Prevalence, Antifungal Susceptibility and Etiology of Vulvovaginal Candidiasis in Sub-Saharan Africa: A Systematic Review with Meta-analysis and Meta-regression

Vulvovaginal candidiasis (VVC) is a commonly occurring form of mucocutaneous candidiasis in women. The aim of this study was to comprehensively investigate the prevalence, antifungal susceptibility, and etiology of VVC in sub-Saharan Africa (SSA). A search of studies was conducted in seven online databases and the reference lists of selected studies. Observational studies published between January 2000, to July 2021, that met the eligibility criteria were included. Meta-analyses with random and fixed-effects model, and subgroup analyses were performed using STATA 16.0. A total of 41 studies including 15 723 participants were included in the meta-analyses. The pooled prevalence of VVC was 33% (95% Confidence Interval (CI): 28 - 38%, I2 = 98%, p < 0.001). Pregnant women had 6% higher odds of having VVC compared to non-pregnant women (Odds Ratio (OR): 1.06, 95% CI: 0.99 - 1.13, p = 0.107). The odds of diagnosing VVC were 40% higher in symptomatic patients than general study population (OR: 1.4, 95% CI: 1.3 - 1.5, p < 0.0001). In 17 studies, a total of 2112 isolates of Candida species were reported: 1514 (71.7%) C. albicans, 510 (24.1%) non-albicans Candida (NAC) species and 88 (4.2%) unidentified Candida spp. Of the NAC species detected, C. glabrata (40.9%, n = 209), C. krusei (21.2%, n = 108) and C. tropicalis (22.7%, n = 116) were the most common. Resistance to fluconazole in C. albicans using disc diffusion methods ranged from 6.8% in Cameroon to 53.7% in Ethiopia. One-third of women in SSA have VVC, mainly caused by C. albicans. Data on the susceptibility of the Candida isolates to commonly used antifungal agents is limited and warrants further research.

Investigation of the Detailed Internal Structure and Dynamics of Itraconazole by Solid-State NMR Measurements

The structure and dynamics of itraconazole were investigated by ¹³C 2DPASS MAS SSNMR and spin-lattice relaxation time measurement to get an insight into its multiple biological activities, e.g., antifungal, antiviral, anticancer activities, etc. The molecular correlation time at chemically different sites of carbon nuclei was calculated by considering that the spin-lattice relaxation mechanism is mainly dominated by chemical shift anisotropy interaction and heteronuclear dipole-dipole interaction. The spin-lattice relaxation time is long for C35, C6, C5, and C34 carbon nuclei that participated in the 1, 2, 4-triazole ring. On the contrary, it is comparatively shorter for C1, C2, C3, and C4 carbon nuclei associated with the sec-butyl group in the triazolane side-chain region. Chemical shift anisotropy (CSA) parameters of C5, C6, C34, and C35 nuclei are much higher than those of C1, C2, C3, C4 nuclei, indicating that the relaxation mechanism at a high value of magnetic field is predominated by chemical shift anisotropy interaction. The molecular correlation time of carbon nuclei residing at the side-chain region is 2-3 orders of magnitude lesser than that of those participated in the 1,2,4-triazole ring. The spin-lattice relaxation time is very long for carbon nuclei C28 and C30 bonded with chlorine. Asymmetry and anisotropy parameters are also very high for the spinning CSA sideband pattern corresponding to the C28 and C30 nuclei. The molecular correlation time is on the order of 10^-3 s for C28 and 10^-4 s for C30, whereas for side-chain carbon nuclei, it is on the order of 10^-6 s. This suggests that the effective magnetic field experienced by C28 and C30 nuclei is affected by the polarization of the chemical bond. A huge variation in molecular correlation time is observed for chemically different sites of carbon nuclei of the itraconazole molecule. These investigations vividly portrayed how the structure is correlated with the dynamics of a valuable drug, itraconazole, with multiple biological activities. This study will enlighten the way of inventing advance medicine for multiple biological activities in the pharmaceutical industry.

In silico drug repurposing for the identification of potential candidate molecules against arboviruses infection

Arboviral diseases caused by dengue (DENV), Zika (ZIKV) and chikungunya (CHIKV) viruses represent a major public health problem worldwide, especially in tropical areas where millions of infections occur every year. The aim of this research was to identify candidate molecules for the treatment of these diseases among the drugs currently available in the market, through in silico screening and subsequent in vitro evaluation with cell culture models of DENV and ZIKV infections. Numerous pharmaceutical compounds from antibiotics to chemotherapeutic agents presented high in silico binding affinity for the viral proteins, including ergotamine, antrafenine, natamycin, pranlukast, nilotinib, itraconazole, conivaptan and novobiocin. These five last compounds were tested in vitro, being pranlukast the one that exhibited the best antiviral activity. Further in vitro assays for this compound showed a significant inhibitory effect on DENV and ZIKV infection of human monocytic cells and human hepatocytes (Huh-7 cells) with potential abrogation of virus entry. Finally, intrinsic fluorescence analyses suggest that pranlukast may have some level of interaction with three viral proteins of DENV: envelope, capsid, and NS1. Due to its promising results, suitable accessibility in the market and reduced restrictions compared to other pharmaceuticals; the anti-asthmatic pranlukast is proposed as a drug candidate against DENV, ZIKV, and CHIKV, supporting further in vitro and in vivo assessment of the potential of this and other lead compounds that exhibited good affinity scores in silico as therapeutic agents or scaffolds for the development of new drugs against arboviral diseases.

Hepatotoxicity induced by antifungal drugs itraconazole and fluconazole in rats: a comparative in vivo study

Itraconazole and fluconazole are oral antifungal drugs, which have a wide spectrum antifungal activity and better efficacy than the older drugs. However, both drugs have been associated with hepatotoxicity in susceptible patients. The mechanism of antifungal drug-induced hepatotoxicity is largely unknown. Therefore, the aim of this present study was to investigate and compare the hepatotoxicity induced by these drugs in vivo. Rats were treated intraperitoneally with itraconazole or fluconazole either single (0, 10, l00 and 200 mg/kg) or subchronic (0, 10, 50 and loo mg/kg per day for 14 days) doses. Plasma and liver samples were taken at the end of the study. A statistically significant and dose dependent increase of plasma alanine aminotransferase (ALT) and alkaline phosphatase (ALP) activities were detected in the subchronic itraconazole-treated group. In addition, dose-dependent hepatocellular necrosis, degeneration of periacinar and mizonal hepatocytes, bile duct hyperplasia and biliary cirrhosis and giant cell granuloma were observed histologically in the same group. Interestingly, fluconazole treated rats had no significant increase in transaminases for both single and subchronic groups. In the subchronic fluconazole treated rats, only mild degenerative changes of centrilobular hepatocytes were observed. These results demonstrated that itraconazole was a more potent hepatotoxicant than fluconazole in vivo in rats.

Itraconazole suppresses an elicitation phase of a contact hypersensitivity reaction

Contact dermatitis is caused by epicutaneous exposure to environmentally and/or industrially derived allergens. As the exposure is unavoidable in many instances, therapeutic suppression of allergic inflammation appears to be of clinical relevance. It was recently reported that itraconazole (ITZ), an anti-fungal agent, may be of therapeutic importance in allergic skin diseases. Therefore, we were interested in the effect of ITZ on contact hypersensitivity (CHS). Mice (C3H/HeN or Balb/c) were administered with ITZ orally before sensitization or challenged with haptens (dinitrofluorobenzene or oxazolone). Consequently, the administration of ITZ before challenge, but not before sensitization, significantly suppressed the reaction. Intriguingly, ITZ failed to suppress the irritant dermatitis induced by croton oil or benzalkonium chloride, suggesting that it may affect molecule(s) rather selectively involved in the elicitation of CHS. To further analyze mechanisms involved, splenic T cells obtained from sensitized or naive mice were stimulated with plate-bound anti-CD3 in the presence or absence of ITZ and release of cytokines was tested by ELISA. T cells from hapten-immunized mice produced a significant amount of IFN-gamma, which was markedly suppressed by ITZ. Our study demonstrates that ITZ selectively suppresses the elicitation phase of CHS possibly via downmodulation of IFN-gamma.

In vitro evaluation of cytochrome P450-mediated drug interactions between cytarabine, idarubicin, itraconazole and caspofungin

PURPOSE

Antifungal prophylaxis is an important component of induction therapy for patients with acute myeloid leukemia (AML). Azole antifungal agents are increasingly used in this context. In vitro assays were performed to assess whether cytochrome P450 (CYP450) enzymes were affected by combinations of cytarabine or idarubicin with itraconazole or caspofungin.

METHODS

The high throughput microtiter assay was used to determine whether cytarabine, idarubicin and itraconazole or caspofungin were CYP450 isoenzyme substrates, inhibitors of CYP450 isoenzymes, and to determine potential CYP450 metabolism interactions between these agents.

RESULTS

Idarubicin is a substrate for CYP450 2D6 and 2C9. Cytarabine is a substrate of CYP450 3A4. Idarubicin inhibits CYP450 2D6, and cytarabine, itraconazole, and caspofungin inhibit CYP450 3A4. Cytarabine metabolism was significantly decreased when combined with caspofungin or itraconazole.

CONCLUSIONS

The inhibition of cytarabine metabolism may have important clinical implications. These in vitro findings warrant investigation with in vivo pharmacokinetic studies.

Advances in the management of keratomycosis and Acanthamoeba keratitis

PURPOSE

In the late 1960s, the management of fungal keratitis was a serious unresolved problem. Little was known of the epidemiology of the disease, and there were no antifungal agents formulated for use in the eye.

METHODS

A thorough review of the literature was done back to 1969 on clinical reports and experimental studies for keratomycosis and Acanthamoeba keratitis.

RESULTS

Since 1969, through basic and clinical research, the epidemiology of the disease worldwide is better understood. One new topical antifungal agent, natamycin, with efficacy against filamentous fungi has been developed and the pharmacokinetics of topically applied antifungal drops have been explored. Progress has been slow but the prognosis for keratomycosis has immeasurably improved over the period. Acanthamoeba was first recognized as an ocular pathogen in 1973 and was the cause of an epidemic in the 1980s caused by contaminated contact lens, although other risk factors were also identified. At the onset of the epidemic, there was no known treatment. but as a result of intense research efforts, within a few years a well-defined therapeutic approach had been developed that had a significant impact on the prognosis for this initially devastating infection. For both infections, the role of corticosteroids for controlling the inflammation remains controversial, but the place for keratoplasty is now well defined.

CONCLUSIONS

Although there has been steady progress in the management of both infections, continued research is the way to define more effective medical and surgical therapy.

Itraconazole

Itraconazole is a broad spectrum triazole antifungal agent. It has favourable pharmacodynamic and pharmacokinetic profiles and is available as both oral and i.v. formulations. Over the last two decades, clinical and animal infection studies have demonstrated the efficacy of itraconazole in a wide range of superficial fungal infections including difficult-to-treat dermatophytoses and onychomycoses. Furthermore, shortened treatment regimens have proven to be effective, ranging from 1-day treatment for vaginal candidosis to 1-week pulse therapy per month, for 2-4 months, in onychomycosis and follicular dermatophytosis. Clinical experience with itraconazole in the treatment of deep mycoses is less comprehensive. However, results in systemic candidosis, sporotrichosis, blastomycosis, paracoccidioiodomycosis, certain types of histoplasmosis and aspergillosis are extremely encouraging. Itraconazole is less effective in the treatment of chromomycosis and coccidioidomycosis. Nevertheless, considering the refractory nature of these diseases, itraconazole has proven to be a valuable addition to the antifungal drugs currently available for treatment. Itraconazole has been well-tolerated with doses of up to 400 mg/day being generally free of serious adverse effects. However, a potential for drug interactions exists, mediated through the cytochrome P450 enzyme 3A4 system, which should be considered when itraconazole is used as part of a multi-drug regimen.

Case report. Sporotrichosis successfully treated with itraconazole in Japan

A case of lymphocutaneous sporotrichosis that had developed from the dorsum nasi to the left buccal region of a 65-year-old woman was treated with itraconazole 100 mg day-1. The lesion healed in 10 weeks after starting treatment leaving crusts, mild erythema and pigmentation, and the treatment was completed 16 weeks after the start of treatment. Neither adverse reactions nor abnormal clinical laboratory values were noted. Until the present time, 1 year and 2 months after the completion of treatment, no recurrence has been observed. In Japan, 43 cases of sporotrichosis have been treated with itraconazole, and 38 cases (88%) have been assessed as effective or better. The mean dose of itraconazole and the mean duration of administration are 100 mg day-1 and 11 weeks, respectively, in these reported Japanese cases. The use of itraconazole is expected to be one of the effective therapies for sporotrichosis.

Persistent keratoacanthoma: challenges in management

BACKGROUND

Keratoacanthoma is a common cutaneous neoplasm, although the persistent form is less common and often more difficult to manage. Multiple treatment approaches have been attempted with variable efficacy. Establishing the diagnosis and selecting a treatment plan for persistent keratoacanthoma is often challenging.

OBJECTIVE

Our purpose is to describe the difficulty one may encounter in the diagnosis and treatment of persistent keratoacanthoma. Hopefully, review of this clinical conundrum may facilitate the management of the reader's future patients.

METHODS

We describe a case of persistent keratoacanthoma where the diagnosis was initially elusive and the management challenging. Our thought process during each stage of diagnosis and management is described in the form of "issues" with references to the appropriate literature.

RESULTS

After several diagnostic and therapeutic interventions, successful treatment was achieved with administration of oral isotretinoin. Long-term remission continued as the dosage was tapered.

CONCLUSION

Persistent keratoacanthoma may be challenging to diagnose and manage, presenting a clinical conundrum. Careful review of the clinicopathologic presentation and an understanding of the various treatment options may result in a successful outcome.

Therapy of sinuorbital aspergillosis with amphotericin B colloidal dispersion

Invasive aspergillosis is a feared complication in the management of patients with malignancies. We report a 13-year-old boy with acute myelogenous leukaemia and chronic sinusitis who developed a sinuorbital fungal infection during cytostatic and prolonged antibiotic treatment. The clinical findings, diagnostic measures and treatment and its adverse effects are described and discussed. Special emphasis is given to our experience of the use of colloidal dispersed amphotericin B (Amphocil).

Blastomycosis of the eyelid

BACKGROUND

Published reports indicate that eyelid involvement occurs in approximately 25% of patients with systemic blastomycosis and that mortality exceeds 60% in untreated patients. The purpose of this study is to investigate this purportedly frequent association.

METHODS

The Medical Diagnostic index of the Mayo Clinic was used to identify patients who were treated for blastomycosis from 1976 through 1993. The medical records of affected patients were reviewed.

RESULTS

Of 79 patients with blastomycosis, only 1 (1.27%; 95% confidence interval, 0.03%-6.85%) had eyelid involvement. The diagnosis of systemic disease was established in this patient after biopsy of the eyelid lesion, and the infection responded satisfactorily to treatment with itraconazole.

CONCLUSION

Contrary to previous reports, eyelid involvement with systemic blastomycosis is uncommon.

Histoplasmosis: the otolaryngologist's perspective

Within the upper aerodigestive tract, histoplasmosis often mimics carcinoma, making prompt and accurate diagnosis imperative. More severe and potentially lethal infections with Histoplasma capsulatum are now being seen as the numbers of patients at the extremes of age, as well as those with compromised immune systems, increase. We reviewed the cases of 115 hospitalized patients with disseminated histoplasmosis. Of these, 9 patients were identified with otolaryngologic manifestations: 4 were infected with human immunodeficiency virus (HIV), 1 was diabetic, and 3 were renal transplant patients. Sites of involvement included the larynx (in 2 cases) and the oral cavity and oral pharynx (in 7 cases). Eight of the 9 patients had a positive biopsy result; the other, a positive culture. Treatment with amphotericin B was generally effective, while the use of newer azole anti-fungal agents were less effective. As the number of immunocompromised patients continues to increase in modern clinical practice, histoplasmosis will undoubtedly be encountered more frequently in the head and neck area.