A Cross sectional Study on Clinicomycological Aspects of Mucocutaneous Candidiasis in a Tertiary Care Center

Background: Candida is an ubiquitious organism causing superfi cial fungal infections that are commonly encountered in clinical practice. The knowledge of the change in the epidemiology, clinical spectrum and antifungal susceptibility may aid for the appropriate treatment decisions. Aim and Objective: To identify different candida species from various clinical patterns of mucocutaneous candidiasis Materials and Methods: A cross sectional study was conducted on 100 randomly selected patients with symptoms and signs of mucocutaneous candidiasis attending the OPD, Mycology section of Dermatology Department. Under aseptic conditions sample collection was done by skin scraping, vaginal and oral swabs. The collected samples were treated with 10% KOH and examined under the light microscope for the presence of pseudohyhae. Culture in SDA, subculture in Hichrome agar and sugar fermentation tests were done for all patients with positivity for candida in 10% KOH examination. Results: Mucosal candidiasis was found in 82 patients and 18 patients had cutaneous candidiasis. The minimum age group affected was a one month old infant and maximum age group affected was 70 years. There was a female predominance with 73% and males were 27% (M:F ratio 1:2.7). Oral candidiasis was detected in 48 patients, followed by Vulvovaginal candidiasis in 32 patients, Balanoposthitis, intertrigo toe cleft and intertrigo fi nger webspace in 2 patients each. Pseudomembranous candidiasis was present in 30 patients (62.5%), followed by angular cheilitis 10 patients (20.8%) and acute erythematous type in 8 patients (16.7%). Immunosuppression was the major predisposing factor found in 67% of patients. Among the immunosuppressed, 52 patients (77.61%) had diabetes mellitus, 29 patients (43.28%) were on immunosuppressives for various conditions like pemphigus vulgaris, bullous pemphigoid, Systemic lupus erythematoses, multicentric reticulohistiocytosis, pustular psoriasis and post renal transplant state. Nonalbicans species was isolated in 63%, of which C.tropicalis was isolated in 45 patients followed by C.glabrata in 9 patients, C.krusei in 8 patients and C.parapsilosis in 1 patient and C.albicans species constituted 37%. Conclusion: Mucosal candidiasis were more common than cutaneous candidiasis. Nonalbicans species were the most common isolate of which C.tropicalis were isolated in higher number than C.albicans. Research Article A Cross sectional Study on Clinicomycological Aspects of Mucocutaneous Candidiasis in a Tertiary Care Center Subhashini Mohan1*, R Madhu2 and C Janaki3 1Assistant Professor Dermatology, ESIC Medical College, KK nagar, Chennai, Tamilnadu India 2Assistant Professor Dermatology, Madras Medical College, Chennai, Tamilnadu, India 3Former Professor of Dermatology, Madras Medical College, Chennai, Tamilnadu, India Received: 10 October, 2018 Accepted: 01 November, 2018 Published: 02 November, 2018 *Corresponding author: Subhashini Mohan, Assistant Professor Dermatology, ESIC Medical College , KK nagar, Chennai , Tamilnadu, India, Email:


Introduction
Candidiasis refers to a diverse group of infections caused by the yeasts of genus Candida which have been known for centuries. These organisms usually cause superfi cial infections involving the skin, nail, mucous membrane but can also produce serious systemic infections like septicemia, endocarditis and meningitis in immunosuppressed individuals [1]. Candida species constitute a part of the normal fl ora of the digestive system and the female genital tract. Colonization with these organisms may occur during birth or later in life [1,2].
In healthy individuals, such colonization is asymptomatic and their overgrowth is limited by the immune system and other bacteria occupying the gastrointestinal tract and vagina. When the immune system is deranged or an alteration in the ecology occurs, there is overgrowth of these organisms producing infection [1,2]. There are over 200 species of Candida till date and their epidemiology is constantly changing with varying clinical patterns, virulence and antifungal susceptibility [2]. and systemic antifungals for 4 weeks were excluded from the study.

Mycological examination
Specimens from mucosal and cutaneous scrapings were examined in 10% potassium hydroxide (KOH) solution for the presence of fungal spores, hyphae and pseudohyphae (Figure1).
The rate of culture positivity for candidiasis in SDA was 100% in our study.Inoculation was done on Sabouraud's dextrose agar (SDA) with chloramphenicol (0.005mg/ml) at 37 0 C and was observed every day for the growth of candidial colonies which appeared as white or cream colored, smooth with a yeasty odour ( Figure 2). Hichrome media was used for species identifi cation which was by the production of different colors and corn meal agar was used for detection of chlamydospores ( Figure 3). Germ tube test was done by incubating the colonies with human serum at 37 0 C for two hours and observed for the formation of germ tube under light microscope ( Figure 4).
Sugar fermentation using glucose, lactose, sucrose, maltose and galactose were also carried out to differentiate between the various species.

Interpretation
Candida produces an enzyme beta-N-acetyl galactosaminidase/hexosaminidase into the growth media which helps in identifi cation of Candida. Hichrome media is a selective and differential media which facilitates rapid isolation of yeasts from mixed cultures and allows differentiation on the basis of colonization and colony morphology. The subspecies identification was done based on the colour of the colony (Table 1) ( Figures 5,6).

Clinical patterns
Mucosal candidiasis was found in 82 patients and 18 patients had cutaneous candidiasis. The minimum age group affected was a one month old infant and maximum age group affected was 70 years. There was a female predominance with 73% and males were 27% (M:F ratio 1:2.7).
Immunosuppression was the major predisposing factor found in 67% of patients.Among the immunosuppressed, 52 patients
In HIV pateints with oral candidiasis, C.albicans was isolated commonly followed by C.tropicalis. This is similar to a study by Ranganathan et al who reported C. albicans as the common agent followed by C.tropicalis [14]. reported C.albicans to be common followed by C.glabrata [17,18].

C.glabrata was commonly isolated in diabetic individuals by
Goswami et al [19]. Ritcher et al described C.albicans to be the most common in recurrent VVC followed by C.glabrata [20]. The predisposing factors among patients with intertriginous lesions were found to be hot humid climate, excessive sweating and obesity. Prolonged immersion in water was the predisposing factor noted in these patients.
Further, in the present study C.glabrata has been isolated exclusively in immunosuppressed individuals in mucosal candidiasis. C.krusei was isolated almost in equal proportion in mucosal and cutaneous samples. C.parapsilosis was isolated in a single patient with vulvovaginal candidiasis. Bauters et al described isolation of C.parapsilosis in 8.9% of vaginal candidiasis patients [21]. The isolation of C.tropicalis higher than C.albicans has not been reported in mucocutaneous samples. But there have been increasing reports of C.tropicalis in other sites such as blood stream and urine samples. Blood stream infections by C.tropicalis more than C.albicans has been reported by Kothari et al, Shivprakasha et al and Adhikari et al [22][23][24]. C.tropicalis higher than C.albicans has been reported in neonatal septicemia by Rani et al [25,26]. These reports imply an increase in the incidence of nonalbicans species especially C.tropicalis in Indian subcontinent. This unexplained increase of this species had led many researchers to undertake DNA studies. Dassanayake et al has demonstrated the evolutionary divergence of distinct genetic subgroups in C.tropicalis using DNA fi nger printing studies [27].

Conclusion
In summary, Mucosal candidiasis were more common than cutaneous candidiasis. Nonalbicans species were the most common isolate of which C.tropicalis were isolated in higher number than C.albicans. However, further studies in larger population would provide conclusive information on the changing epidemiology of mucocutaneous candidiasis.