Optimal management of oropharyngeal and esophageal candidiasis in patients living with HIV infection

Oral Candida in post-radiotherapy patients with xerostomia/hyposalivation: A narrative review

OBJECTIVE

Head and Neck Cancer (HNC) patients receiving radiotherapy (RT) often suffer from xerostomia and/or hyposalivation. As saliva plays an important antimicrobial and cleansing roles, these patients are at higher risks of opportunistic infections. This narrative review aims to provide an overview of current evidence on oral Candida colonisation and infection in these patients.

METHODS

A literature review of clinical studies on oral Candida colonisation and candidiasis in HNC patients receiving radiotherapy/chemoradiotherapy was conducted.

RESULTS

Many clinical studies found high levels of Candida colonisation and a substantial proportion of post-RT HNC patients suffering from oropharyngeal candidiasis (OPC). Importantly, oral Candida could be a reservoir for life-threatening systemic infection in immunocompromised patients. The rising prevalence of non-albicans Candida species and drug-resistant infections has made identification of Candida species and antifungal susceptibility more important. Recent advances in oral microbiome and its interactions with Candida are discussed. This review also offers perspectives on limitations of current evidence and suggestions for future research.

CONCLUSION

Further research to better understand Candida carriage, microbiome, OPC, and xerostomia/hyposalivation post-RT would aid in devising a more comprehensive long-term management plan and novel therapeutic approaches for HNC patients to achieve the full benefits of RT while minimising side effects.

Candida albicans skin infection in diabetic patients: An updated review of pathogenesis and management

Candida species, commensal residents of human skin, are recognized as the cause of cutaneous candidiasis across various body surfaces. Individuals with weakened immune systems, particularly those with immunosuppressive conditions, are significantly more susceptible to this infection. Diabetes mellitus, a major metabolic disorder, has emerged as a critical factor inducing immunosuppression, thereby facilitating Candida colonization and subsequent skin infections. This comprehensive review examines the prevalence of different types of Candida albicans-induced cutaneous candidiasis in diabetic patients. It explores the underlying mechanisms of pathogenicity and offers insights into recommended preventive measures and treatment strategies. Diabetes notably increases vulnerability to oral and oesophageal candidiasis. Additionally, it can precipitate vulvovaginal candidiasis in females, Candida balanitis in males, and diaper candidiasis in young children with diabetes. Diabetic individuals may also experience candidal infections on their nails, hands and feet. Notably, diabetes appears to be a risk factor for intertrigo syndrome in obese individuals and periodontal disorders in denture wearers. In conclusion, the intricate relationship between diabetes and cutaneous candidiasis necessitates a comprehensive understanding to strategize effective management planning. Further investigation and interdisciplinary collaborative efforts are crucial to address this multifaceted challenge and uncover novel approaches for the treatment, management and prevention of both health conditions, including the development of safer and more effective antifungal agents.

Changing Paradigm of Yeast Isolates in HIV-Seropositive Patients with Oropharyngeal Candidiasis (OPC)

Background Oropharyngeal candidiasis (OPC) is a common fungal infection in HIV-seropositive patients. Understanding the spectrum of yeast isolates and their antifungal susceptibility patterns is crucial for effective management. This study aimed to determine the yeast isolates, antifungal susceptibility patterns, and associated factors in HIV-seropositive patients with OPC. Material and methods A prospective observational study was conducted on 350 HIV-seropositive patients attending an Integrated Counselling and Testing Centre (ICTC) at the Indira Gandhi Institute of Medical Sciences (IGIMS), Patna, Bihar. Yeast isolates from oropharyngeal lesions were identified, and their antifungal susceptibility was determined by automated method VITEK 2. Demographic characteristics, highly active antiretroviral therapy (HAART) status, and CD4+ cell count categories were analyzed for associations. Results This study of 350 HIV-seropositive patients revealed that 100 tested positive for Candida, with distinct differences between HAART (n=67) and non-HAART (n=33) groups. HAART patients had a younger age distribution and higher median CD4+ cell counts (350 vs. 250 cells/mm³, U = 175, p < 0.05) compared to non-HAART patients. Candida albicans was the most common species in both groups, but significant variations in species distribution (χ² = 9.23, p < 0.05) and antifungal susceptibility were noted. Specifically, susceptibility differences were significant for flucytosine (χ² = 7.21, p = 0.027) and voriconazole (χ² = 8.64, p = 0.013), emphasizing the influence of HAART on managing immune function and antifungal resistance in HIV patients. Conclusion This study provides insights into the spectrum of yeast isolates and their antifungal susceptibility patterns in HIV-seropositive patients with OPC. The findings emphasize the importance of considering multiple factors, such as Candida species, HAART status, and individual patient characteristics, in treatment decisions. The results will aid in the development of evidence-based management protocols for this vulnerable population. Further research is warranted to explore additional factors influencing antifungal susceptibility and optimize treatment strategies for this patient population.

Superficial Dermatophytosis across the World's Populations: Potential Benefits from Nanocarrier-Based Therapies and Rising Challenges

The most prevalent infection in the world is dermatophytosis, which is a major issue with high recurrence and can affect the entire body including the skin, hair, and nails. The major goal of this Review is to acquire knowledge about cutting-edge approaches for treating dermatophytosis efficiently by adding antifungals to formulations based on nanocarriers in order to overcome the shortcomings of standard treatment methods. Updates on nanosystems and research developments on animal and clinical investigations are also presented. Along with the currently licensed formulations, the investigation also emphasizes novel therapies and existing therapeutic alternatives that can be used to control dermatophytosis. The Review also summarizes recent developments on the prevalence, management approaches, and disadvantages of standard dosage types. There are a number of therapeutic strategies for the treatment of dermatophytosis that have good clinical cure rates but also drawbacks such as antifungal drug resistance and unfavorable side effects. To improve therapeutic activity and get around the drawbacks of the traditional therapy approaches for dermatophytosis, efforts have been described in recent years to combine several antifungal drugs into new carriers. These formulations have been successful in providing improved antifungal activity, longer drug retention, improved effectiveness, higher skin penetration, and sustained drug release.

Evaluation and comparison of antifungal effect of voriconazole with nystatin on candida species derived from neoplastic patients undergoing maxillofacial radiotherapy

Background

Radiotherapy is a common treatment for head-and-neck malignancies and causes complications such as oral candidiasis and the change of oral Candida species from albicans to nonalbicans. Voriconazole has acceptable antifungal effect. The aim of this study was to determine and compare the antifungal effect of nystatin with voriconazole on these species.

Materials and Methods

The samples used in this in vitro study were identified by polymerase chain reaction-restriction fragment length polymorphism from patients before and 2 weeks after head-and-neck radiotherapy in Seyed Al-Shohada Hospital. The antifungal effect of nystatin and voriconazole was determined by microdilution method and measurement of the minimum inhibitory concentration (MIC) and the minimum fungicidal concentration, and the results were analyzed by Mann-Whitney analysis.

Results

The results showed that all species before and after radiotherapy showed 100% sensitivity to nystatin. Prior to radiotherapy, 57.1% of albicans species isolated were in the sensitive range (MIC ≤1) and 42.9% were in the dose-dependent range (MIC = 2) to voriconazole. After radiotherapy, 58.3% of albicans species were in the sensitive range and 41.7% of these species were in the dose-dependent range to voriconazole.

Conclusion

The results of the present study showed that before radiotherapy, all species were sensitive to nystatin, while a percentage of albicans and nonalbicans were resistant to voriconazole. In the 2nd week of radiotherapy similar to prior to radiotherapy, all species isolated from patients were sensitive to nystatin, while a percentage of albicans and nonalbicans were resistant to voriconazole.

Mucosal Infection with Unmasked Candida albicans Cells Impacts Disease Progression in a Host Niche-Specific Manner

Shielding the immunogenic cell wall epitope β(1, 3)-glucan under an outer layer of mannosylated glycoproteins is an essential virulence factor deployed by Candida albicans during systemic infection. Accordingly, mutants with increased β(1, 3)-glucan exposure (unmasking) display increased immunostimulatory capabilities in vitro and attenuated virulence during systemic infection in mice. However, little work has been done to assess the impact of increased unmasking during the two most common manifestations of candidiasis, namely, oropharyngeal candidiasis (OPC) and vulvovaginal candidiasis (VVC). We have shown previously that the expression of a single hyperactive allele of the MAP3K STE11ΔN467 induces unmasking via the Cek1 MAPK pathway, attenuates fungal burden, and prolongs survival during systemic infection in mice. Here, we expand on these findings and show that infection with an unmasked STE11ΔN467 mutant also impacts disease progression during OPC and VVC murine infection models. Male mice sublingually infected with the STE11ΔN467 mutant showed a significant reduction in tongue fungal burden at 2 days postinfection and a modest reduction at 5 days postinfection. However, we find that selection for STE11ΔN467 suppressor mutants that no longer display increased unmasking occurs within the oral cavity and is likely responsible for the restoration of fungal burden trends to wild-type levels later in the infection. In the VVC infection model, no attenuation in fungal burden was observed. However, polymorphonuclear cell recruitment and interleukin-1β (IL-1β) levels within the vaginal lumen, markers of immunopathogenesis, were increased in mice infected with unmasked STE11ΔN467 cells. Thus, our data suggest a niche-specific impact for unmasking on disease progression.

Simultaneous Massive Esophageal Mucosal Candidiasis and Profound Cytomegaloviral Esophageal Ulcers with Recurrence of Both Infections 12 Years Later in a Patient with Long-Standing AIDS: Endoscopic, Radiologic, and Pathologic Findings

Immunocompromised patients with acquired immunodeficiency syndrome (AIDS) can develop opportunistic esophageal candidial and cytomegaloviral infections. A case is reported which extends the clinico-endoscopic severity of these infections. A 32-year-old bisexual man with AIDS since 1997, and intermittently compliant with antiretroviral therapy, presented (2007) with dysphagia and 32 kg-weight loss. EGD revealed a massive, cheesy, esophageal mucosal exudate from Candida albicans. Cytomegalovirus was isolated by viral culture. The patient improved after fluconazole/ganciclovir therapy. The patient re-presented (2019) with hematemesis and dysphagia. EGD revealed cheesy esophageal exudate and profound “punched out” esophageal ulcers mimicking pseudo-diverticula. Histopathology confirmed candidiasis. Viral cultures revealed cytomegalovirus. Barium esophagram revealed deep esophageal ulcers/pseudo-diverticula. Repeat EGD 8 weeks later after ganciclovir/micafungin therapy revealed mostly healed lesions. This demonstrates that AIDS patients may have massive mucosal esophageal candidiasis; that both infections can recur years after apparent eradication; and that cytomegaloviral esophageal ulcers may be profound and mimic pseudo-diverticula. A comprehensive literature review revealed only one abstract of esophageal pseudo-diverticula associated with cytomegalovirus. Simultaneous esophageal candidial and CMV infections have also been rarely reported in immunocompromised patients without AIDS.

Risk factors for the development of esophageal candidiasis among patients in community hospital

The aim of this study was to clarify risk factors for esophageal candidiasis (EC) in immunocompetent patients in a community hospital. 7736 patients who underwent esophagogastroduodenoscopy at our hospital from April 2012 to July 2018 were enrolled. The relationships between EC and the following factors: age, gender, body mass index, lifestyle, lifestyle-related diseases, medication, and endoscopic findings were analyzed. EC was observed in 184 of 7736 cases (2.4% morbidity rate). Multivariate analysis revealed that significant risk factors for the development of EC were: diabetes mellitus {odds ratio (OR): 1.52}, proton pump inhibitor (PPI) use (OR: 1.69), atrophic gastritis (AG) (OR: 1.60), advanced gastric cancer (OR: 4.66), and gastrectomy (OR: 2.32). When severe EC (Kodsi grade ≥ II) was compared to mild EC (grade I), the most significant risk factors were advanced gastric cancer (OR: 17.6) and gastrectomy (OR: 23.4). When considering the risk of AG and PPI use with EC development, the risk increased as follows: AG (OR: 1.59), PPI use (OR: 2.25), and both (OR: 3.13). PPI use, AG, advanced gastric cancer and post-gastrectomy are critical risk factors for the development of EC. We suggest close monitoring for EC development when PPIs are administered to patients with these factors.

Comparative Efficacy of Antifungal Agents Used in the Treatment of Oropharyngeal Candidiasis among HIV-Infected Adults: A Systematic Review and Network Meta-Analysis

The objective of this study was to assess the comparative efficacy and safety of different antifungal agents used for the treatment of oropharyngeal candidiasis (OPC) in adult patients with HIV. A systematic search was performed on the four major databases (Medline, Embase, CENTRAL and Scopus) to identify randomized controlled trials (RCTs) that evaluated the efficacy of antifungal agents in HIV patients with OPC. A network meta-analysis was performed from the data extracted from the selected studies. The agents were ranked according using surface under the cumulative ranking (SUCRA). The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to determine the quality of evidence. A total of 15 trials were included in the quantitative analysis involving the data from a total of 2883 participants. Fluconazole was ranked as the most effective antifungal agent to achieve clinical cure (SUCRA = 0.87) in OPC followed by posaconazole and itraconazole. Posaconazole was ranked the most efficacious agent in achieving mycological cure (SUCRA = 0.81), followed by fluconazole. While nystatin was ranked the safest, the effect estimates of none of the other systemic antifungal agents were significantly higher than fluconazole. Based on the available evidence, fluconazole can be considered as the most effective drug in the treatment of OPC among HIV-infected adults and has a favorable safety profile, followed by posaconazole.

Prevalence of HIV-associated esophageal candidiasis in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Esophageal candidiasis (OC) is a common AIDS-defining opportunistic infection. Antiretroviral therapy (ART) reduces the occurrence of OC and other opportunistic infections among persons living with HIV (PLHIV). We sought to determine and compare the prevalence of OC in the ART and pre-ART era among PLHIV in sub-Saharan Africa (SSA).

METHODS

We searched PubMed, Embase, Web of Science, and the African Journals Online databases to select studies in English and French reporting the prevalence of HIV-associated OC in SSA from January 1980 to June 2020. Reviews, single-case reports, and case series reporting < 10 patients were excluded. A random-effect cumulative meta-analysis was performed using STATA 16.0, and trend analysis performed using GraphPad Prism 8.0.

RESULTS

Thirteen eligible studies from 9 SSA countries including a total of 113,272 patients were qualitatively synthesized, and 9 studies were included in the meta-analysis. Overall pooled prevalence of HIV-associated OC was 12% (95% confidence interval (CI): 8 to 15%, I 2 = 98.61%, p <. 001). The prevalence was higher in the pre-ART era compared to the ART era, but not to statistical significance (34.1% vs. 8.7%, p = 0.095). In those diagnosed by endoscopy, the prevalence was higher compared to patients diagnosed by non-endoscopic approaches, but not to statistical significance (35.1% vs. 8.4%, p = .071). The prevalence of OC significantly decreased over the study period (24 to 16%, p < .025).

CONCLUSION

The prevalence of OC among PLHIV in the ART era in SSA is decreasing. However, OC remains a common problem. Active endoscopic surveillance of symptomatic patients and further empirical studies into the microbiology, optimal antifungal treatment, and impact of OC on quality of life of PLHIV in SSA are recommended.

Streptococcus mutans Secreted Products Inhibit Candida albicans Induced Oral Candidiasis

In the oral cavity, Candida species form mixed biofilms with Streptococcus mutans, a pathogenic bacterium that can secrete quorum sensing molecules with antifungal activity. In this study, we extracted and fractioned culture filtrate of S. mutans, seeking antifungal agents capable of inhibiting the biofilms, filamentation, and candidiasis by Candida albicans. Active S. mutans UA159 supernatant filtrate components were extracted via liquid-liquid partition and fractionated on a C-18 silica column to resolve S. mutans fraction 1 (SM-F1) and fraction 2 (SM-F2). We found anti-biofilm activity for both SM-F1 and SM-F2 in a dose dependent manner and fungal growth was reduced by 2.59 and 5.98 log for SM-F1 and SM-F2, respectively. The SM-F1 and SM-F2 fractions were also capable of reducing C. albicans filamentation, however statistically significant differences were only observed for the SM-F2 (p = 0.004). SM-F2 efficacy to inhibit C. albicans was confirmed by its capacity to downregulate filamentation genes CPH1, EFG1, HWP1, and UME6. Using Galleria mellonella as an invertebrate infection model, therapeutic treatment with SM-F2 prolonged larvae survival. Examination of the antifungal capacity was extended to a murine model of oral candidiasis that exhibited a reduction in C. albicans colonization (CFU/mL) in the oral cavity when treated with SM-F1 (2.46 log) and SM-F2 (2.34 log) compared to the control (3.25 log). Although both SM-F1 and SM-F2 fractions decreased candidiasis in mice, only SM-F2 exhibited significant quantitative differences compared to the non-treated group for macroscopic lesions, hyphae invasion, tissue lesions, and inflammatory infiltrate. Taken together, these results indicate that the SM-F2 fraction contains antifungal components, providing a promising resource in the discovery of new inhibitors for oral candidiasis.

Antimicrobial Evaluation of Latex and TLC Fractions from the Leaves of Aloe adigratana Reynolds

Background

The highest prevalence and emergence of microbial infections coupled with the threat of antimicrobial resistance constitute a global concern, which entails searching for novel antimicrobial agents. Medicinal plants are among the major sources of medicines for novel drug discovery. Aloe adigratana is one of the endemic Aloe species in Ethiopia where the leaf latex of the plant is traditionally used for the treatment of various pathogenic conditions such as wound, dandruff, malaria, and diabetes. In spite of such claims, there was no scientific study done so far. The aim of the current study was, therefore, to evaluate the antimicrobial effect of leaf latex of A. adigratana and its thin layer chromatography (TLC) fractions.

Methods

Thin layer chromatography (TLC) separation was employed for isolation of bioactive compounds. Agar well diffusion and microdilution assay method were used to evaluate the antimicrobial actions of the leaf latex and TLC fractions against six bacterial strains and four Candida species of reference and clinical isolate microbial strains.

Results

Three major fractions, AA01, AA02, and AA03, were identified by TLC. Among the tested microbial strains, the reference strain of Staphylococcus aureus ATCC 29213 (MIC = 0.06 mg/mL) and clinical Candida krusei 242/18 (MIC = 0.14 mg/mL) exhibited higher susceptibility towards AA02, while reference strains of Klebsiella pneumoniae ATCC 700603 (MIC = 0.19 mg/mL) revealed the highest susceptibility towards AA01. The leaf latex displayed the highest activity against Staphylococcus aureus ATCC 29213 and clinical Candida krusei 242/18 with a MIC value of 0.19 mg/mL.

Conclusion

The leaf latex and TLC fractions were found to be active against the tested bacterial and Candida species. Therefore, this finding supports the traditional claim of Aloe adigratana and the need for characterization of the TLC fractions to provide as lead compounds for further comprehensive antibacterial and antifungal activities.

Educational Case: Infectious Esophagitis

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, seehttp://journals.sagepub.com/doi/10.1177/2374289517715040.¹

Diagnosis and Treatment of Esophageal Candidiasis: Current Updates

Esophageal candidiasis (EC) is the most common type of infectious esophagitis. In the gastrointestinal tract, the esophagus is the second most susceptible to candida infection, only after the oropharynx. Immunocompromised patients are most at risk, including patients with HIV/AIDS, leukemia, diabetics, and those who are receiving corticosteroids, radiation, and chemotherapy. Another group includes those who used antibiotics frequently and those who have esophageal motility disorder (cardiac achalasia and scleroderma). Patients complained of pain on swallowing, difficulty swallowing, and pain behind the sternum. On physical examination, there is a plaque that often occurs together with oral thrush. Endoscopic examination is the best approach to diagnose this disease by directly observing the white mucosal plaque-like lesions and exudates adherent to the mucosa. These adherent lesions cannot be washed off with water from irrigation. This disease is confirmed histologically by taking the biopsy or brushings of yeast and pseudohyphae invading mucosal cells. The treatment is by systemic antifungal drugs given orally in a defined course. It is important to differentiate esophageal candidiasis from other forms of infectious esophagitis such as cytomegalovirus, herpes simplex virus, gastroesophageal reflux disease, medication-induced esophagitis, radiation-induced esophageal injury, and inflammatory conditions such as eosinophilic esophagitis. Except for a few complications such as necrotizing esophageal candidiasis, fistula, and sepsis, the prognosis of esophageal candidiasis has been good.

Possible Risk Factors for Candida Esophagitis in Immunocompetent Individuals

Background

Candida esophagitis (CE) is a condition typically diagnosed in patients who are immunocompromised. Risk factors leading to the development of CE in immunocompetent patients have not been entirely elucidated. This study set out to identify risk factors associated with the development of CE in immunocompetent patients.

Methods

This study was a single-center retrospective chart review. Patients diagnosed with CE confirmed by endoscopic biopsy or brushings at our hospital between 2007 and 2017 were reviewed. The medical histories, endoscopy reports and pathology results were noted. Abdominal pain, heartburn, dysphagia and odynophagia were the common indications for endoscopy. A total of 241 patients were identified as having been diagnosed with CE by endoscopic brushing or biopsy. Of these patients, 161 were excluded due to the presence of immunocompromising and 80 patients were included who had no underlying immunocompromising conditions.

Results

Eighty patients with CE satisfied the inclusion criteria. The mean age of patients at the time of diagnosis was 39.8 years old (95% CI: 34.9 - 44.7). The incidences in men and women were similar in this study (49% women and 51% men). Of these patients, 56 (70%) (95% CI: 59-80%; P < 0.005) were taking proton pump inhibitors (PPIs). Fifteen patients (19%) had a previous upper endoscopy with evidence of reflux esophagitis, and they were all treated with PPIs and subsequently found to have CE on repeat upper endoscopy with a mean of 21.6 months of PPI treatment. There were 16 (20%) patients without any attributable risk factor and were completely healthy.

Conclusions

CE is an opportunistic infection typically seen in immunocompromised. We report incidence of CE in immunocompetent patients. In our cohort of immunocompetent patients, PPI use was the most common risk factor associated with the development of CE. This could be related to hypochlorhydria resulting from PPI use. However, the cause remains unclear in some patients.

Oropharyngeal Candidosis in HIV-Infected Patients-An Update

Oropharyngeal candidosis (OPC) is an opportunistic fungal infection that is commonly found in HIV-infected patients, even in the twenty-first century. Candida albicans is the main pathogen, but other Candida species have been isolated. OPC usually presents months or years before other severe opportunistic infections and may indicate the presence or progression of HIV disease. The concept of OPC as a biofilm infection has changed our understanding of its pathobiology. Various anti-fungal agents (both topical and systemic) are available to treat OPC. However, anti-fungal resistance as a result of the long-term use of anti-fungal agents and recurrent oropharyngeal infection in AIDS patients require alternative anti-fungal therapies. In addition, both identifying the causative Candida species and conducting anti-fungal vulnerability testing can improve a clinician's ability to prescribe effective anti-fungal agents. The present review focuses on the current findings and therapeutic challenges for HIV-infected patients with OPC.

The Effect of Nutritive and Non-Nutritive Sweeteners on the Growth, Adhesion, and Biofilm Formation of Candida albicans and Candida tropicalis

OBJECTIVE

To determine the effect of glucose, sucrose, and saccharin on growth, adhesion, and biofilm formation of Candida albicans and Candida tropicalis.

MATERIALS AND METHODS

The growth rates of mono-cultures of planktonic C. albicans and C. tropicalis and 1:1 mixed co-cultures were determined in yeast nitrogen broth supplemented with 5% (30 mM) and 10% (60 mM) glucose, sucrose, and saccharin, using optical density measurements at 2-h intervals over a 14-h period. Adhesion and biofilm growth were performed and the growth quantified using a standard 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay. The biofilm architecture was visualized using scanning electron microscopy. One- and two-way analysis of variance (ANOVA) was performed to analyse the differences among multiple means.

RESULTS

The highest planktonic growth was noted in 5% glucose after 14 h (p < 0.05). No significant planktonic growth was observed in either concentration of saccharin. Both the concentrations of glucose and sucrose elicited significantly increased adhesion from MTT activity of 0.017 to >0.019 in mono- as well as co-cultures (p < 0.05), whilst the lower concentration of saccharin significantly dampened the adhesion. Maximal biofilm growth was observed in both species with the lower concentration of sucrose (5%), although a similar concentration of saccharin abrogated biofilm development: the highest MTT value (>0.35) was obtained for glucose and the lowest (>0.15) for saccharin.

CONCLUSION

In this study, glucose and sucrose accelerated the growth, adhesion, and biofilm formation of Candida species. However, the non-nutritive sweetener saccharin appeared to dampen, and in some instances suppress, these virulent attributes of Candida.

Oropharyngeal candidiasis prevalence among HIV-infected patients at the teaching hospital of Treichville (Abidjan, Côte d'Ivoire)

AIM OF THE STUDY

The aim of this study was to determine the mycological profile of oropharyngeal candidiasis among HIV-infected patients from Internal Medicine, Infectious and Tropical Diseases, and Pneumo-Phthisiology Diseases departments of the Teaching Hospital of Treichville in Abidjan, Côte d'Ivoire.

PATIENTS AND METHODS

This was a cross-sectional study carried out on patients with lesions suggestive of oropharyngeal candidiasis from October 2010 to April 2011. Oral swabs were cultured, and Candida species were identified using a germ tube test, a chlamydospore formation assay, and the API 20C system.

RESULTS

A total of 286 patients were included, among whom 99.1% were infected with HIV. The prevalence of oropharyngeal candidiasis was 79.4% (CI_95%=74.4-83.8). Five different species of Candida were identified, with the predominant species being Candida albicans (95.2%). Most affected patients were female (54.6%, P<0.0001) between the ages of 30 and 45 (78.4%, P<0.0001). The most lesion types observed were thrush (87.8%). Patients infected with HIV1 (95.6%), with a primary school level of education (52.8%), under antiretroviral therapy (88.5%) and with tuberculosis as an associated pathology (62.5%) were the most commonly affected. Patients were mostly under ART first line treatment (86.4%) and at the beginning of the treatment (86.4%).

CONCLUSION

Oropharyngeal candidiasis is frequent among HIV-infected patients. Better and early management of this vulnerable population should allow for a reduction in the high prevalence observed.

Isolation of Candida Species from Gastroesophageal Lesions among Pediatrics in Isfahan, Iran: Identification and Antifungal Susceptibility Testing of Clinical Isolates by E-test

Background:

Candida species can become opportunistic pathogens causing local or systemic invasive infections. Gastroesophageal candidiasis may depend on the Candida colonization and local damage of the mucosal barrier. Risk factors are gastric acid suppression, diabetes mellitus, chronic debilitating states such as carcinomas, and the use of systemic antibiotics and corticosteroids. The aim of this study is collection and molecular identification of Candida species from gastroesophageal lesions among pediatrics in Isfahan, and determination of minimum inhibitory concentration (MIC) ranges for clinical isolates.

Materials and Methods:

A total of 200 patients underwent endoscopy (130 specimens from gastritis and 70 samples from esophagitis) were included in this study between April 2015 and November 2015. All specimens were subcultured on sabouraud dextrose agar, and genomic DNA of all strains was extracted using boiling method. Polymerase chain reaction and DNA sequencing of the ITS1-5.8SrDNA-ITS2 region were used for the identification of all Candida strains. MIC ranges were determined for itraconazole (ITC), amphotericin B (AmB), and fluconazole (FLU) by E-test.

Results:

Twenty of 200 suspected patients (10%) were positive by direct microscopy and culture. Candida albicans was the most common species (60%) followed by Candida glabrata (30%), Candida parapsilosis (5%), and Candida kefyr (5%). MIC ranges were determined for FLU (0.125–8 μg/mL), ITC (0.008–0.75 μg/mL), and AmB (0.008–0.75 μg/mL), respectively.

Conclusion:

Every colonization of Candida species should be considered as a potentially factor of mucocutaneous candidiasis and should be treated with antifungal drugs.

The 2015 Clinical Guidelines for the Treatment and Prevention of Opportunistic Infections in HIV-Infected Koreans: Guidelines for Opportunistic Infections

The Committee for Clinical Guidelines for the Treatment and Prevention of Opportunistic Infections of the Korean Society for AIDS was founded in 2011. The first edition of the Korean guidelines was published in 2012. The guideline recommendations contain important information for physicians working with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) in the clinical field. It has become necessary to revise the guidelines due to new data in this field. These guidelines aim to provide up-to-date, comprehensive information regarding the treatment and prevention of opportunistic infections in HIV-infected Koreans. These guidelines deal with several common opportunistic infections, including pneumocystis pneumonia, tuberculosis, cryptococcal meningitis, etc. A brief summary of the revised guidelines is provided below. Recommendations are rated using the same system used in the previous guidelines.

Novel approach of adaptive laboratory evolution: triggers defense molecules in Streptomyces sp. against targeted pathogen

Adaptive laboratory evolution by competition-based co-culture: triggers and enhance specific bioactive molecules against targeted pathogen.

Oropharyngeal candidiasis in children with lymphohematopoietic malignancies in Mashhad, Iran

Background and Purpose:

Over the past years, the role of fungi as a cause of nosocomial infections in hospitalized patients has been accentuated. Candida species constitute an important group of fungi causing diseases in immunocompromised patients. Oropharyngeal candidiasis continues to be a prevalent infection in immunodeficient patients. In this study, we aimed to determine the incidence of oropharyngeal candidiasis in children with lymphohematopoietic malignancies.

Materials and Methods:

In total, 102 patients with lymphohematopoietic malignancies and 50 healthy controls were examined in terms of Candida infections via direct sampling of the oropharyngeal cavity. Fresh smears were prepared with 10% potassium hydroxide and Gram staining was carried out. Subsequently, the obtained specimens were cultured on Sabouraud dextrose agar for further analysis.

Results:

The most common Candida species were Candida albicans (31%), other non-C. albicans species (14.7%), C. glabrata (6.8%), and C. krusei (0.98%) in the case group, while in the control group, other non-C. albicans species (10%) and C. albicans (8%) were the most common species.

Conclusion:

In the present study, Candida species were the most common fungal pathogens in pediatric cancer patients; therefore, efforts should be made to prevent fungemia and fungal pneumonia. Also, non-C. albicans species must be considered as a new risk factor for pediatric cancer patients.

[Skin symptoms associated with human immunodeficiency virus infection]

The recently observed accelerated increase of human immunodeficiency virus infection in Hungary poses a major public concern for the healthcare system. Given the effective only but not the curative therapy, prevention should be emphasized. Current statistics estimate that about 50% of the infected persons are not aware of their human immunodeficiency virus-positivity. Thus, early diagnosis of the infection by serological screening and timely recognition of the disease-associated symptoms are crucial. The authors' intention is to facilitate early infection detection with this review on human immunodeficiency virus-associated skin symptoms, and highlight the significance of human immunodeficiency virus care in the everyday medical practice.

Molecular identification of Candida species isolated from gastro-oesophageal candidiasis in Tehran, Iran

AIM

The aim of this investigation is identification of Candida strains isolated from patients with gastro-oesophageal candidiasis in Tehran, Iran.

BACKGROUND

Gastro-oesophageal candidiasis is a rare infection and appears mainly in debilitated or immunocompromised patients. Colonization by Candida spp. may occur in this region and the organism can remain for several months or years in the absence of inflammation. The main infection symptom is the presence of white plaques in gastro-oesophageal surface. C. albicans remains the most prevalent Candida spp. identified in gastrointestinal candidiasis. Regarding differences in susceptibilities to antifungal drugs among Candida spp., identification of isolates to the species level is significant to quick and appropriate therapy.

PATIENTS AND METHODS

A total of 398 patients underwent gastrointestinal endoscopy during February 2012 to October 2014 were included in the present study. Histological sections from all endoscopic gastric and oesophageal biopsies were prepared, stained with Periodic acid-Schiff (PAS), and examined for the presence of fungal elements. Part of the biopsy sample was sub-cultured on sabouraud glucose agar. The genomic DNA of each strain was extracted using FTA(®) Elute MicroCards. Molecular identification of Candida isolates was performed by PCR-RFLP technique with the restriction enzyme HpaII.

RESULTS

Twenty-one out of 398 cases (5.2%) were found to have gastro-oesophageal candidiasis. Candida albicans was the main strain isolated from clinical samples (90.5%), followed by C. glabrata (4.7%), and C. parapsilosis (4.7%).

CONCLUSION

Due to varying antifungal susceptibility of Candida spp. careful species designation for clinical isolates of Candida was recommended by a rapid and meticulous method like PCR-RFLP.

Artemisinins, new miconazole potentiators resulting in increased activity against Candida albicans biofilms

Mucosal biofilm-related fungal infections are very common, and the incidence of recurrent oral and vulvovaginal candidiasis is significant. As resistance to azoles (the preferred treatment) is occurring, we aimed at identifying compounds that increase the activity of miconazole against Candida albicans biofilms. We screened 1,600 compounds of a drug-repositioning library in combination with a subinhibitory concentration of miconazole. Synergy between the best identified potentiators and miconazole was characterized by checkerboard analyses and fractional inhibitory concentration indices. Hexachlorophene, pyrvinium pamoate, and artesunate act synergistically with miconazole in affecting C. albicans biofilms. Synergy was most pronounced for artesunate and structural homologues thereof. No synergistic effect could be observed between artesunate and fluconazole, caspofungin, or amphotericin B. Our data reveal enhancement of the antibiofilm activity of miconazole by artesunate, pointing to potential combination therapy consisting of miconazole and artesunate to treat C. albicans biofilm-related infections.

The effect of eating sea cucumber jelly on Candida load in the oral cavity of elderly individuals in a nursing home

We conducted a double-blind randomized controlled study of elderly individuals in a nursing home to investigate the effect of the consumption of jelly containing sea cucumber on their oral Candida load. The jelly contained a hydrolysate of the sea cucumber Stichopus japonicus, which contained triterpene glycosides called holotoxins. The holotoxins worked as a fungicide, and their minimum inhibitory concentrations for Candida albicans were 7 µg/mL. Eight individuals in the nursing home took the sea cucumber jelly for a week and their oral Candida were counted before and after the intervention. Nine individuals took a control jelly without S. japonicus. The sea cucumber jelly showed inhibitory effects on the oral Candida. Thus, daily consumption of the S. japonicus jelly has the potential to reduce the oral Candida load in the elderly in nursing homes.

Potentiation of azole antifungals by 2-adamantanamine

Azoles are among the most successful classes of antifungals. They act by inhibiting α-14 lanosterol demethylase in the ergosterol biosynthesis pathway. Oropharyngeal candidiasis (OPC) occurs in about 90% of HIV-infected individuals, and 4 to 5% are refractory to current therapies, including azoles, due to the formation of resistant biofilms produced in the course of OPC. We reasoned that compounds affecting a different target may potentiate azoles to produce increased killing and an antibiofilm therapeutic. 2-Adamantanamine (AC17) was identified in a screen for compounds potentiating the action of miconazole against biofilms of Candida albicans. AC17, a close structural analog to the antiviral amantadine, did not affect the viability of C. albicans but caused the normally fungistatic azoles to become fungicidal. Transcriptome analysis of cells treated with AC17 revealed that the ergosterol and filamentation pathways were affected. Indeed, cells exposed to AC17 had decreased ergosterol contents and were unable to invade agar. In vivo, the combination of AC17 and fluconazole produced a significant reduction in fungal tissue burden in a guinea pig model of cutaneous candidiasis, while each treatment alone did not have a significant effect. The combination of fluconazole and AC17 also showed improved efficacy (P value of 0.018) compared to fluconazole alone when fungal lesions were evaluated. AC17 is a promising lead in the search for more effective antifungal therapeutics.

Urban legends series: oral manifestations of HIV infection

Human immunodeficiency virus-related oral lesions (HIV-OLs), such as oral candidiasis (OC) and oral hairy leukoplakia (OHL), have been recognized as indicators of immune suppression since the beginning of the global HIV epidemic. The diagnosis and management of HIV disease and spectrum of opportunistic infection has changed over the past 30 years as our understanding of the infection has evolved. We investigated the following controversial topics: (i) Are oral manifestations of HIV still relevant after the introduction of highly active antiretroviral therapy (HAART)? (ii) Can we nowadays still diagnose HIV infection through oral lesions? (iii) Is the actual classification of oral manifestations of HIV adequate or does it need to be reviewed and updated? (iv) Is there any novelty in the treatment of oral manifestations of HIV infection? Results from extensive literature review suggested the following: (i) While HAART has resulted in significant reductions in HIV-OLs, many are still seen in patients with HIV infection, with OC remaining the most common lesion. While the relationship between oral warts and the immune reconstitution inflammatory syndrome is less clear, the malignant potential of oral human papillomavirus infection is gaining increasing attention. (ii) Effective antiretroviral therapy has transformed HIV from a fatal illness to a chronic manageable condition and as a result expanded screening policies for HIV are being advocated both in developed and in developing countries. Affordable, reliable, and easy-to-use diagnostic techniques have been recently introduced likely restricting the importance of HIV-OLs in diagnosis. (iii) The 1993 EC-Clearinghouse classification of HIV-OLs is still globally used despite controversy on the relevance of periodontal diseases today. HIV-OL case definitions were updated in 2009 to facilitate the accuracy of HIV-OL diagnoses by non-dental healthcare workers in large-scale epidemiologic studies and clinical trials. (iv) Research over the last 6 years on novel modalities for the treatment of HIV-OLs has been reported for OC and OHL.