Medical Mycology in India: past, present and future by H.C

1
Medical Mycology in India past, present and
future

• by
• H.C. Gugnani, Ph.D. FRC. Path.
• Dr. B. R. Ambedkar Centre for Biomedical
  Research, University of Delhi
• Delhi-110007 (formerly at Vallabhbhai Patel
  Chest Institute, University of Delhi)

2
Dedication to Dr. Libero Ajello

• Late Dr. Ajello was not only a pioneer medical
  mycologists but also an embodiment humility and
  kindness.
• With his great qualities of head and heart, he
  helped numerous mycologists around the globe,
  particularly those in the developing countries in
  several ways.
• Above all, he was a very humble and a kind person

3
Interaction with fungi

• The interaction of Indians with fungi started
  thousands of years ago.
• There is scientific evidence that the mushroom,
  Amanita muscaria may have been the oldest of the
  hallucinogens used by the Aryans, about 3500
  years ago, and may possibly be the most widely
  used cryptic symbolism in the Rig Veda

4
Interaction with fungi-contd.

• According to Wasson, Soma, the narcotic God of
  ancient India was believed to have originated
  from the Aryans, who invaded India, 3500 years
  ago, from the north which is now Afghanistan,
  into the Indus Valley, and with them, brought
  their cult of Soma.
• Soma is one of the few enthnogens that is looked
  upon as a god rather than a sacred mediator.
• After a detailed study of descriptions, Wasson
  concluded that Soma was a mushroom and
  specifically, Amanita muscara, the fly agaric.
  Interdisciplinary studies in 1967 also testified
  to this.

5
Early work on fungi in India

• There are references to the use of mushrooms as
  foods and medicines in India in the ancient
  medical text, Charaka Samhita (3000500 BC).
• However, their scientific study is of recent
  origin. In the 18th century, Koening got his
  collecton from Tamil Nadu State identified as
  Podaxis pistillaris (LPers) Mosse by Linnaeus.
• Subsequently Sir J.D. Hooker made a collection of
  fungi from hills that led to a series of papers
  by an English mycologist, Reverend M.J. Berkley.
  This first phase lasted up to 1899.
• A significant feature of the second phase
  (1900-1960) was the involvement, besides European
  and American workers, of several Indian workers
  on larger as well as microfungi

6
Earliest records of fungal Disease

• The earliest record of fungal disease in man is
  in Athara Veda (About 2000-100 BC), of mycetoma
  described under the name Padavalmita(Foot
  anthill) (Saran et al. 1972).
• Gill, an English physician in South India first
  described a probable case of mycetoma in 1842 in
  his dispensary report in Madura (Madurai) in
  Tamil Nadu. Godfrey, a Garrison surgeon working
  in Bellary first described mycetoma (as morbus
  tuberculosis pedis) in medical literature in
  1946 (Lancet 1 593-594).

7
Early research in medical mycology in India

• In 1859, Eyere, one of Godfreys colleagues
  described 40 cases treated between 1844 and 1848.
  
• It was Carter, who in 1861 first suggested the
  fungal etiology of the disease (Trans Med Phys
  Soc Bombay 7 206-221) and introduced the term
  mycetoma
• Later in 1874, Carter published a monograph On
  Mycetoma and Fungus Diseases of India (J
  Churchill Ltd.).

8
Early research in medical mycology in
India-continued

• Carter also described the pathological features
  of mycetoma, caused by the organism now known as
  Madurella mycetomatis.
• Powell reported ringworm from Assam in 1904
• Research in medical mycology in India started in
  1920 under Lt. Col H. W. Acton (with C. McGuire,
  A. Maplestone, NC Dey, G. Panja, K.P. Banerjee
  and others) at Calcutta School of Tropical
  Medicine, Calcutta.
• Acton described red-grained mycetoma from India
  Pioneering work was done on other mycoses.

9
Early research in Mycology and Pl. Pathology in
India

• E.J. Butler, a British physician, started the
  work on fungal diseases of plants in India in
  1903 with the publication of monograph on Potato
  diseases of India (Agr Ledger 4 112-119.).
• He worked at the I.A.R.I from 1905-1921 in Pusa
  (Bihar) and established a strong school of
  mycology and plant pathology.
• Butler is aptly called the father of Indian
  Plant Pathology. Before departing from India,
  he published in 1918 a book on Fungi and
  Diseases in Plants, which remains a classic till
  to-day.

10
Early research in Mycology and pl. pathology plan
in India-contd.

• Butler published an authoritative list of Indian
  fungi in collaboration with G.R. Bisby (Butler
  Bisby 1930).
• This publication has been continuously updated
  until the last edition by Sarabhoy et al (1993).

11
Establishment of separate Med. Mycology
Departments/Sections

• Calcutta (Kolkata) School of Tropical Medicine,
  Calcutta - A separate Department of Dermatology
  Medical Mycology was established in 1931 with Dr
  A. Maplestone in charge and Drs NC Dey, D Panja
  and LN Ghosh
• An independent Medical Mycology Department was
  established in 1960 with Dr SR Bose as head.
• Later Drs Maya Sanyal, N Basu, A Thammaya, and
  worked as a team for nearly three decades with
  other associates, mainly Drs PK Maiti, A Ray, PK
  Haldar and others in RG Kar Medical College and
  University College of Medicine, Kolkata.

12
Vallabhbhai Patel Chest Institute, University of
Delhi

• Mycological work started in the institute in 1957
  with investigation of role of fungi in Bagassosis
  under an ICMR Project.
• The Department of Medical Mycology was
  established in 1959 with appointment of Dr HS
  Randhawa as foundation staff Dr RS Sandhu joined
  in the same year. Other Faculty staff who worked
  in the Department include Dr ZU Khan (1974-1992)
  and Dr HC Gugnani (1997-2004), Dr A Chowdhary
  (2001- to date). Dr Randhawa is continuing to
  work in the Dept. (after retirement in 1998) as
  Senior Emeritus Scientist of INSA.

13
All India Institute of Medical Sciences, New Delhi

• Medical Mycology section established under the
  leadership of Col. Prof SL Kalra, Head, Dept. of
  Microbiology in 1960 with Dr LN Mohapatra as
  Faculty staff in charge, later joined by HC
  Gugnani as ICMR project staff in 1962.
• Later the Mycology section was headed by Dr R
  Kumar and more recently by Dr Uma Banerjee.

14
National Institute of Communicable Diseases, Delhi

• Section of Medical Mycology was established in
  1964 (under the Division of Microbiology) with HC
  Gugnani as the foundation staff (research
  office), later joined by SK Shome (Assistant
  Director) in 1967.
• Later Drs ZU Khan, R Rajendran and K
  Chandrasekhar worked for varying periods.
• Currently the Division of Med. Mycology is headed
  by Dr Chandrasekhar (Joint Director).

15
Madras Medical College, Chennai Govt. Gen.
Hospital

• The Mycology Section was started in 1960 under
  Dermatology Dept. as brain child of Prof. A. S.
  Thambiah with Dr PV Venugopal, and Dr A Kamalam.
• Other faculty staff who worked were Dr G
  Sentamilselvi, VR Janaki and C Janaki as academic
  staff.
• The section is presently headed by Dr C Janaki.

16
Post-gradaute Institute of Medical Education
Research, Chandigarh

• Mycology section was started under Dept. of
  Microbiology with the pioneering efforts of Dr P
  Talwar in 1964 . It was raised to the status of
  Division in 1979.
• Dr A Chakrabarti joined as Faculty staff in 1988
  and took over the reins of the Division in 1991
  after retirement of Dr Talwar, and is currently
  supported by Dr Shiva Prakash.

17
Department of Biological scienes, R.D University,
Jabalpur

• The work in medical mycology in this centre in MP
  (in Central India) was pioneered by Dr S M Singh
  in 1978 under the stewardship pf Prof GP Agarwal,
  the then Head of Dept.
• The Laboratory has been has been providing
  mycological diagnostic services to the hospitals
  in and around Jabalpur for the past 20 years
• His current team in the Department includes Dr
  Jayshree Naidu and Dr Nwage Rao.

18
Lokmanya Tilak Muncipal Medicl College General
Hospital

• Mycology section established in the Department of
  Microbiology in 1979 by Dr Lina Deodhar, then
  Professor and Head of Dept. and Dr VB Ambekar.
• With the expanding medical mycological work and
  research, Dr Uma Tendolkar, Associate Professor
  assumed the charge of the section in 1984 and is
  still with the Department.

19
Society for Indian Human and Animal Mycologists
(SIHAM)

• SIHAM was founded in 1995 in Jabalpur (M.P.) with
  the tenuous and laudable efforts of Prof. SM
  Singh and other colleagues with only 17 members.
• Since then the society has steadily grown to its
  present strength of about 300 members
• The first annual Conference was organized by
  Prof. SM Singh at R.D. University, Jabalpur in
  February 1996. Subsequent Conferences were held
  in Jodhpur (organized by Prof. K.R Joshi),
  Chennai, Annamlai Nagar in Tamil Nadu (Prof. PV
  VenugopaL), and Chandigarh (Dr A Chakrabarty) in
  1998, 2000, 2002 2004 respectively.

20
SIHAM -continued

• It is because of these continued efforts that we
  are now attending the sixth Conference of SIHAM
  in Hyderabad today (Jan 2006), organized by Dr R
  Iyer and his colleagues.
• SIHAM Mycoses Newsletter was started in 2002
  with the laudable efforts of Dr A Chakrabarti
  (who is also it Editor), and with financial
  support of M/S Pfizer, India. It has continued
  to serve as a commendable source of valuable
  information and educational material on mycoses.
• SIHAM is planning to publish its own journal.

21
Training workshops in Medical Mycology

• Several training courses and workshops have been
  organized in medical mycology in different parts
  of the country. These included
• International workshop organized in PGI,
  Chandigarh in November with Faculty from USA UK,
  India with the financial support by British
  Council.
• A National workshop was held very recently in
  Chennai in October 2005 as a part of the
  National Conference of Association of Medical
  Microbiologists of India (with resource persons
  as Drs A Chakrabarti, Dr Pankajlakshmi Venugopal
  her colleagues, Dr Shiva Prakash.
• These workshops have been attended by a large
  number of participants from several parts of
  India, and few from Nepal.

22
New species-fungal pathogens

• Candida viswanathii, a new species recovered from
  CSF and sputum (Viswanathan Randhawa, 1959 Sci
  Cult 25 86-87 Sandhu Randhawa Mycopath
  Mycol Appl 1962 18 181-18
• Artrogrpahis kalrae (Tewari Macpherson) Sigler
  Carmichael) originally recovered from sputum,
  pathogenic for laboratory mice (Tewari
  Macpherson. Mycologia 1971, 63 602-611).
• It was then named as Oidiodendron kalrai. The
  species is known to cause cutaneous and systemic
  infections.

23
New species-fungal pathogens

• Saksena discoveed in 1953 a new genus, Saksenaea
  with S. vasfiormis as the type species (also the
  only known species).
• This fungus is world-wide saprobe in soil and has
  emerged as an important human pathogen, mostly
  associated with cutaneous and sub-cutaneous
  infections.

24
New/Novel fungal pathogens

• Misra, Srivastava Latas (1979) discovered a new
  mucoraceous fungus, Aphanomyces with A. elegans
  as the type species (the only known species of
  the genus).
• This has emerged as an important pathogen of
  immunocompetent and immuno-compromised host.

25
Novel fungal pathogens

• Ustilago maydis, a plant pathogen causal agent of
  maize smut, was identified as a etiological agent
  of a unique case of brain mycosis, manifesting as
  brain tumour with symptoms of blindness and
  raised intracranial tension (Randhawa, HS, Tandon
  HD Smetana HF. Bull Cal Sch Trop Med 1959 7
  45-46.
• Association of Candida tropicalis with maize
  stalk rot (Lalaramani et al. 1974 Experientia
  59109-11.
• Systemic mycosis (cerebral phaeohyphomycosis)
  caused by Chaetomium globosum. (Anandi et al.
  2001) J Clin Microbiol 1989 27 2226-2229).

26
Novel fungal pathogens-contd.

• Nodulisporium sp as an etiological agent of human
  infection (cerebral phaeo-hyphomycosis) (Umabala
  et al. J Clin Microbiol 2001, 39 4213-4318)
• Maxillary sinusitis caused by Ascotrihca
  chartarum (Singh et al. 1990 J Med Vet Mycol 28
  275-278.)
• Rhizoctonia sp. as etiological agent of mycotic
  keratitis (Srivastava et al. 1968 Sabouraudia
  15 125-131.

27
Novel fungal pathogens-contd.

• Acremonium recifei as a as a causal agent of
  myctoma (Koshi et al Am J trop Med Hyg 1979 28
  692-696).
• Cutaneous phaeohyphomycosis due to Alternaria
  chlamydospora (Singh et al. 1990 J Med Vet Mycol
  28 275-278).
• Aspergillus versicolor as the causal agent of
  cerebral abscess (Venugopal et al Sabouraudia
  1978, 13)

28
Novel fungal pathogens-contd.

• Cylindrocarpon sp. as an etiological agent of
  mycetoma (Hemashettar et al. 2000 JCM
  384288-91)   
• Emericella quadrilineata (anamorph Aspergillus
  tetrazonus) as an etiological agent of
  onychomycosis (Gugnani et al. 2004 JCM 42
  914-916.).

29
Development of rapid/novel diagnostic
techniques 

• Application of paraffin bait for better recovery
  of Nocardia asteroides from clinical specimens
  (Mishra Randhawa 1969 Appl Microbiol 18
  686-687.)
• Modified inositol assimilation by Cryptoooccus
  neoformans, yielding results within 48 hrs as
  against 14 days by Adams-Cooper technique
  (Paliwal et al., 1979 Canad J Microbiol 25
  346-348.)
•  

30
Novel techniques - continued

• Use of Berthiolate color reaction for rapid
  detection of urea hydrolysis (within 30-50
  minutes) by C. neoformans and other yeasts
  (Paliwal et al. 1977 Environ Microbiol
  33219-220) as against 8-72 hrs usually required
  with Christensen urea agar
• Use of L-DOPA pigmentation test for development
  of mouse-grey violaeous black pigment 15-30 min.,
  diagnostic of C. neoformans in inoculated in
  phosphate-buffered liquid medium incubated at 37
  0C, as compared with over 5 hrs using the test
  described by Hopfer Groschel (1975) (Paliwal
  Randhawa, 1978 Antonie van Leeuwenhoek
  44261-264).

31
Rapid/novel diagnostic techniques

• Simplified Staib (birdseed/nigerseed) agar for
  pigment production by C. neoformans (Paliwal et
  al. J Clin Microbiol 1978 7 346-346.)
• A new medium, tobacco agar, for pigment
  production of Cryptoooccus neoformans (Tendolkar
  et al. Indian J Med Microbiol 2003 21
  277-279.This has led to a new use of the medium
  i.e. differentiating Candida dubliniensis from
  Candida albicans (Khan et al., 2004 J. Clin
  Microbial 42 4796-4798.).

32
Novel diagnostic techniques-continued

• Cotton seed agar (7 aqueous seed extract of
  Gossipium hirsutum or G. arboreum) as an
  inexpensive but efficacious medium for in vitro
  conversion of Blastomyces dermatitidis to yeast
  form (Chaturvedi et al. 1990 J Med Vet Mycol 28
  139-145.

33
Ecology Epidemiology of Mycoses Histoplasmosis

• Isolation of Histoplasma capsulatum, the
  etiological agent of histoplasmosis from one of
  the three samples of soil admixed with bat guano
  in Serampore (Sanyal M Thammaya Indian J Med
  Res 1975 63 1020-1028,)
• The samples were collected from an abandoned room
  of a 350-year old palatial building building
  infested with insectivorous bat, Scotophilus
  heathi.

34
Blastomycosis

• Recovery of Blastomyces dermatitidis, from the
  visceral organs of a bat (Rhinopoma hardwickei
  hardwickei), thus implicating these flying
  mammals as an additional host or a vector of this
  dimorphic pathogen. (Khan et al. 1982 Sabouraudia
  20 137-144, Randhawa et al. 1985 Sabouraudia 23
  78-86.)
• These findings and the report of the first
  autochthonous case of blastomycosis in India
  (Randhawa et al 1983 Sabouraudia 21 215-221.)
  established the endemicity of this disease in
  India.
•  

35
Other systemic mycoses

• Coccidioidomycosis - First authentic case of this
  disease (originating from Arizona in USA)
  reported from India (Baruch et al. 1996 Lancet
  348 1313) followed by another such case
  (Verghese et al.2002 Med Mycol 40307-9.)
• Rhinosporidiosis - Asian water buffalo (Babalus
  bubalis) as a host for Rhinosporidium seeberi
  (Rao et al, 1975)

36
Aspergillosis

• Series of studies demonstrating the frequent
  occurrence of ABPA in India (Khan et al Scand J
  RespDis 1976 57 73-87 Shah A. Indian J. Chest
  Dis. Allied Sci 199436 273-289.
• Association of a virulence with p-aminobenzoic
  acid deficiency in Aspergillus fumigatus (Sandhu
  et al 1976 Infect Immun 13 527-532)

37
Aspergillosis-contd.

• Identification, cloning, and expression of a 44
  Kda novel allergen/antigen of A. fumigatus with
  sequence homology to L3 ribosomal protein with a
  probable role in resistance of the fungus to
  antifugnal drugs (Saxena et al. 2003 Clin Exp
  Immunol 134 86-91.
• Role of surfactant proteins SPA-A, SP-D and MBL
  in the host defense against allergic and invasive
  aspergillosis by in vitro and in vivo studies
  (Madan et al.2005, Med Mycol 43, Supplement 1
  S155-163).

38
Infection due to Cryptococcus neoformans and its
ecology

• First report of cutaneous infection due to
  Cryptococcus laurentii (Kamalam Thambiah 1977
  Brit J Dermatol 97 221-223.) 
• Isolation of C. neoformans var. gattii from
  flowers of Euclayptus camaldulensis, from the
  bark of E. terreticornis and C. n. var.
  neoformans (var. grubii) from decayed wood
  inside trunk hollows of Syzygium cumini and of C.
  n. var. neoformans from Ficus religiosa trees in
  Chandiagrh, Delhi/New Delhi (Padhye et al. 1993,
  Randhawa et al.,2001 2003 Gugnani et al. 2005).

39
C. neoformans - ecology contd.

• Recovery of C.n. var. grubii from the flowers of
  Eucalyptus camaldulensis. The two isolates were
  clonal (Gugnani et al 2005 Med Mycology 43
  565-569,)
• These studies evidence that natural habitat of C.
  neoformans is not confined to any particular tree
  
• First study of molecular characterization of
  clinical and environmental isolates of C.
  neoformans from India (Kidd et al 2001, )

40
Infections to other yeasts and yeast-like fungi

• An nosocomial outbreak due to an unusual yeast,
  Pichia anomala involving 379 neonates and
  children (Chakrabarti et al. 2001 JCM 39
  1702-1706. Molecular studies of 40 isolates
  multilocus enzyme electrophoresis suggested the
  clonal naure of the isolates
• First report of nosocomial outbreak of candidemia
  due to Candida tropicalis in neonates documenting
  clonal origin of isolates. (Chowdhary et al.
  Mycoses2003, 46 287-292).

41
Dermatomycoses

• Demonstration of soil as a natural source and
  rodents (mainly Meriones hurrine, Suncus murinus
  ) as animal reservoirs of Trichophyton simii
  Pahye et al, 1966 Hindustan Antibiotic Bull
  Gugnani et al. 1967, 1975 Sabouraudia 6 77-80.,
  Mykosen 18 529-536.)
• First report of an epizootic of dermatophtytosis
  in poultry due to Trichophyton simii (Gugnani
  Randhawa, 1973, Sabouradia 11 1-3. )

42
Dermatomycoses-contd.

• A focus of Trichophyton schoenleini infection of
  scalp in children (favus) in the Kashmir valley,
  possibly originating from Middle east (Hajni et
  al, 1987) and of T, yaoundei in Karnataka
  (Hemishettyar et al 1990 J Med. Vet Mycol)
• Association of Trichophyton mentagrophytes with
  the bark of Eucalyptus tree (E. camaldulensis )
  (Musa et al 2000 . J Mycol Medicale 2000 10
  136-139 )

43
Dermatomycoses contd. phaeohyphomycoses

• Studies from Jabalpur highlighted for the first
  time the etiological role of non-dermatophytic
  filamentous fungi including dematiaceous fuingi
  in causing cutaneous infections in India.
• The species included Nattrassia mangiferae,
  Curvularia lunata, C. pallescens, Alternaria
  chlamydospora, Exserohilum rostratum (Singh SM
  Barde AK Indian J Dermatol Venerol Lepr 1980 46
  350-355 Barde AK Singh SM. Mycoses 1983 26
  365-370 Agarwal A, Singh SM. Mycoses 1995 38
  301-303, Mycopathologia 1995 131

44
Dermatomycoses contd. phaeohyphomycoses contd.

• Further studies by other workers. viz. Mathews,
  Verghese, Ranjan and their associates have
  highlighted the role of dematiaceous fungi in
  causing subcutaneous phaeohyphomycosis

45
Mycetoma

• Several investigators from different parts of
  India have made significant contributions on the
  prevalence and etiology of mycetoma in the
  country. Some of the studies are by Klokke et al.
  1968 Desai et al. 1970 Koshi et al. 1972
  Dasgupta et al . 1974 Taralakshmi /
  Pankajlaksmi, 1977 Kamalam Thambiah, 1987
  Joshi et al. 1987 Venugopal Venugopal 1995
  Sanyal et al. 1976 Sentamilselvi et al. 1997.

46
Mycetoma- contd.

• Some of the notable contributins on the etiology
  of myctoma include first isolations of
  Leptosphaeria senegalensis and L. tompkinsii from
  outside of Africa (Pankajlkshmi Taralakshmi. Int
  J Dermatol 1990)

47
Molecular diagnosis of fungal infections in India

• Use of PCR in the diagnosis of fungal
  endophthalmitis from Sankar Netralaya, ChennaI
  (Anand et al. Ophthalmology 108 326-330.. Indian
  J Med Res 200, 114 133-140.)
• Demonstration of usefulness of PCR in laboratory
  diagnosis of systemic fungal infections in a
  study from Mumbai (Iyer et al. Indian J Med
  Microbiol 2002, 20 132-136.)

48
Molecular diagnosis of fungal infections in
India-contd.

• Use of PCR in diagnosis of cryptococcal
  meningitis (Iyer Revathi S, Banker (Indian J Med
  Sci 2002 56. 593-597.
• We need to evaluate PCR in greater number of
  laboratories before confirming the usefulness of
  this technique.