomatoes, animals skin & in droppings etc.animals skin & in droppings etc.Found in gas oil in Germany, paper pulp factory in France, Found in gas oil in Germany, paper pulp factory in France, isolated from irradiated soil.isolated from irradiated soil.Normal human floraNormal human flora-- isolated from faeces & sputumisolated from faeces & sputumOpportunistic infections in immune compromised Opportunistic infections in immune compromised (“Geotrichosis”)(“Geotrichosis”)
?Also may cause environmental damage?Also may cause environmental damage-- eg. destroy dataeg. destroy data--storing storing polycarbonate resin found in CDs! polycarbonate resin found in CDs! (disc becomes (disc becomes transparent). Also sig cause of citrus fruit rot.transparent). Also sig cause of citrus fruit rot.
Item 4: 7CItem 4: 7C
Clinical historyClinical history
This culture was isolated from a corneal This culture was isolated from a corneal scarping collected from a 12 y.o. with an scarping collected from a 12 y.o. with an eye injuryeye injury
ColonyColony-- white, creamwhite, cream-- coloured, smooth texturecoloured, smooth textureMicroscopy (CMA tween 80) shows elongated Microscopy (CMA tween 80) shows elongated blastospores, parallel ”logs in a stream”, curved along blastospores, parallel ”logs in a stream”, curved along pseudohyphaepseudohyphae
Differential features of Differential features of C. kefyrC. kefyr::Raffinose POS, 2Raffinose POS, 2--keto gluconate (2KG) NEG, keto gluconate (2KG) NEG, ethylamine POS, growth on 0.1% ethylamine POS, growth on 0.1% cyclohexcyclohexG at 37C, G w/o niacin.G at 37C, G w/o niacin.
97% labs correct to genus level90% correct to species level
Results obtained from Microbiology QAP
EpidemiologyEpidemiology
Found worldwide in humans, other Found worldwide in humans, other mammals & dairy foodsmammals & dairy foodsEmerging fungal pathogen.Emerging fungal pathogen.InfectionsInfections-- occasionally superficial occasionally superficial candidiasis. Reported cases of pulmonary candidiasis. Reported cases of pulmonary infections, disseminated infection, infections, disseminated infection, oesophagitisoesophagitis in immune compromised. in immune compromised.
A Review of 2005 Mycology QAP A Review of 2005 Mycology QAP ((despatchdespatch 6)6)
OkchaOkcha Lee Lee Catherine WuCatherine Wu
Mycology Unit, CIDMLS, ICPMR Mycology Unit, CIDMLS, ICPMR Westmead hospitalWestmead hospital
Item 2005:6:7AItem 2005:6:7A
Clinical notes:Clinical notes:
Culture was isolated from fingernail scrapings taken Culture was isolated from fingernail scrapings taken from a 23 yearfrom a 23 year--old African man with suspected old African man with suspected onychomycosis. Direct microscopy showed the onychomycosis. Direct microscopy showed the presence of septate hyphae.presence of septate hyphae.
ColonyColony
Initially whitish, finally becoming dark grayInitially whitish, finally becoming dark graySpreading, fastSpreading, fast
MicroscopyMicroscopy
Hyphae: melanized or hyaline, falling intoHyphae: melanized or hyaline, falling intoathroconidiaathroconidia
Chlamydospore: conidia single or in chains, darkChlamydospore: conidia single or in chains, darkbrown, thick walled, swollen up to 7brown, thick walled, swollen up to 7µµm widem wide
PathogenicityPathogenicityOnychomycosisOnychomycosisDermatophytosis like infectionDermatophytosis like infection
EcologyEcologySoil fungus or plant pathogen in tropical and subtropical Soil fungus or plant pathogen in tropical and subtropical areasareas
* 60% correct to genus level* 60% correct to genus level
Item 2005:6:7BItem 2005:6:7B
Clinical notes:Clinical notes:
Culture was isolated from a wound swab taken from Culture was isolated from a wound swab taken from a 30 yeara 30 year--old man recovering from severe burns.old man recovering from severe burns.
Colony Colony
Bright yellow with dark yellow reverse.Bright yellow with dark yellow reverse.
MicroscopyMicroscopy
MicroscopyMicroscopy
Hyphae: sparsely Hyphae: sparsely septatedseptatedSporangiophores:Sporangiophores:Sporangia: <100Sporangia: <100µµmmColumella: sphericalColumella: sphericalSporangiospores: variable in size and shapeSporangiospores: variable in size and shapeChlamydospores: presentChlamydospores: presentRhizoids: presentRhizoids: presentGrowth temperature: growth at 37Growth temperature: growth at 37ººCC
no growth at 42 no growth at 42 ººCC
Comparison between Comparison between Rhizomucor variabilisRhizomucor variabilisand and Mucor hiemalisMucor hiemalis
Ellipsoidal, spherical, up to Ellipsoidal, spherical, up to 38 38 ×× 30 um30 um
Spherical, ellipsoidal to cylindrical Spherical, ellipsoidal to cylindrical in various shape, up to 40in various shape, up to 40µµm m widewide
columellacolumella
Up to 80um diameterUp to 80um diameterSubsphericalSubspherical, up to 100um , up to 100um diameterdiameter
sporangiasporangia
Up to 15mm long, 14um Up to 15mm long, 14um wide, branchedwide, branched
Up to 2mm long, 9Up to 2mm long, 9--23um wide,23um wide,branchedbranched
SporangioSporangio--phoresphores
Whitish to Whitish to ochraceousochraceousGreyishGreyish--ochraceousochraceouscolonycolony
Schematic diagram of ribosomal gene cluster of fungi
Comparison of sequencing results between Comparison of sequencing results between Rhizomucor variabilisRhizomucor variabilis and and Mucor hiemalisMucor hiemalis
97% 642/658 97% 642/658 bpbp))99% (638/644 99% (638/644 bpbp))LSU D1/D2 region (21LSU D1/D2 region (21--664 664 bpbp))
98% (484/488 98% (484/488 bpbp))
98% (547/557 98% (547/557 bpbp))
99% (487/488 99% (487/488 bpbp))
100% 557/557 100% 557/557 bpbp))
SSU Base pairs (37SSU Base pairs (37--524 524 bpbp))
Base pairs (556Base pairs (556--1112 1112 bpbp))
92% (452/487 92% (452/487 bpbp))not in databasenot in databaseITS 1 and ITS 2 regionITS 1 and ITS 2 region
Relationship between Relationship between Rhizomucor variabilisRhizomucor variabilis and and Mucor hiemalisMucor hiemalis
Rhizomucor variabilisRhizomucor variabilis may concern degenerate cultures of may concern degenerate cultures of Mucor Mucor hiemalishiemalis
Phylogenetically it proved to be very close to Phylogenetically it proved to be very close to Mucor hiemalisMucor hiemalis
IdentificationIdentification
Rhizomucor variabilisRhizomucor variabilis
* 63% answered to * 63% answered to Mucor sppMucor spp and 3.6% to and 3.6% to Rhizomucor variabilisRhizomucor variabilis
Item 2005:6:7CItem 2005:6:7C
Clinical notes:Clinical notes:
Culture was isolated from a lung biopsy taken from a Culture was isolated from a lung biopsy taken from a 15 year15 year--old girl with acute lymphocytic leukaemia.old girl with acute lymphocytic leukaemia.
ColonyColony
Usually green, creamUsually green, cream--buff or honeybuff or honey--yellow where yellow where cleistotheciacleistothecia formform
Reverse may be olive to purpleReverse may be olive to purple--brownbrown
MicroscopyMicroscopy
Microscopy Microscopy
Conidiophores: short (< 250um)Conidiophores: short (< 250um)Conidial heads: short columnar (< 80um)Conidial heads: short columnar (< 80um)ConidiogenousConidiogenous cells: cells: biseriatebiseriate, , metulaemetulae and and phialidephialideConidia: globose (3Conidia: globose (3--3.5 um in 3.5 um in diamdiam))Teleomorph: Teleomorph: EmericellaEmericella nidulansnidulans cleistotheciacleistothecia with with reddish ascospores are often surrounded by Hreddish ascospores are often surrounded by Hüüllelle cells cells (up to 25um in (up to 25um in diamdiam))
A Review of the 2005 Mycology A Review of the 2005 Mycology QAPQAP
Mycology Items 2005:8:7 A,B,CMycology Items 2005:8:7 A,B,CMirka RejMirka RejMicrobiology DepartmentMicrobiology DepartmentSymbion and Laverty Pathology North RydeSymbion and Laverty Pathology North Ryde
Item 2005:8:7AItem 2005:8:7A
Clinical Notes: Clinical Notes: Culture was isolated from a knee aspirate Culture was isolated from a knee aspirate taken from a ten year old leukemic boy taken from a ten year old leukemic boy with osteomyelitis of the right knee. with osteomyelitis of the right knee.
gangrenous skin gangrenous skin ulcersulcerspulmonary infectionspulmonary infectionsperitonitisperitonitissystemic infections systemic infections (may be isolated (may be isolated from blood cultures)from blood cultures)
Documented as a cause of:
Clinical importance of Clinical importance of ScedosporiumScedosporium prolificansprolificans
ScedosporiumScedosporium prolificansprolificans in nature occurs in soil in nature occurs in soil and is traumatically introduced into humans by and is traumatically introduced into humans by thorns or splinters. thorns or splinters. In the body it has a predilection for cartilage and In the body it has a predilection for cartilage and joint areas. joint areas. In immunocompromised patients or In immunocompromised patients or transplantation patients fatal dissemination may transplantation patients fatal dissemination may occur. occur. A fatal case of endocarditis was reported.A fatal case of endocarditis was reported.
Isolates are often resistant to antifungal agents.Isolates are often resistant to antifungal agents.
annellidic rings difficult to see long thin appendages(swan neck)
formation ofclastothecia
+ (P.boydi) -
synnemata + -cultures white cottony
mycelium later turnsgrey to brown
first moist grey to blacklater dark grey, white
tufts in the centre.growth at 45 degrees - +
•Bottle shaped annellides
•Annellides with parrallel sides may also be seen.
Scedosporium prolificans
Item 2005:8:7BItem 2005:8:7B
Clinical Notes:Clinical Notes:Culture was isolated from the fingernail Culture was isolated from the fingernail scraping taken from a 50 year old woman scraping taken from a 50 year old woman with chronic paronychia. with chronic paronychia.
The species can be recognised by the following growth characters:
Clinical Importance of Candida Clinical Importance of Candida guilliermondiiguilliermondii
is found from normal skin, in sea water, is found from normal skin, in sea water, faeces of animals, fig wasps, buttermilk, faeces of animals, fig wasps, buttermilk, leather, fish and beer. leather, fish and beer. has been isolated from numerous human has been isolated from numerous human infections. infections.
Clinical ImportanceClinical ImportanceYeasts are considered opportunistic Yeasts are considered opportunistic
pathogens causing disease in patients:pathogens causing disease in patients:with a breakdown in the body’s with a breakdown in the body’s immune system immune system on prolonged treatment with antibioticson prolonged treatment with antibioticson corticosteroids or cytotoxic drugson corticosteroids or cytotoxic drugswith intravascular catheterswith intravascular catheterswith diabetes mellituswith diabetes mellitusknown to be intravenous drug abusersknown to be intravenous drug abusers
96% correct to genus level. 89% correct to species level.
Item 2005:8:7CItem 2005:8:7C
Clinical Notes:Clinical Notes:A 40 year old market gardener presented A 40 year old market gardener presented with a tender subcutaneous nodule on the with a tender subcutaneous nodule on the leg. Fluid aspirated from the nodule grew leg. Fluid aspirated from the nodule grew Culture C. Culture C.
Identification: Identification: MicromorphologyMicromorphology•The conidiogenous cells are slender annellides.
•Tips of annellides are narrow, elongated and rocket shaped.
•Conidia gather in clusters at the end, sides of conidiophore and at points along the hyphae.
•Inflated germinating cells.
•Budding yeast like cells.
•Conidia 1-3 x 2-5 µm in size, hyaline, smooth, thin walled and broadly ellipsoidal.
Clinical Importance of Clinical Importance of Exophiala jeanselmeiExophiala jeanselmei
Mainly associated with Mainly associated with phaeohyphomycoticphaeohyphomycotic cysts. cysts. The fungus has also been documented The fungus has also been documented as a cause of blackas a cause of black--grained mycetoma. grained mycetoma. Has been reported from a small number Has been reported from a small number of cases of chromoblastomycosis.of cases of chromoblastomycosis.
Differences Differences betweembetweem Exophiala Exophiala jeanselmei and jeanselmei and WangiellaWangielladermatitidis (Exophiala dermatitidis (Exophiala
dermatitidis)dermatitidis)Exophialajeanselmei
Wangielladermatitidis
growth at 42degrees
- +
conidiogenous cell annellidetapering extensions
to the tip.
phialide.do not showexidence ofextension.
Exophiala jeanselmei
Wangiella dermititidis
ReferencesReferencesBooks:Books:
Ellis, D., Davis, S., Ellis, D., Davis, S., AlexiouAlexiou, H., Pfeiffer, T., , H., Pfeiffer, T., ManatakisManatakis, Z. (1992). ", Z. (1992). "Descriptions of Descriptions of MedicatMedicatQAP fungiQAP fungi". Mycology Unit, Adelaide Children's Hospital. ". Mycology Unit, Adelaide Children's Hospital. Hocking, A., Hocking, A., WoodgyerWoodgyer, A. , A. "Clinically Significant Non"Clinically Significant Non--Dermatophyte Fungi a Practical Dermatophyte Fungi a Practical Guide to IdentificationGuide to Identification". AIMS National Scientific Meeting 2001, Melbourne". AIMS National Scientific Meeting 2001, MelbourneHoogHoog G., G., GuarroGuarro, J. (1995). ", J. (1995). "Atlas of Clinical FungiAtlas of Clinical Fungi" " CentraalbureauCentraalbureau voorvoorSchimmelculturesSchimmelcultures, The Netherlands, and , The Netherlands, and UniversitatUniversitat RoviraRovira i i VirgiliVirgili, Spain], Spain]LaroneLarone, D. (1995). , D. (1995). "Medically Important Fungi" 3rd Edition"Medically Important Fungi" 3rd Edition. American Society for . American Society for Microbiology, Washington. Microbiology, Washington. MurryMurry, P., Baron, E., , P., Baron, E., PfallerPfaller, M., , M., TenoverTenover, F., , F., YolkenYolken, R. (1995). ", R. (1995). "Manual of Clinical Manual of Clinical Microbiology" 6th EditionMicrobiology" 6th Edition. American Society for Microbiology, Washington. . American Society for Microbiology, Washington.