Fungi!
AlanPostlethwaite
BSc(Hons)Podiatry,DipBMec,FPSPract
29November2015
1
Agenda
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ClassificaJonoffungalinfecJons
Structureoffungi
FungalorganismsandinfecJon
Someavailabletreatments
Newboysontheblock
Yourrole!
2
Howmany?
•  Approx.1,500,000species
•  Lessthan100pathogenictoman
•  Whichdoweusuallycomeacross?
3
Howmany?
•  Approx.1,500,000species
•  Lessthan100pathogenictoman
•  Whichdoweusuallycomeacross?
– TineaPedis
– Onychomycosis
4
Howmany?
•  Approx.1,500,000species
•  Lessthan100pathogenictoman
•  Whichdoweusuallycomeacross?
– TineaPedis
– Onychomycosis
(Dermatophytes)
5
Whatarethese?
1
4
2
5
3
6
6
TheDiversityofFungi:
Fromtrufflestotoenailstoterminaldiseases
RelaBonshipswithHumans:thegood,thebad,andtheugly
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AnJbioJcsderivedfromfungi(penicillin,cepaholosporin)
Gastronomy
–  Wine,beer;bread;soysauce,truffles
EcologicalRole:decomposingorganicma\er;
Indispensableinnutrientcyclingandexchange
Biocontrol-entomopathogenicfungi
OtherenzymaJcprocesses,e.g.cellulasesfromTrichoderma
areusedin"biostoning"ofdenimfabricstogiverisetothesoc,
whitenedfabric--stone-washeddenim
Detrimentaltothefoodchain(plantpathogens)
HumanandassociateddomesJcanimaldiseases
ProduceToxins
Onychomycosis;UsJlagoMaydisandbluecorn
7
ThePathogenicFungi
FungalinfecJonsclassifiedonthedegreeofJssueinvolvementand
modeofentryintothehost:
•  Superficial-localizedtotheskin,thehair,andthenails.
•  Subcutaneous-infecJonconfinedtothedermis,subcutaneous
Jssueoradjacentstructures.
•  Systemic-deepinfecJonsoftheinternalorgans.
PrimaryandOpportunisJc
•  Requirethehost(hostdependent;PneumocysJs,Microsporidia,
C.albicans)
•  Terminateinhost(Aspergillus,Histoplasma)
8
Howdowegetinfected?
FungalnailinfecJonhasli\letodowithpersonal
cleanliness.
•  Canbeassimpleas
–  bangingatoeorfinger;
–  trimmingnailstooclosely;
–  wearingJghtshoes.
Allenoughtoweakenthenailandexposethe
underlyingnailbedtoinfecJon.
•  ToenailsaremostvulnerabletoinfecJon,
–  (spendmuchoftheirdaydark,warmandmoist)
9
Whatisthebiggestproblemforus?
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PaJentcompliance!
Why??
IttakesJmeandrepeJJvetreatment
Nailgrowthrate?
Halluxfullyinfected?
10
Increasedrisk
•  Agingisacommonriskfactorfornailfungusfor
severalreasons,including:
–  DiminishedbloodcirculaJon
–  Moreyearsofexposuretofungi
–  Nailsmaygrowmoreslowlyandthickenwithage,
makingthemmoresuscepJbletoinfecJon
11
Otherfactors
•  Perspiringheavily
•  Workinginahumidormoistenvironment
•  WearingsocksandshoesthathindervenJlaJonanddon't
absorbperspiraJon
•  Walkingbarefootindamppublicplaces,suchasswimming
pools,gymsandshowerrooms
•  PresenceofTineaPedis(Athlete’sfoot)
•  Havingaminorskinornailinjury,adamagednail,or
anotherinfecJon
•  Havingdiabetes,circulaJonproblemsoraweakened
immunesystem
12
Fungi
FILAMENTOUSFUNGI/
MOULDS
MOULDS
DIMORPHIC
FUNGI
CLINICALLY
MYCOLOGICALLY
YEASTS
YEASTS
DERMATOPHYTES
MICROSPORUM
YEAST-LIKE
FUNGI
TRICHOPHYTON
13
EPIDERMOPHYTON
BasicBiologyofFilamentousFungi(moulds)
•  ThecellwallcomprisesofchiJn.
•  MainbodyoftheplantistheThallus–produces
hyphae–formsmycelium.
•  ReproducebyformaJonofspores.
•  Producemicroormacroconidiaasexually.
14
BasicBiologyofYeasts
•  Unicellular
•  Reproduceby‘budding’.
•  CandidaAlbicans(oropharangeal/gastrointesJnal
commensal)–causescandidiasis,thrush
•  Note:Dimorphicfungicangrowasmycelialfungi
orassinglecellyeasttype.
15
SourcesofFungalinfecBon
•  Animals–Zoophilicfungi
–  E.g.microsporumcanis(catanddogringworm)
•  Soil–Geophilicfungi
•  Humans–Anthropophilicfungi
–  Spreadviainfectedsurfacesandcommoninthecommunity
•  Dermatophytesmayoriginatefromanyofthesesources
16
Fungi
•  FungiareeukaryoJcorganisms(cellswithorganelles&acellwall)
•  Fungiarethemajordecomposersoforganicma\ere.gcellulose
•  Fungicauseabout70%ofallthemajorcropdiseases
•  Thediversemetabolicpathwaysoffungigeneratemanycommercial
productssuchasethanol,organicacids,enzymes,anJbioJcsBUTsome
extremelypotenttoxinsthataffecthumanandanimalhealthe.gaflatoxins
•  Withtheadventoftransplantsurgeryandtheincreasein
immunosuppressivecondiJons,includingAIDS,fungiareemergingasa
significantgroupoflife-threateninghumanpathogens
17
FungalStructure
•  FungiareeukaryotesthatobtainfoodbyabsorpJon.
•  AbsorpJvenutriJonmeansthatfungiexcretehydrolyJc
enzymestobreak-downcomplexorganicmoleculesinto
simpleonesthatcanbeabsorbed.
•  Fungimaybeunicellular(yeasts)ormulJcellular(most).
•  AllfungireproducebyasexualmechanismsBUTmostcan
reproducebysexualprocessesaswell
•  Fungiaredispersedbymeansofsporesofalmostinfinite
variety,producedbyeitheranasexualorasexualprocess
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FungalStructure
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Somespeciesoffungiconsistofsinglecells(yeasts)
Mostspecies,however,consistofmulJplethread-like
cellscalledhyphae.
Thehyphaeareorganisedintoanetworkoffibres
calledamycelium(i.e.themouldthatbecomes
apparentondecayingfood)
FungihaveacellwallconsisJngofthepolysaccharide
chiBn.
19
Hyphae
20
FungalStructure
•  Likehumancells,fungalcellscontainanucleus,endoplasmic
reJculum,mitochondria,andotherorganelles.
•  BUTmostfungalcellspossessarigidcellwallcontaining
polysaccharidessuchaschiJnandglucan,whichdifferfromhuman
&bacterialcellwalls.
•  Theplasmamembranediffersfromthehumaninthetypeofsterol
present
–  Ergosterol,insteadofcholesterol,istheprimarycomponentof
thecellmembraneinfungi.
–  TheprimaryfuncJonofergosterolsistomodulatemembrane
fluidityandiniJategrowthandincreasethesize
21
FungalSpores
•  Manykindsoffungiproduceseed-likestructuresduring
reproducJonthatarealsocalledspores.
•  Thesporesofalargenumberofimportantfungiarelessthan5µm
aerodynamicdiameter-hencecanenterthelungs.
•  Theyalsomaycontainsignificantamountsofmycotoxins
(secondarymetabolitesproducedbymicrofungi)
•  DiseasesassociatedwithinhalaJonoffungalsporesincludetoxic
pneumoniJs,hypersensiJvitypneumoniJs,tremors,chronic
faJguesyndrome,kidneyfailure,andcancer.
•  InBritain>20mouldsareknowntocauseallergicreacJons
includinghayfever&rhiniJs
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Fungalvshumancells
•  UniquecellwallusingchiJnasthemainstructural
polymer
•  Cellmembranecontainsuniquefungalsterols
•  Someuniquecytoplasmicmembraneenzymesin
somespecies
•  NB:thesemayallbetargetedbyan6-fungal
therapies
23
FungalBy-Products
•  Fungiproduceawiderangeofsecondarymetabolites-theyplay
noroleinthenormal,basicmetabolicpathwaysusedforgrowth
andenergyproducJon,etc.
•  SomeofthesesecondarymetaboliteshaveanJbioJcproperJes.
•  Othersarepotenttoxinsthataredangerouswheneatenby
humansorotheranimalse.g.aflatoxins
•  Othersincludepigmentsinsertedintothefungalwallsorreleased
intothesurroundingenvironment,orflavour&odourcomponents
oftoadstools.
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Aspergillusfumigatus
CausesAspergillosisviafungalsporesinhaledfromdecomposingorganicma\er
(A)Typicalsporingheadsofthefungusinlaboratoryculture.
(B)MicroscopicsecJonoflungJssue,stainedtoshowhyphaeofAspergillusinanairsac.Sucha
ballofhyphaegrowingsaprotrophicallyinthelungistermedanaspergilloma.
25
It’snotallbad
YeastsandFungihavemanyuses.
26
Penicillin
•  TheanJbacterialeffectofpenicillinwasdiscoveredbyAlexanderFleming
in1929.
•  Henotedthatafungalcolonyhadgrownasacontaminantonanagar
platestreakedwiththebacteriumStaphylococcusaureus,andthatthe
bacterialcoloniesaroundthefungusweretransparent,becausetheir
cellswerelysing.
•  FleminghaddevotedmuchofhiscareertofindingmethodsfortreaJng
woundinfecJons
•  Heimmediatelyrecognisedtheimportanceofafungalmetabolitethat
mightbeusedtocontrolbacteria.
•  Thesubstancewasnamedpenicillin,becausethefungal
contaminantwasidenJfiedasPenicilliumnotatum
27
•  FlemingfoundthatitwaseffecJveagainstmanyGramposiJvebacteriain
laboratorycondiJons,andheevenusedcrudepreparaJonsofthis
substance,fromculturefiltrates,tocontroleyeinfecJons.
•  However,hecouldnotpurifythiscompoundbecauseofitsinstability,andit
wasnotunJltheperiodoftheSecondWorldWar(1939-1945)thattwo
otherBriJshscienJsts,FloreyandChain,workingintheUSA,managedto
producetheanJbioJconanindustrialscaleforwidespreaduse.
•  AllthreescienJstssharedtheNobelPrizeforthiswork,whichsavedliterally
millionsoflives.
•  ItissJlla"frontline"anJbioJc,incommonuseforsomebacterial
infecJonsalthoughthedevelopmentofpenicillin-resistanceinseveral
pathogenicbacterianowlimitsitseffecJveness
28
FungalInfecJon
•  Fungicancauseavarietyofdiseaseswith3majordivisions:
allergies,toxicityreacJons,andfungalinfecJons.
•  AllergicreacJonstofungiarecausedbysensiJvitytofungal
proteinssuchasinhaledfungalspores.
•  ToxicityreacJonsresultfromtheconsumpJonoffungaltoxinsin
contaminatedfoodorpoisonousmushrooms.
–  FungalallergiesandtoxicreacJonsareimportantconcernsinagricultureand
otherindustrieswherefungalcontaminaJoniscommon.
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Mycoses
•  4groupsbasedontheJssueorbodysiteinvaded.
Superficial-affectthehairshacandtheoutermost,nonlivinglayeroftheskine.g
Jneanigra(Exophialawerneckii)&piedra(Piedraiahortae)
•  Cutaneous-involveinfecJonoftheskin,hair,andnailse.gdermatophyeand
candidainfecJons
•  Subcutaneous-affecttheskinaswellasthemuscleandconnecJveJssue
immediatelybelowtheskine.gmycetoma
•  Systemic-involvethebloodandinternalorganse.gblastomycosis
30
Dermatophytosis
•  Dermatophytosis(Jneaorringworm)ofthescalp,glabrousskin,andnails
iscausedbyacloselyrelatedgroupoffungiknownasdermatophytes
–  havetheabilitytouJlisekeraJnasanutrientsource,i.e.theyhaveaunique
enzymaJccapacity[keraJnase].
•  Thediseaseprocessindermatophytosisisuniquefortworeasons:
–  nolivingJssueisinvadedthekeraJnisedstratumcorneumissimply
colonised.Presenceofthefungusanditsmetabolicproductsusuallyinduces
anallergicandinflammatoryeczematousresponseinthehost.Thetypeand
severityofthehostresponseisocenrelatedtothespeciesandstrainof
dermatophytecausingtheinfecJon.
–  thedermatophytesaretheonlyfungithathaveevolvedadependencyon
humanoranimalinfecJonforthesurvivalanddisseminaJonoftheirspecies.
31
Cutaneous
•  1.DermatophyteinfecJonsarecommoninfecJonsoftheskin,hair,andnails.
Becauseofthecircularskinpatchesfoundinalldermatophytoses,theyareocen
referredtoasringworm,orJnea,infecJons.
•  TheinfecJousfungibelongtooneofthreeGeni
–  Trichophyton
–  Epidermophyton
–  Microsporum
•  Thesefungioriginatefrominfectedhumans,animals,orsoils.
•  Transmissionisusuallyfrompersontopersonorfromanimaltoperson.
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DermatophytesaccordingtoMycologyOnline(2015)
h\p://www.mycology.adelaide.edu.au/Mycoses/Cutaneous/Dermatophytosis/
Species
Natural habitat
Incidence
Epidermophyton floccosum
Humans
Common
Trichophyton rubrum
Humans
Very Common
Trichophyton interdigitale
Humans
Very Common
Trichophyton tonsurans
Humans
Common
Trichophyton violaceum
Humans
Less Common
Trichophyton concentricum
Humans
Rare*
Trichophyton schoenleinii
Humans
Rare*
Trichophyton soudanense
Humans
Rare*
Microsporum audouinii
Humans
Less Common*
Microsporum ferrugineum
Humans
Less Common*
Trichophyton mentagrophytes
Mice, rodents
Common
Trichophyton equinum
Horses
Rare
Trichophyton erinacei
Hedgehogs
Rare*
Trichophyton verrucosum
Cattle
Rare
Microsporum canis
Cats
Common
Soil
Common
Microsporum nanum
Soil/Pigs
Rare
Microsporum cookei
Soil
Rare
Microsporum gypseum
*Geographicallyrestricted.
33
DermatophyteInfecJon
•  DermatophyteinfecJonsarerestrictedtothedeadJssuesoftheskinandits
appendages(suchasnailsorhair).
•  Minortrauma,prolongedorrepeatedcontactwithliquid,andpoorskinhygiene
promoteinfecJonsbythesefungi.
•  Moisture,warmth,andperspiraJoncoupledwithpaJentproperJessuchas
specificskinchemistryandgeneJcpredisposiJonincreasethechancesof
developingadermatophyteinfecJon.
•  Tineapedis(athlete'sfoot)ocenoccursbetweenthetoes
•  Usually,theinfecJonbeginswithitchingandthedevelopmentofsmallfluidfilledblisters.
•  Themoistskinpeelsandcracks,allowingsecondarybacterialinfecJonsto
develop.Peeling,cracking,pain,anditchingcharacterisechronicinfecJon.
34
TineaPedis
www.dartmouth.edu
www.latrobe.edu.au
www2.provlab.ab.ca
35
2.CandidalInfecJon
•  Theseyeastsarenormalinhabitantsofthemucousmembranesofthenose,
mouth,vagina,andanus.
•  CandidaalbicanscancausesymptomsanddiseaseifthelocalcondiJonsorthe
host'sweakenedimmunesystemallowittoovergrow.
•  SuscepJbilitytoCandidainfecJonsisincreasedwhentheskinisweakenedby
injury,burns,orprolongedexposuretowetenvironments.
•  Warm,moistcondiJons,asfoundinthefoldsofskininandaroundthearmpits,
groin,breasts,inbetweentoesetc
•  RarelyCandidainvadesdeeperJssuesaswellastheblood,causinglifethreateningsystemiccandidiasis-morecommoninimmunocompromised
36
CandidaInfecJonofwebofskinbetweenthefingers
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Footwear&humidity
•  ThewearingoffootwearisthemajorcontributortofootinfecJons.
•  Plantarsurfaceoffootsuppliedbyalargenumberofeccrinesweatglandswhich
increaseexcreJoninwarmcondiJons.
•  Occlusivefootwearcreatesawarmenvironment,prevenJngevaporaJonand
thushydraJngthefoot.
•  Leydenetal(1987)demonstratedthisbyhydraJngthenaturallydryregionof
theforearm.Within24hoursthenormalbacterialpopulaJonhadincreased
from103to106organisms/cmsquared.Alargeincreasewasinthepathogen
Staphylococcus
•  Acer7daysofhydraJontheresultsdisplayedatriplingofthe24hourbacterial
density,includingpredominanceofDiptheroids.Theauthorsstatedthis
populaJoncloselyresemblesthatwhichisfoundonthefoot.
38
NormalSkinFlora
• 
Marshalletal(1986)believethatsomedifferencesmustexistbetweenfootfloraand
otherskinsites.Thedifferencesarea\ributedtoanatomicalvariaJonsalreadymenJoned
plusthewearingofocclusivefootwear.TheauthorsinvesJgatedthreesites.
•  1.sole
•  2.dorsum
•  3.4thtoeclec
• 
TheirresultsdisplayedMicrococciandCoryneformasthemostnumerous.Staphylococci
wereweredominantonthesoleanddorsumwithCornyeformdominantinthe4thtoe
clec.
• 
Pelczaretal(1992)listStaphylococcusepidermis&aureus,Propionibacteriumacnes,
Diptheroids,Pityosporumspp.andCandidaspp.asthenormalskinflora.
39
TreatmentopJons?
•  MedicaJon
–  TopicalsoluJons/lacquers
–  Tablets
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• 
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• 
Chemicalnailremoval
Surgery
Laser/lighttherapy
HolisJc
40
Howdotreatmentswork?
Terbinafine(Lamisil)
•  Interfereswithcellmembranes.
•  Stopsfungifromproducingergosterol,an
essenJalcomponentoffungalcellmembranes.
•  Thisdisruptsthecellmembraneandcausesholes
toappear.
EssenJalconsJtuentsofthefungalcellsleakout.
ThiskillsthefungiandclearsuptheinfecJon.
41
Similarproducts
•  Caneston(clotrimazole)
•  CanestonOral&Duocream(clotrimazole,
flucoazole)
•  Daktarin(micanazole)
•  Diflucan(fluconazole)
•  Nizoralcream(ketoconazole)
42
Differenttopicalapproach
•  MYKORED(Salicylicacid/BenzoicAcid)
•  ChangedpHlevelInhibitsmycelialgrowth
•  ChangesstructuralorganizaJonofthemycelium
atvariouslevels(wall,mitochondria,vacuoleand
nucleus)
•  Fungalfilamentsappearemptyincreasinguptake
ofacid
•  Alcoholbasedriesenvironment
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Whennottotreat
Pregnancy
Breastfeeding
DecreasedkidneyfuncJon.
DecreasedliverfuncJon.
Psoriasis.
Peoplewithalong-termautoimmunedisease
affecJngconnecJveJssue,calledsystemiclupus
erythematosus(SLE).
•  Children(somemedicineisnotlicensedforusewith
children).
• 
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• 
• 
44
Top5USANailtreatments
PurNail
NailClenZ
Curanail
NailRx
zetaclear
EDITOR RATINGS:
Recommended, Good, Or Fair Buy
Recommended
Good
Good
PURNAIL NAILCLENZ CURANAIL
$59.95
$49.95
$33.00
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NAILRx
$39.95
ZETACLEAR
$49.95
UndecylenicAcid,Clotrimazole,Amorolfine,Teatree/LavOil,Teatree/Almondoil
Dry5-10m?
45
LamisilAt1%Cream
ChemistDirect
15g£5.99
Tablets£2.47
Boots 15g£6.25
Tablets-presc
Amazon 15g£5.00
Trade 15g£4.74–6.78
GP
£8.20presc
Terbinafinehydrochloridebased-
inhibitsergosterolsynthesisbyinhibiJng
squaleneepoxidase,anenzymethatis
partofthefungalcellmembrane
46
Curanail5%NailLacquer
AmorolfineTreatment
Amazon:n/a
Boots:£23.99
ChemistDirect:£24.32
Trade:£14.39-£17.99(3ml)
NowknownasLOCERYLCURANAIL
Amorolfinehydrochloridebased–stops
producJonofergosterol
ClaimstotreatMILDfungalinfecJons
47
LocerylLacquer5ml(POM)
Trade:£23.98-£28.79
Amorolfinehydrochloridebased–stops
producJonofergosterol
48
Excilor3.3ml
Boots:£19.99
Amazon:£14.64-£17.24
ChemistDirect:£18.49+£3.49
P&P
Trade:£9.87-£13.07
AceJcacid&alcoholbased
49
Clearzal
Boots: £21.49
Clearzal.co.uk£20.99
ChemistDirect£12.99
Amazon £11.99–13.59
Trade £11.04–12.78
ApplicaJon:freeedgeandsulcionly
Nolacquer,acidsoralcohol.
ClearsALLFungi,bacteria&viruses??
50
GehwolMedNail&Skincream15ml
Amazon:£6.32-£7.88
MankyFeet.co.uk:£12.99
(showsimprovementsin2
weeks!??)
Boots:n/a
Trade:£3:91-£4:50
Clotrimazolebased
51
MYKORED
Boots n/a
ChemistDirect
n/a
Amazon 50ml£10.79
Trade 50ml£6.66–7.30
Liquid–Salicylicacidcomplex
Cream–Clotrimazolebased
(combinaJonofcomponents–noone
oneacJveingredient)
52
10mlCLASSIKOOLORGANICANTIFUNGALFUNGUS
BACTERIALNAILOIL
Amazon:£3.79
eBay:£4.39
Carrieroil+8otheressenJaloils
Nonastychemicalsoralcohol!
NOFun-Gus!!
53
PACTMedlight
•  PhotodynamicAnJmicrobialTherapy.
•  UsesPACTNailFungusGel
•  AcJvatedbyexposuretolightfromthe
PACTMEDlightdevice.
•  Canonbury£2995+VAT
•  +gel(£24.99+VAT)
54
Evidence?
•  ExperimentalinvesJgaJonshavedemonstrated
conclusivelythatbothdermatomycetesandyeasts
canbeeffecJvelykilledbyphotodynamicacJon
•  (andGram-posiJveandGram-negaJvebacteria
andfungi)
•  onlyaverysmallnumberofinvivoanimaland
humantrialshavebeenpublished.
55
PACTtreatmentprotocol
• 
• 
• 
• 
Heavyde-bridementofeachaffectednail
10minutegelapplicaJonofeachaffectednail
9.5minutelightapplicaJonofeachaffectednail
Frequency:3completetreatmentsareneeded
within2-3weeks
56
Laser
ConsideraJons:
Capitalcost
ChargetopaJents
Evidence
Easeofuse(LLLT)
Lowlevellasertherapybecomingmoreaccessible
e.g.Omega
USAcosts$10-14,000
UK?
57
CLEARANAIL–
ControlledMicroPenetraJon(CMP)
Algeos £1999+VAT
UsedinconjuncJonwithliquidTerbinafine
e.g.Lamisil1%ATspray
58
Surgery
• 
• 
• 
• 
• 
• 
Totalnailavulsion
Doesitremovethefungalspores?
Phenolisethenailmatrix?
ApplyanJ-fungalagentpostsurgery?
Li\leevidenceoneffecJveness
Extrememethod!
59
HolisJctherapy
• 
• 
• 
• 
AppleCidervinegarsoak
TeaTreeOil
OreganoOilextract
Others????
60
HolisJccures–EarthClinic.com
MostPopularToenailFungusRemedies:
AppleCiderVinegar36
DisBlledVinegar17
TeaTreeOil14
Ted'sRemedies14
Listerine10
HydrogenPeroxide10
Iodine8
CoconutOil8
Vicks7
Garlic7
OreganoOil7
Bleach6
LemongrassEssenBalOil5
SeaSalt3
Mouthwash3
UrineTherapy3
CastorOil3
DietaryChanges3
Cayenne3
61
Tothinkabout…..
•  InfecJonsofthefootmustbetreatedquicklyandefficientlyto
preventseriouscomplicaJonsfromoccurring,especiallyifthe
host'simmunesystemiscompromised.
•  ThenormalfloraoftheskinhastheabilitytoestablishinfecJonof
thefootifthebarrieroftheskinisbroken.
•  BecausethefootisexposeddirectlytosurfaceswhenambulaJng
thisbarriercaneasilybedisruptedallowingtheentryofpathogens.
62
Andyou??
• 
• 
• 
• 
• 
Youhavearoletoplay
NHSPodiatrydonottreatfungalinfecJons
GP’sarereluctanttoprescribe
Yourprofessionalapproachcanhelp-easily!
Advise,demonstrate,treat
–  Whichtreatment?
–  Isitfungal?GP–sample(getjar1st)
63
Summary
•  Fungalsporesareallaroundus
•  PaJentscanmoreeasilybeinfectedthantreated
•  Widerangeoftreatments
–  Cost
–  Time
–  Compliance
–  Compromised
64
TheEnd
•  Itisuptoyouhowfaryouwanttogo
•  YoucanhelppaJentsandyoucanimproveyour
profession
•  QuesJons!
65