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|Year : 1982 | Volume
| Issue : 1 | Page : 24-9
Candida in pulmonary tuberculosis.
Jain SK, Agrawal RL, Sharma DA, Agrawal MM
|How to cite this article:|
Jain S K, Agrawal R L, Sharma D A, Agrawal M M. Candida in pulmonary tuberculosis. J Postgrad Med 1982;28:24
In recent years, there is a continuous growing interest for the diagnosis of mycoses. Most of the subjects affected with mycoses have received antibiotics and/or corticosteroids, and the majority have some severe basic pulmonary disease like tuberculosis. When the host resistance is impaired, these unrecognised opportunistic fungi may affect the progress of the disease or may even become fatal. Hence, there is need to consider the possible importance of these saprophytic organisms when they are found repeatedly and evidently from the site of the lesion. The present study was therefore designed (1) to find out the prevalence of Candida in pulmonary tuberculosis, and (2) to study the correlation of its positivity with the duration, type and the extent of the disease.
One hundred and forty, diagnosed, pulmonary tuberculosis cases (10-64 years) were randomly selected amongst those admitted in the Government Tuberculosis Hospital, Allahabad from January 1979 to February 1980. They were grouped into two: (1) Fresh or untreated group included those cases who had the disease for a maximum of 6 months' duration and had not taken antitubercular treatment or if taken then for less than a month, and (2) chronic or treated group-cases are those who had illness for more than 6 months, and had antitubercular treatment for more than a month. Those cases who were not fitting in these two groups were excluded from the study. Early morning sputum was collected from each case after a proper mouth wash with hot saline water and with proper aseptic precaution and was homogenized with the help of sterile glass beads for smear and culture of fungus. Direct smear examination of the sputum was done by 10% KOH, India ink preparation, and Gram's staining. For culture, a sterile platinum loopful of sputum was inoculated on three different Sabourauds' dextrose agar media prepared by Emmons modification. They were (1) Sabouraud's dextrose agar (SDA) plain, (2) SDA with chloramphenicol (0.04 mg/ml), and (3) SDA with Chloramphenical (0.04 mg/ml) and Cycloheximide (0.5 mg/ml). If there was no growth for 4 weeks, the culture was taken as negative. To exclude oral contaminants, a plain Sabouraud's dextrose agar culture tube as a control having inoculation of mouth rinsed water was kept along with slants of each case. Any growth in the control was subtracted from a similar fungal growth present in the test specimen. Evaluation of the amount of growth was done according to Kahanpaa. Criteria for diagnosis of secondary candidiasis in the present study were as follows: (1) heavy growth of Candida i.e. more than 30 colonies in the culture repeatedly for at least three times, and (2) yeast cell budding, pseudomycelium, and blastospore in direct smear examination.
For identification of Candida species, the help of a few books and monographs were taken., ,  Pure growth of yeast (free from bacteria) was used for the identification of Candida species. C. albicans was recognized on the basis of pseudomycelium, blastospore and chlamydospore formation on corn meal agar with Tween-80 media, ,  and formation of germ tube (R.B. effect)-(Serum tube method)., , ,  C. albicans and other species of Candida were further distinguished by biochemical reaction, in which formation of acid and/or gas under anaerobic condition was noted in different sugars i.e. glucose, maltose, sucrose and lactose.
Statistical Method: To notice the significance of data achieved, Chi-square (x2) were implicated, the results of which are presented underneath the observation tables in the form of x2 ...... df .... p value. The conventional level of significance was taken at p = 0.05. Wherever cell frequencies were less than five, Yate's correction was applied. Figures in parenthesis in observation tables denote percentages.
Out of 140 cases of pulmonary tuberculosis, Candida species were grown in 33 (23.57%) cases. The fungus positivity was higher in the chronic group of cases than that of the fresh one, but the difference was not statistically significant [Table - 1].
[Table - 1] shows that out of 33 Candida species, 26 (18.57%) were identified as C. albicans followed by C. tropicalis 3 (9.09%), C. pseudotropicalis 2 (6.06%), and C. krusei 2 (6.06%).
.An increase in the duration of illness was related with higher prevalence of Candida species. Difference in positivity of Candida below 3 years and above 3 years of duration of illness was found statistically significant [Table - 2].
.The results of Candida growth according to the extent of disease are presented in [Table 3.] Statistically, the growth of Candida was independent of the extent of the lesion in fresh and treated cases.
.A comparison of Candida growth in sputum specimens of cavitary and noncavitary groups was made [Table - 3]. Candida species were found in higher percentage of cases (26.02%) in the cavitary group than that of noncavitary group (20.89%), but the difference was not statistically significant. The positivity was higher in the treated group both in the cavitary and noncavitary type of lesion than in the fresh group.
There is a considerable variation of 9 to 80% in the incidences reported in the literature on the occurrence of Candida species in the sputum of patients with pulmonary tuberculosis [Table - 4].
The difference in the prevalence of Candida as a whole group and C. albicans as found by various investigators may probably be due partly to the actual difference in species prevalence and partly to the techniques employed for detection. In the literature, it was revealed that only a few workers have separated the prevalence of Candida species other than C. albicans in pulmonary tuberculosis. Pandalai and Kurup found C. krusei in 2 (2.9%) and C. parapsilosis in 6 (8.7%) out of 69 cases. Grower and Junnarkar noted C. tropicalis in 4 (4%) and C. parapsilosis in 2 (2%) in their series of 100 cases. Khanna et al. reported C. krusei in 2 (1.8%) and C. stelloidea in 2 (1.8%) out of 110 patients. In our study we found C. tropicalis in 3 (2.14%), C. pseudotropicalis in 2 (1.4%) and C. krusei in 2 (1.4%) amongst a total of 140 cases.
A correlation of Candida positivity with duration of illness was found in the present study. Higher the duration of illness, more was the percentage of positivity (p<0.05).
The relationship of isolation of Candida with the extent of the lesion was studied in the present study. Statistically, the growth of Candida was independent of the extent of the lesion in fresh and treated cases (p>0.05). Schwarting and Skinner also gave similar opinion. They observed no clear correlation between a sputum finding of Candida and the stage of tuberculosis.
Fungus positivity was higher in the cavitary than that of the noncavitary group but the difference was statistically not significant (p > 0.05). An interesting finding of our study was that the percentage of positivity was more in even noncavitary cases of chronic group (9/40; 22.50%) than that of cavitary cases (5/27; 18.52%) of the fresh group. Chronicity of illness plays a more important role in the positivity of fungi rather than the basis of cavitation. Khanna et al were of the opinion that positivity of fungi in pulmonary tuberculosis was related to the chronicity of the lesion. Schwarting and Skinner were also of view that the presence of cavity has little to do with the incidence of Candida in the sputum of tuberculosis cases. It is concluded that prevalence of Candida in pulmonary tuberculosis mainly depends on the duration of illness and chronicity of the disease.
The authors are grateful to the Director, V. P. Chest Institute, Delhi for his kind permission and Dr. H. S. Randhawa, Ph.D., Head of Medical Mycology for his valuable guidance and training given to one of the authors on mycology.
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