Association between oral candidiasis and low CD4+ count among HIV positive patients in Hoima Regional Referral Hospital

Prevalence of Oropharyngeal Candidiasis and distribution of Candida species among People Living with Human Immunodeficiency Virus in Africa: a systematic review and meta-analysis

Background

The incidence of oropharyngeal candidiasis among people living with human immunodeficiency virus in Africa is on the rise. Oropharyngeal candidiasis is mainly caused by C.albicans; however, a shift in the etiology towards non-Candida albicans species is increasing. In addition, there are variations in the epidemiological distribution of Candida species causing oropharyngeal candidiasis among people living with human immunodeficiency virus in Africa.

Objective

This review aimed to determine the prevalence of oropharyngeal candidiasis and the distribution of Candida species among people living with human immunodeficiency virus in Africa.

Materials and Methods

This systematic review protocol was registered in the base PROSPERO database prior to its conduct (CRD42021254473). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol guidelines (PRISMA-P) were followed for this study. The PubMed, Scopus and EMBASE databases were searched to identify published studies published between 1st January 2000 and 8th October 2022. The eligible studies were included in the meta-analysis and analyzed using a random effects model. The risk of bias of the included studies was assessed using the Joanna Briggs Institute quality assessment tool for prevalence studies.

Results

The database search yielded 370 titles from PubMed (n=192), EMBASE (n=162) and SCOPUS (n=16). Fourteen studies with a total of 3,863 participants were included in the meta-analysis. The pooled prevalence of oropharyngeal candidiasis was 49.0% (95% CI: 37% - 62%). A total of 2,688 Candida isolates were reported; approximately 76.6% (n=2,060) were C. albicans, and 21.7% (n=582) were non-C. albicans. Among the non-Candida albicans species, C. glabrata was the most common isolate (29.6%), followed by C. tropicalis (27.7%), C. krusei (17.0%), C. parapsilosis (8.1%) and C. dubliniensis (5.2%). Out of 14 studies, 7 (50.0%) had a low risk of bias, 5 (35.7%) had a moderate risk of bias, and 2 (14.3%) had a high risk of bias.

Conclusion

Almost half of people living with HIV in Africa have oropharyngeal candidiasis, and C. albicans remains the most frequent cause of oropharyngeal candidiasis.

Distribution and antifungal susceptibility profile of oropharyngeal Candida species isolated from people living with HIV in the era of universal test and treat policy in Uganda

Background

Despite the increased frequency of oropharyngeal candidiasis among people living with human immunodeficiency virus (HIV), its management is no longer effective due to empirical treatment and emergence of antifungal resistance (AFR). This study sought to investigate the prevalence of oropharyngeal candidiasis and assess the antifungal susceptibility profile of oropharyngeal Candida species isolated from people living with human immunodeficiency virus. Additionally, we evaluated the correlation between oropharyngeal candidiasis and CD4 T cell as well as viral load counts.

Methods

A descriptive cross-sectional study was carried out from April to October 2023 in which 384 people living with HIV underwent clinical examination for oral lesions. Oropharyngeal swabs were collected and cultured on Sabouraud Dextrose agar to isolate Candida species which were identified using the matrix assisted laser desorption ionization time of flight mass spectrometry. Additionally, the antifungal susceptibility profile of Candida isolates to six antifungal drugs was determined using VITEK® (Marcy-l'Étoile, France) compact system. Data on viral load were retrieved from records, and CD4 T cell count test was performed using Becton Dickinson Biosciences fluorescent antibody cell sorter presto.

Results

The prevalence of oropharyngeal candidiasis was 7.6%. Oropharyngeal candidiasis was significantly associated with low CD4 T cell count and high viral load. A total of 35 isolates were obtained out of which Candida albicans comprised of 20 (57.1%) while C. tropicalis and C. glabrata comprised 4 (11.4%) each. C. parapsilosis, C. dubliniensis and C. krusei accounted for 2 (5.7%) each. Additionally, 7 (20%) isolates were resistant to fluconazole, 1 (2.9%) to flucytocine and 0.2 (5.7%) isolates were intermediate to caspofungin. However, specific specie isolates like C. albicans showed 20% (4/20), C. glabrata 50% (2/4) and C. krusei 50% (1/2) resistance to fluconazole. Additionally, C. krusei showed 50% resistance to flucytosine.

Conclusion

The prevalence of oropharyngeal candidiasis (OPC) among people living with HIV was low, and there was a significant association between OPC and CD4 T cell count as well as viral load. C. albicans was the most frequently isolated oropharyngeal Candida species. C. glabrata and C. krusei exhibited the highest AFR among the non-albicans Candida species. The highest resistance was demonstrated to fluconazole.

Pneumocystis jirovecii Pneumonia in a Patient With Newly Diagnosed HIV and a High CD4 Count

Pneumocystis jirovecii pneumonia (PCP) is a rare, life-threatening opportunistic fungal infection that rarely occurs with CD4 counts greater than 200 cells/mm3. We present a case of PCP in a young male who presented with fever, weakness, dyspnea, and a non-productive cough. He was initially treated for community-acquired pneumonia but was then noted to be HIV positive with signs of immunosuppression such as oral thrush. The CD4 count was found to be very high, at 646 cells/mm3 and 281 cells/mm3 on repeat. The patient was treated with trimethoprim/sulfamethoxazole (TMP/SMX) and fluconazole and further started on highly active antiretroviral therapy (HAART) with TMP/SMX as a means of secondary prophylaxis in the outpatient setting.

COVID-19 Infection as an Exacerbated Factor of Oral Candidiasis in HIV/AIDS Patient

Introduction

Oral candidiasis is an oral mucosal infection caused by Candida sp. This infection can appear in patients with HIV/AIDS associated with immunodeficiency. Another factor that can aggravate the occurrence of oral candidiasis is the COVID-19 infection caused by the SARS-CoV-2 virus as a current pandemic condition. This case report aims to explain the mechanism of COVID-19 infection as a factor that can aggravate the condition of oral candidiasis in HIV/AIDS patients.

Case

A 56-year-old male patient was consulted from the COVID-19 isolation unit to the Department of Oral Medicine with complaints of sore and uncomfortable mouth related to white plaque covering the surface of the tongue. The patient was diagnosed with HIV/AIDS and had a COVID-19 infection. The management instructions were to maintain oral hygiene, administration of antifungal drugs such as nystatin oral suspension and fluconazole, chlorhexidine gluconate 0.2% mouthwash, and vaseline album.

Discussion

Generally, HIV/AIDS patient has dysregulation of the immune system which can suppress host immunity to fight pathogens, making it easy for opportunistic infections such as oral candidiasis. The COVID-19 infection can cause lymphopenia conditions that further reduce the host's ability to fight pathogens. The SARS-CoV-2 virus can also directly attack various tissues in the oral mucosa which can contribute to exacerbating the severity of oral candidiasis in HIV/AIDS patients.

Conclusion

The COVID-19 infection is a factor that can exacerbate the condition of oral candidiasis in HIV/AIDS patients by further decreasing the host's immunity and damaging various tissues in the oral mucosa.

Epidemiology, prevalence, and associated factors of oral candidiasis in HIV patients from southwest Iran in post-highly active antiretroviral therapy era

Background

Oral candidiasis (OC) is one of the most common opportunistic fungal infections among people living with HIV/AIDS (PLWHA). The prevalence of OC and Candida profiles among HIV-infected patients might be changing in the era of Highly Active Antiretroviral Therapy (HAART). This study aimed to identify Candida spp., determine OC prevalence and associated risk factors for PLWHA.

Materials and methods

Oral candidiasis prevalence was explored in oral swabs of 276 patients who referred for consultation at Behavioral Diseases Counseling Center (BDCC). Clinical symptoms, culture and molecular assays were used for OC detection. In statistical analysis, we assessed socio-demographic characteristics, clinical information and treatment history of some infections.

Results

The overall prevalence of OC was 41%. Candida albicans (64.6%) was the most common species, followed by C. glabrata (26.5%) and C. dubliniensis (19.5%). Candida famata, C. africana, and C. stellatoidea as the first fungi isolated from OC in PLWHA from southwest Iran. In 36.3% of patients, mixed cultures of more than one species were observed. Body mass index (BMI) (OR = 0.947; CI = 0.89–0.99; p = 0.045) and CD4 count ≤ 200 cells/mm3 (OR = 4.365; CI = 1.73–10.98; p = 0.002) were the predictors of OC in the final model of multiple logistic regression analysis. Education level, addiction status, sexual behaviors, chest X-ray, other infections and WHO clinical stage were other important risk factors for OC.

Conclusion

Oral candidiasis remains a significant opportunistic infection in post-HAART era among PLWHA. Despite the increasing prevalence of NAC species, C. albicans (64.6%) was still the predominant species. Our results showed that low BMI with OC indicates treatment failure (i.e., failure to increase CD4 count or suppress viral load). Also, low CD4 counts (≤200 cells/mm3) in HIV patients show an impaired immune status, and our findings emphasize that OC can be a clinical indicator of HIV infection in individuals who do not know their HIV status or have failed treatment.

The Role of the Oral Immune System in Oropharyngeal Candidiasis-Facilitated Invasion and Dissemination of Staphylococcus aureus

Candida albicans and Staphylococcus aureus account for most invasive fungal and bacterial bloodstream infections (BSIs), respectively. However, the initial point of invasion responsible for S. aureus BSIs is often unclear. Recently, C. albicans has been proposed to mediate S. aureus invasion of immunocompromised hosts during co-colonization of oral mucosal surfaces. The status of the oral immune system crucially contributes to this process in two distinct ways: firstly, by allowing invasive C. albicans growth during dysfunction of extra-epithelial immunity, and secondly following invasion by some remaining function of intra-epithelial immunity. Immunocompromised individuals at risk of developing invasive oral C. albicans infections could, therefore, also be at risk of contracting concordant S. aureus BSIs. Considering the crucial contribution of both oral immune function and dysfunction, the aim of this review is to provide an overview of relevant aspects of intra and extra-epithelial oral immunity and discuss predominant immune deficiencies expected to facilitate C. albicans induced S. aureus BSIs.

Relationship between CD4+ count, serum inflammatory cytokines, and oral melanotic hyperpigmentation in newly diagnosed HIV-seropositive patients: a nested case-control study

OBJECTIVE

Oral melanotic hyperpigmentation (OMH) in patients with human immunodeficiency virus (HIV) infection has been attributed to the use of antifungal or antiretroviral drugs, as well as HIV-induced cytokine dysregulation. This research aimed to determine the relationship between immunosuppression and cytokine dysregulation in newly diagnosed HIV-seropositive subjects with OMH.

STUDY DESIGN

The study was conducted among newly diagnosed HIV-seropositive patients at the Infectious Disease Clinic, Ibadan, Nigeria. The cases were patients with OMH matched for age and sex with control subjects without OMH. CD4⁺ count and cytokine levels (interleukin-6 and tumor necrosis factor-α) were compared between the cases and control subjects. SPSS version 21 software was used for data analysis.

RESULTS

Seventy newly diagnosed HIV-seropositive patients were studied, which comprised of 35 cases and 35 control subjects. The median CD4⁺ counts for cases and control subjects were 174 cells/mm³ (interquartile range [IQR], 57-250) and 324 cells/mm³ (IQR, 107-424), respectively. Severe immunosuppression (CD4⁺ count, ≤200 cells/mm³) was found in over half of the study participants, being more prevalent among the cases than among the control group (P = .019). Serum cytokine levels did not significantly vary between the cases and control subjects.

CONCLUSIONS

There was a significant association between HIV-OMH and severe immunosuppression in the newly diagnosed HIV-seropositive patients.

Association of oral candidal species with human immunodeficiency virus patients of West Godavari district, Andhra Pradesh - An in vitro study

Introduction:

Human immunodeficiency virus (HIV) infection is a major worldwide health problem characterized by progressive immunosuppression. The morbidity of HIV patients is due to its association with opportunistic infections among which oral candidiasis is common. Regardless of HIV status, candidiasis can prevail when their immune system is depressed. Oral candidiasis can thus serve as a useful marker for both restoration of immune functions and HIV disease progression. Routine identification of Candida species is laborious and time-consuming. HICHROM agar stains different species into different colors facilitating rapid reliable identification of candida species as they differ in their virulence and sensitivity to antifungal drugs.

Materials and Methods:

This cross-sectional study includes a total of 200 HIV seropositive patients from Anti-Retroviral Therapy Centre, West Godavari District. Unstimulated saliva samples were collected in a screw-capped universal container. Five microliters of each sample using a sterile inoculating loop is streaked on the chromogenic agar culture media. The colonies formed are counted using a magnifying glass and LAPIZ colony counter. Candidal colony-forming units per milliliter were analyzed, compared and correlated among different study groups. Different candida species were also identified in the study.

Results:

Nonalbicans Candida was the most common species isolated in our study accounting for 53% and Candida albicans accounting for 47%. Considering initial and final CD4 counts, there is improvement in patients on retroviral therapy.

Conclusion:

Identification of the species is important for epidemiological reasons and for treatment purposes to ensure a better prognosis since some species present reduced susceptibility to azoles.

Oro-facial opportunistic infections and related pathologies in HIV patients: A comprehensive review

Among all the viral infections, acquired immunodeficiency syndrome (AIDS) is considered as one of the most morbid infections caused by the human immunodeficiency virus (HIV). The prime reason for the pathogenesis is the profound immunosuppression that leads to lethal opportunistic infections (OI), neurological disorders, unexpected malignancies and pathologies of the orofacial region. Patients with OI whose HIV status is unknown have shown a mortality rate higher than those with known HIV status. Among HIV-associated infections, orofacial lesions contribute a major proportion of the OI attributed to the plethora of micro-organisms present in the oral cavity. Apart from serious clinical manifestations, opportunistic infections also lead to significant impairment of quality of life. These lesions not only indicate the HIV infection but also among the clinical manifestations, which often occur early in the course of disease. World Health Organization has also provided policies for treatment/prevention of oral lesions, strengthening the promotion and care of oral health in HIV/AIDS patients. The present review provides comprehensive information about orofacial OI in HIV/AIDS patients and emphasis was also given to the malignancies associated with EB and HTLV virus.

Oral colonization by Candida species and associated factors in HIV-infected patients in Ahvaz, southwest Iran

OBJECTIVES

Oropharyngeal candidiasis is one of the most common opportunistic fungal infections among human immunodeficiency virus (HIV)-infected individuals. The most common cause is Candida albicans, followed by non-albicans Candida. This study aimed to identify colonized Candida species in HIV-infected patients from Ahvaz, Iran. Additionally, the relationships between immunity-related factors, lifestyle, and colonization of Candida spp. were studied.

METHODS

Oral swabs were taken from 201 HIV-positive patients referred for consultations at the Behavioral Modification Center. Oral Candida colonization was detected using culture-based and molecular assays. Data were assessed by descriptive statistics and analyzed to investigate the correlation between Candida colonization and various factors, including the CD4⁺ cell count and viral load.

RESULTS

It was found that 43.8% of patients were positive for Candida. The most common species was C. albicans (48.0%), followed by non-albicans Candida isolates, including C. dubliniensis, C. glabrata, C. tropicalis, C. parapsilosis, C. guilliermondii, C. kefyr, and C. krusei. Colonization of Candida spp. in patients was associated with a CD4 count ≤200 cells/mm³ (odds ratio [OR], 4.62; p<0.05), history of shared injections (OR, 6.96; p<0.001), and sex (OR, 3.59; p<0.05).

CONCLUSIONS

The results of this study showed that C. albicans was the dominant pathogen. The risk factors for colonization of Candida spp. were a CD4 count ≤ 200/mm³ , a history of shared injections, and sex. Other factors with potential relationships include viral load, age, and opportunistic infections, but further investigations are needed.

Factors Associated with Oral Candidiasis in People Living with HIV/AIDS: A Case Control Study

Background

Oral candidiasis (OC) is the most frequent opportunistic infection of the oral cavity caused by Candida species overgrowth. A wide variety of risk factor that contributes to yeast infection especially candidiasis. It might be acting as an early marker for people living with HIV/AIDS (PLWHA). There are some risk factors for PLWHA associated OC at Wangaya hospital in Denpasar, Bali, Indonesia.

Aim

To identify risk factors of OC in PLWHA at Wangaya Hospital in Denpasar, Bali, Indonesia.

Settings and Design

Case control study was conducted from March 1, 2016 and July 30, 2019, included 448 participants (207 cases and 241 controls). Consecutive recruitment was employed.

Methods

Cases were PLWHA (18 to 60 years old) with OC and controls without OC. Diagnosis of OC based on the clinical features which are the pseudomembranous candidiasis; oral thrush. An interviewer administered a structured questionnaire used to collect information on risk factors. Statistical analysis used: bivariate analysis was performed on all variables. Chi-square test with statistically significant was at a level of 0.05.

Results

The participants included 207 (46.20%) PLWHA with OC and 241 (53.80%) PLWHA who did not have OC. The majority participants, 293 (65.40%) were male. OC was associated with age [p = 0.03; OR = 0.66 (95% CI:0.45-0.95)]; sex [p = 0.002; OR = 1.88 (95% CI:1.26-2.80)]; Xerostomia [p = 0.000; OR = 4.15 (95% CI:2.76-6.23)]; smoking [p = 0.000; OR = 6.83 (95% CI: 4.46-10.44)]; alcohol consumption [p = 0.000; OR = 5.76 (95% CI: 3.74-8.83)]; antibiotic usage [p = 0.000; OR = 4.49 (95% CI: 2.93-6.90)]; CD4 count [p = 0.000; OR = 3.29 (95% CI:2.24-4.86)]; HIV clinical stage [p = 0.000; OR = 3.58 (95% CI 2.39-5.37)]. No significant association between prothesis with OC.

Conclusion

We found that age, sex, xerostomia, smoking, alcohol consumption, antibiotic usage, CD4 counts and advanced HIV Clinical stage (AIDS) were significant associated risk factors for OC in PLWHA.

Oral candidiasis among African human immunodeficiency virus-infected individuals: 10 years of systematic review and meta-analysis from sub-Saharan Africa

Oral candidiasis (OC) is the most common opportunistic fungal infection among immunocompromised individuals. This systematic review and meta-analysis reports on the contribution of non-albicans Candida species in causing OC among human immunodeficiency virus (HIV)-infected individuals in sub-Saharan Africa between 2005 and 2015. Thirteen original research articles on oral Candida infection/colonization among HIV-infected African populations were reviewed. The prevalence of OC ranged from 7.6% to 75.3%. Pseudomembranous candidiasis was found to range from 12.1% to 66.7%. The prevalence of non-albicans Candida species causing OC was 33.5% [95% confidence interval (CI) 30.9–36.39%]. Of 458 non-albicans Candida species detected, C. glabrata (23.8%; 109/458) was the most common, followed by C. tropicalis (22%; 101/458) and C. krusei (10.7%; 49/458). The overall fluconazole resistance was 39.3% (95% CI 34.4–44.1%). Candida albicans was significantly more resistant than non-albicans Candida species to fluconazole (44.7% vs 21.9%; p < 0.001). One-quarter of the cases of OC among HIV-infected individuals in sub-Saharan Africa were due to non-albicans Candida species. Candida albicans isolates were more resistant than the non-albicans Candida species to fluconazole and voriconazole. Strengthening the capacity for fungal diagnosis and antifungal susceptibility testing in sub-Saharan Africa is mandatory in order to track the azole resistance trend.

In Vitro and In Vivo Antifungal Activity of Lichochalcone-A against Candida albicans Biofilms

Oral candidiasis (OC) is an opportunistic fungal infection with high prevalence among immunocompromised patients. Candida albicans is the most common fungal pathogen responsible for OC, often manifested in denture stomatitis and oral thrush. Virulence factors, such as biofilms formation and secretion of proteolytic enzymes, are key components in the pathogenicity of C. albicans. Given the limited number of available antifungal therapies and the increase in antifungal resistance, demand the search for new safe and effective antifungal treatments. Lichochalcone-A is a polyphenol natural compound, known for its broad protective activities, as an antimicrobial agent. In this study, we investigated the antifungal activity of lichochalcone-A against C. albicans biofilms both in vitro and in vivo. Lichochalcone-A (625 μM; equivalent to 10x MIC) significantly reduced C. albicans (MYA 2876) biofilm growth compared to the vehicle control group (1% ethanol), as indicated by the reduction in the colony formation unit (CFU)/ml/g of biofilm dry weight. Furthermore, proteolytic enzymatic activities of proteinases and phospholipases, secreted by C. albicans were significantly decreased in the lichochalcone-A treated biofilms. In vivo model utilized longitudinal imaging of OC fungal load using a bioluminescent-engineered C. albicans (SKCa23-ActgLUC) and coelenterazine substrate. Mice treated with lichochalcone-A topical treatments exhibited a significant reduction in total photon flux over 4 and 5 days post-infection. Similarly, ex vivo analysis of tongue samples, showed a significant decrease in CFU/ml/mg in tongue tissue sample of lichochalcone-A treated group, which suggest the potential of lichochalcone-A as a novel antifungal agent for future clinical use.