100 Int J Res Med. 2015; 4(2);100-104 e ISSN:2320-2742 p ISSN: 2320-2734
Prevalence of Candida species among HIV positive patients at a tertiary
care hospital
Kalpesh Mistry1, Govind Ninama2, Mitesh Kamothi3
1
Assistant Professor, GMERS Medical College, Gotri
2,3
Associate Professor, Dpt. Microbiology GMERS Medical College, Gotri
INTRODUCTION
Oral candidiasis (also known as oral thrush) is a common opportunistic mycosis (yeast infection) of Candida species on the mucous membranes of the mouth1. Oropharyngeal candidiasis (OPC) is the commonest fungal infection amongst HIV-positive patients worldwide. Infection can spread from the mouth through the pharynx to the oesophagus. A systemic infection of other parts of the body is not as common, but carries a high mortality of between 40% -100% 2.C. albicans is the most common species of yeast isolated from patients with oral candidiasis3. Oral candidiasis has been reported as the third commonest clinical oral presentation in HIV-positive patients. The incidence of opportunistic infections due to Candida albicans and other Candida species has been increasing 4. Oral Candidiasis is the most common HIV related oral lesion and most patients are infected with a strain originally present as a commensal of the
*Corresponding Author:
Dr. Kalpesh Mistry, B 102 Manorath flats.
Behind mother`s school. Gotri Vadodara- 380021
Email –drkalpesh77@yahoo.co.in
oral cavity 5. The spectrum of Candida infection is diverse, starting from asymptomatic colonization to pathogenic forms. The low absolute CD4+ T-lymphocyte count has traditionally been cited as the greatest risk factor for the development of oropharyngeal candidiasis and current guidelines suggest increased risk once CD4+ T lymphocyte counts fall below 200 cells/ μ 6
. Candidiasis is attributed to a reduction in host immune defenses. A change in the distribution profile of Candida species can be an indication of drug resistance or immunosuppression levels in a population. It could be a sensitive and specific indicator of a decrease in the number of CD4 cells and would show the onset of significant immune deficiency in people with HIV
Therefore, taken together with other parameters of observed changes in the severity of OPC, CD4 cell count and viral load, the change in species characteristics could give an indication of immunological changes occurring in the patients 7.
The first step in the development of a Candida infection is colonization of the mucocutaneous surfaces 8. HIV infection is not only associated with increased colonization rates but also with the
ORIGINAL ARTICLE
ABSTRACT
BACKROUND: Candidiasis and its species are commonly isolated during the human immunodeficiency virus (HIV) disease progression. Changes in the clinical severity of candidiasis and the type of species of Candida isolated may be a reflection of disease progression. The aim of the study was to determine different species of Candida in HIV positive patients. MATERIAL AND METHODS: the study was carried out in 346 HIV positive patients during January 2005 to October 2005 by collecting oral swabs for Candida and were cultured and identified at species level. RESULTS: A total of 78 (87.6%) Candida species were identified in the study. Four different Candida species were isolated. Candida albicans was the most prevalent species (67.94) followed by C. krusei (12.82%), C. tropicalis (8.97%) and C. parapsilosis (6.41%). Isolation of Candida on culture was independent of whether the patients were on anti-retroviral therapy or not. Conclusions: Candida albicans was the most prevalent (67.94) species isolated. In immunocompromised patients as other species of Candida are also isolated it becomes important to indentify Candida species causing severe infections.
101 Int J Res Med. 2015; 4(2);100-104 e ISSN:2320-2742 p ISSN: 2320-2734 development of overt disease. During the
course of HIV infection, the rate of Candida infection is inversely related to the CD4 counts of the patient which in turn depends on the use of Anti-retroviral treatment 9. HIV-positive patients carry more and a greater variety of yeasts than HIV-negative subjects. The prolonged management of oral candidiasis in HIV patients might cause the development of drug resistance candidiasis. Although the introduction of antiretroviral therapy(ART) has had a major impact on the infectious complications of AIDS, Candidiasis still remains a common opportunistic infection in HIV-infected patients.10 Hence this present study is aimed to determine the prevalence of oral Candida albicans infection in HIV positive patients.
MATERIAL AND METHODS
The study was carried out over a period of 10 months from January 2005 to October 2005 at Shree MP Shah Medical College Jamnagar. The study groups included were adults with HIV attending the OPD clinic. Inclusion criteria were a previous positive diagnosis of HIV, patients with confirms diagnosis of oropharyngeal candidiasis and no history of antifungal therapy within two weeks prior to attendance.
The oral cavity mucosa from each participant was swabbed with sterile cotton, which was then aseptically cut into 10 ml brain heart infusion broth and incubated at 35-37° C for 18 to 24 hours. The broth was then sub-cultured onto Sabouraud dextrose agar (HI- Media India) and incubated for 48 hours. Plates with no growth after 48 hours were re-incubated for a further one week. Pure cultures of yeasts were identified using API ID 32C test kit strips (BioMerieux, France). Colonies of yeast were emulsified in API suspension medium to form a turbidity equivalent to 2 McFarland Standard. Cupules of the test strips were filled with 135 ul of the test organism and incubated at 35-37°C for 24 to 48 hours.
RESULT
A total of 346 HIV positive patients were taken into study of which 209 were male and 137 were females. The highest number of males screened was between age group
of 36-45 (87), followed by 26-35 (73) and 46-55 (42), while the age group of 56-65 (3), 66-75 (1) and 15-25 (1) were the lowest screened. The highest number of females screened were in the age group 26-35 (52) followed by 36-45 (33), 46-55 (24) and 56-45 (16) while the age group of 15-25 (10) and 66- 75 (2) were the lowest screened.
Table: 1 Candida species among HIV positive patients
Organism No of isolates (%)
Candida albicans 151 (63.71)
Candida tropicalis 34 (14.34)
Candida krusei 27 (11.39)
Candida parapsilosis 25 (10.54)
Total 237
Out of the 237 Candida species isolated 151 (63.71%) were Germ tube positive and were identified as Candida albicans. The other species of Candida were C.tropicalis 34 (14.34%) followed by C. krusei 27 (11.39%), Candida parapsilosis 25 (10.54%), respectively.
Table: 2 Species of Candida isolated from HIV positive patients on ART
Species of Candida Isolates Percentage
C. albicans 53 67.94
C. krusei 13 16.66
C. tropicalis 7 8.97
C. parapsilosis 5 6.41
Table: 3 Species of Candida isolated from HIV positive patients not on ART
Species of Candida Isolates Percentage
C. albicans 97 61.00
C. tropicalis 25 15.72
C. krusei 17 10.69
C. parapsilosis 20 12.57
Candida albicans was the most prevalent species isolated from HIV patients on ART 53 (67.94%) and those not on ART 97 (61.00%). Other species of Candida isolated from patients on ART were C. krusei 13 (16.66%), C. tropicalis 7 (8.97%) and C. parapsilosis 5 (6.41%).Whereas Candida albicans 97 (61%), C. tropicalis 25 (15.72%), C. parapsilosis 20 (12.57%) and C. krusei 17 (10.69%) were isolated from those HIV positive patients who were not receiving ART.
DISCUSSION
102 Int J Res Med. 2015; 4(2);100-104 e ISSN:2320-2742 p ISSN: 2320-2734 isolatedyeasts in clinical laboratories from
HIV/AIDS patients 13.
Studies have shown that this organism can account for up to 75% of the yeasts recovered from sites of infection. Rapid identification of candidiasis is important for the clinical management of immunocompromised patients 14. During the course of HIV infection, the rate of Candida infection is inversely related to the CD4 counts of the patient which in turn depends on the use of Anti-retroviral treatment 6. The result of this study provides evidence of the isolation of Candida species of HIV infected persons on Antiretroviral Therapy (ART) as well as in those not on ART. The current isolation rate of C. albicans in HIV patients on ART was 53 (67.94%) close to Soa Paulo, Brazil (66.4%)15 and Ethiopia 61.8%5 and were much lower than the reports of Iran 82.2%4 Germany 74.8% 16 and higher than reports from Hongkong 54.8 % 17 and Nigeria 34.4% 18 HIV patients whether on ART or not on ART are predisposed to candidiasis infection. In this study those patients who were on ART suffered from candidiasis were 53 (67.94 %) and those who were not on ART suffered from candidiasis infection were 97 (61%). This does not agree with most studies, as reported that following the introduction of ART there was reduction in occurrence of opportunistic infections, prevalence of oral manifestation and oral candidiasis19. Arribas et al also suggested that the reduction in the frequency of candidiasis was only related to immunological improvement after introduction of antiretroviral therapy including protease inhibitor (P1), which increase the number of CD4+ cells 20. However, some HIV positive patients with relatively high CD4+ cell counts develop candidiasis
6
.This is similar to report of Hamza et al that Candida species can be found in both HIV positive and HIV negative patients with some significant difference 21.
In respect of the other species of Candida, C. albicans was the most frequently isolated species. This confirms the finding of this study with other studies like Enwuru et al (40.5%) 22, Rejane et al
(57.4%)23 in Lagos and Brazil respectively. Similarly Nweze and Ogbonnaya in Nigeria24 isolated C. albicans in 60% of the samples followed by C. tropicalis, C. parapsilosis and C. guillerimondi. Costa et al reported that C. albicans presented the highest frequency (50%) followed by C. tropicalis (20.9%), C. parapsilosis (19.3%), C. guillerimondi (4.8%) C. krusei (1.6%)25. In this study C. albicans presented the highest frequency (67.94%) followed by C. krusei (12.82%), C. tropicalis (8.97%), C. parapsilosis (6.41%).
Candida albicans still remains the leading cause of candidiasis in HIV infected person whether on ART or not. Therefore it is essential to diagnosis and identifying the organism at species level in order to guide treatment.
CONCLUSION
Several species of Candida infection occurs in patients with HIV irrespective of the patients receiving ART or not. Although CD4 count is an important marker for considering starting ART or not, it is important that all patients should be routinely screened for candidiasis as it helps to monitor disease progression and it also prevents complications like Candidemia. Identifying Candida to its species level is important because it helps in guiding appropriate treatment. Clinicians must be aware of the wide breath of debilitating conditions in which Candidemia can arise in the management of systemic fungal infections.HIV patients not on ART should also be screened for candidiasis as presence of it in such individuals could be an indication to start ART.
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