Journal of Medical Research and Surgery
PROVIDES A UNIQUE PLATFORM TO PUBLISH ORIGINAL RESEARCH AND REMODEL THE KNOWLEDGE IN THE AREA OF MEDICAL AND SURGERY
Journal of Medical Research and Surgery
PROVIDES A UNIQUE PLATFORM TO PUBLISH ORIGINAL RESEARCH AND REMODEL THE KNOWLEDGE IN THE AREA OF MEDICAL AND SURGERY
Indexed ArticlesSelect your language of interest to view the total content in your interested language
Correspondence to: Paschal Chiedozie Amakiri, Chester Medical School, University of Chester, United Kingdom, Tel: +447721652992; E-mail: 1818021@chester.ac.uk
Received date: January 25, 2020; Accepted date: January 31, 2020; Published date: February 15, 2020
Citation: Nkwoemeka NE, Anyamene CO, Okwelogu IS, et al. (2020) Fungal Isolates in HIV positive and negative subjects attending Chukwuemeka Odumegwu
Ojukwu University Teaching Hospital, Amaku, Awka, Anambra State, Nigeria. J Med Res Surg. 1(2): pp. 1-9.
Copyright: © 2020 Amakiri PC, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Background: Fungal pathogens are the leading cause of severe healthcare-associated infections in immunocompromised patients, especially from low-income countries like Nigeria. Acquired Immunodeficiency Syndrome (AIDS) arising from HIV infection is reputed to be a key in immune suppression globally. Presently, Anambra state is number 5 in HIV prevalence in Nigeria. This study was aimed at screening patients from the Chukwuemeka Odumegwu Ojukwu University Teaching Hospital, for fungal infections. Samples were collected with consideration to gender, age, occupation, education status and clinical presentations.
Methods: Sampling was done according to global best practices. Patients’ consent and details were obtained by signing a consent form and filling of questionnaires respectively. Key questionnaire details included sociodemographic and personal details, history of present illness, clinical signs and symptoms. All patients were screened afresh for HIV-1 and HIV-2 using an immuno-chromatographic technique with Determine kit (Alere, Japan) and Stat-pack kit (USA). Specimens screened include Urine, Blood, Oropharyngeal swab, Skin scraping, and Sputum. All samples were labeled, transported and processed within 1-2 hours of collection.
Results: A total of 1200 participants (610 males and 590 females) were examined. About 16.5% and 54.41% of the subjects examined were positive for HIV infections and fungal infections respectively. Overall, 233 males (19.41%) and 420 females (35.0%) had fungal infections. Fungal infections were most prevalent in patients between 30-39 years, 17.75%, followed by 40-49 years (15.0%). Infection was least prevalent in patients between 15-29 years at 5.0%. Farmers had the highest prevalence rate of fungal infection, though not significant when compared with those of traders, artisans and public servants (X2 =0.621; df=2; P>0.05). Candida species were the most prevalent fungal pathogen, accounting for 609 (67.1%) followed by Aspergillus spp. 234 (25.8%) and Cryptococcus species 31 (3.4%). Penicillium and Fusarium spp. were the least prevalent pathogens (1.9%). Oropharyngeal candidiasis was the most common fungal infection (49.9%-17.4% HIV negative and 32.46% HIV positive patients); followed by Pneumocystis pneumonia (28.80%-9.50% HIV negative and 19.30% HIV positive patients). Similarly, Cryptococcal meningitis was the least recorded infection at 16.81% (6.43% HIV negative and 10.38% HIV positive patients). Significantly, fungal infections were more prevalent in HIV infected patients (62.14%) compared to HIV negative patients (33.33%).
Conclusion: This study has revealed that HIV positive and negative patients are often affected with fungal infections in Anambra State, Nigeria. This may have contributed to impaired immune system in patients and development of AIDS in HIV infected patients. Poor personal hygiene and intimate association with household pets among subjects examined were the suspected sources of infection. Therefore, there is an urgent need for improved surveillance and monitoring of fungal infections in the area and in other Teaching Hospitals in the country as well as treatments of infected subjects.
Fungal pathogens, Immunocompromised, HIV patients,Healthcare-associated infections.
Fungi are neither plants nor animals. They were once thought to be plants but are now classified as their own kingdom. Fungal pathogens especially Candida species are the leading cause of severe healthcare-associated infections in immunocompromised persons globally [1]. Infectious tropical diseases especially from fungal organisms have a huge effect in terms of mortality and morbidity and impose a heavy economic burden on affected countries. These diseases predominately affect the world’s poorest people [2]. Fungal infections are increasingly becoming common and yet often neglected in developing countries [3,4].
The fungus Candida albicans, a common cause of infection in mucosal tissues, forms long filaments called hyphae, comprised of tubular cells that are required for virulence [5]. However, a protein fragment released by filaments of the fungus Candida albicans destroys host cells [6]. Fungi are major contributors to the opportunistic infections that affect HIV/AIDs patients especially in settings where resources are insufficient or are not provided at all [7]. Opportunistic fungi cause lethal systematic infections and impose high medical costs on health systems [8].
Oropharyngeal Candidosis (OPC) is the most prevalent opportunistic fungal infection that is commonly found in HIVinfected patients, even in the 21st century. Wibawa, et al. [9] pointed out that fungal infections remain a clinical challenge in HIV patients with severe immune suppression. Globally, the phenomenon of HIV/AIDS is best viewed as a pandemic affecting nearly all the countries of the world. According to the annual report of the Joint United Nations Programme on HIV/ AIDS (UNAIDS), there are approximately 36.7 million people worldwide living with HIV/AIDS at the end of 2016. Of these, 2.1 million were children (< 15 years old), there were 1.8 million new infections and 1.0 million AIDS-related deaths [10].
Nigeria is a large, multi-ethnic, multicultural, multiplex and diversely confounding society. HIV/AIDS in Nigeria is one of the HIV sub epidemics in a generalized epidemic setting [11]. HIV infection and AIDS remain a disease of public health concern in Nigeria. This is because Nigeria is the most populous country in sub-Saharan Africa and its one of the countries highly affected by the HIV/AIDS scourge [12]. The estimated number of people living with HIV in Nigeria as of 2016 was 3.2 million, giving a prevalence rate of 2.9% among the adult population, only 51% of those living with HIV are accessing Highly Active Anti-Retroviral Therapy (HAART) [10]. Approximately, 160,000 people died from AIDS-related illnesses in Nigeria [10]. Anambra state is number 5 state in terms of HIV prevalence in Nigeria (A high prevalence of 30% of fungal opportunistic infection was recorded in HIV subjects attending a Tertiary Hospital in South-East, Nigeria [13].
The present study sought to determine the incidence and prevalence of fungal infections in immunosuppressed patients at the Chukwuemeka Odumegwu Ojukwu University Teaching Hospital, Awka
The study was carried in Anambra State, the eighth-most populous State in Nigeria, located in the South-East geopolitical zone of Nigeria (National Population Commission, 2006). The area is located between latitude 6° 20’ 00” North and Longitude 7° 00’ 00” East. It has a population of 2,061,961.984 (2,117.984 males and 2,059,844 females), (NPC, 2006). Anambra State has a tropical climate. The average temperature is 25.9°C while the average rainfall in a year is 1386 mm. A survey of existing health care facilities showed that there are private hospitals and a major teaching hospital/HIV Centre in Awka. This served as a referral center for the state and her environs.
The study population comprised of HIV-positive and HIVnegative patients attending Chukwuemeka Odumegwu Ojukwu University Teaching Hospital, Amaku Awka. The State Teaching Institution located in Anambra State and serving patients of all socio-economic status in South Eastern, Nigeria. The hospital offers both general and fertility health services for the people of Anambra and its environs.
Positive and HIV-negative patients. At enrolment, informed consent was obtained and each study participant was asked to complete a questionnaire that consisted of socio-demographic and personal details, history of present illness, clinical signs and symptoms, etc. Patients were grouped using the WHO staging system which ranges from the asymptomatic stage (Stage I) to mild symptoms (Stage II), advanced symptoms (Stage III), and severe symptoms (stage IV) [14]. The Simple Random Sampling without replacement described by Shelabh [15] was used. HIV Positive and HIV negative patients were selected among all the patients attending the hospital within the specified period. Descriptive statistics of socio-demographic variables and characteristics of the sample populations were expressed. Male and female subjects aged between 15 and >60 years old attending Chukwuemeka Odumegwu Ojukwu University Teaching Hospital, Amaku Awka were recruited. Patients younger than 15 years of age, individuals who refused to answer the questionnaires, individuals with a history of urinary tract infection symptoms, Diabetes mellitus, hypertension, renal diseases or sickle cell disease were not recruited.
Ethical approval for this study was obtained from the Hospital Management Board’s Ethics Committee, Chukwuemeka Odumegwu Ojukwu University Teaching Hospital, Amaku Awka.
The Specimen collection was done through the assistance of experienced Medical laboratory scientists
The HIV status of the patients was confirmed by guidelines provided by the National AIDS Control Organization (NACO, Strategy III) [16].
A total of 1200 patients were examined and 198 (16.5%) tested positive to HIV while 1002 (83.5%) tested negative to HIV. A total of 81 male and 117 female patients, representing 13.2% and 9.75% respectively tested positive to HIV and fungal infections. Cumulatively, 198 (16.5%) and 653 (54.41%) tested positive to HIV and fungal infections. The age group of study subjects ranged from 15 to >60 years. Infections with respect to age range were highest for 30-39 years, with 213 (17.75%) fungal infection and closely followed by 40-49 years 180 (15.0%). The least age range was >60 years which recorded 90 (7.5%). Fungal infection occurred most in subjects whose occupation was predominantly farming 183 (15.25%). The highest education status with fungal infection were the illiterates 17.08% (202) (Table 1).
Table 1: Socio-Demographic characteristics of subjects.| Characteristics | No. of subjects screened (%) | No. Tested +ve for HIV No. (%) | No. Tested -ve for HIV No. (%) | No. Tested +ve for fungal Infections No. (%) | No. Tested -ve for fungal Infections No. (%) |
|---|---|---|---|---|---|
| Gende | |||||
| Male | 590 (49.2) | 81 (6.75) | 509 (42.41) | 233 (19.41) | 357 (29.75) |
| Female | 610 (50.8) | 117 (9.75) | 493 (41.08) | 420 (35.0) | 190 (15.83) |
| Total | 1200 (100) | 198 (16.5) | 1002 (83.5) | 653 (54.41) | 547 (45.58) |
| Age (YEARS) | |||||
| 15-29 | 170 (14.2) | 26 (2.17) | 144 (12.0) | 60 (5.0) | 110 (9.17) |
| 30-39 | 278 (23.2) | 62 (5.17) | 216 (18.0) | 213 (17.75) | 65 (5.42) |
| 40-49 | 310 (25.8) | 48 (4.0) | 262 (21.8) | 180 (15.0) | 130 (10.83) |
| 50-59 | 240 (20.0) | 39 (3.25) | 201 (16.75) | 110 (9.17) | 130 (10.83) |
| >60 | 202 (16.8) | 23 (1.91) | 179 (14.92) | 90 (7.5) | 112 (9.33) |
| Total | 1200 (100) | 198 (16.5) | 1002 (83.5) | 653 (54.41) | 547 (45.58) |
| Occupation | |||||
| Housewives | 148 (12.3) | 13 (1.08) | 135 (11.25) | 32 (2.67) | 116 (9.67) |
| Students | 168 (14.0) | 20 (1.67) | 148 (12.33) | 14. (1.17) | 154 (12.83) |
| Farmers | 218 (18.2) | 53 (4.42) | 165 (13.75) | 183 (15.25) | 35 (2.92) |
| Civil Servants | 298 (24.8) | 46 (3.83) | 252 (21.0) | 158 (13.17 | 140 (11.67) |
| Traders | 195 (16.3) | 43 (3.58) | 152 (12.67) | 130 (10.83) | 65 (5.41) |
| Artisans | 173 (14.4) | 23 (1.92 | 150 (12.5) | 136 (11.3) | 37 (3.08) |
| Total | 1200 (100) | 198 (16.5) | 1002 (83.5) | 653 (54.4) | 547 (45.58) |
| Education Status | |||||
| Primary | 281 (23.4) | 59 (4.92) | 222 (18.5) | 198 (16.5) | 83 (6.91) |
| Secondary | 371 (30.9) | 39 (3.25) | 332 (27.67) | 140 (11.67) | 231 (19.25) |
| Tertiary | 335 (27.9) | 32 (2.67) | 303 (25.25) | 110 (9.17) | 225 (18.75) |
| Illiterates | 213 (17.8) | 68 (5.67) | 145 (12.08) | 205 (17.08) | 8 (0.67) |
| Total | 1200 (100) | 198 (16.5) | 1002 (83.5) | 653 (54.4) | 547 (45.58) |
| Religion | |||||
| Catholic | 525 (43.8) | 95 (7.9) | 430 (35.8) | 253 (21.08) | 272 (22.66) |
| Protestants | 309 (25.8) | 50 (4.17) | 259 (21.58) | 180 (15.0) | 129 (10.75) |
| Muslim | 80 (6.7) | 9 (0.75 | 71 (5.92) | 40 (3.33) | 40 (3.33) |
| Pentecostal | 175 (14.6) | 24 (2.0) | 151 (12.58) | 95 (7.9) | 80 (6.67) |
| Other | 111 (9.3) | 20 (1.67) | 91 (7.58) | 85 (7.08) | 26 (2.17) |
| Total | 1200 (100) | 198 (16.5) | 1002 (83.5) | 653 (54.4) | 547 (45.58) |
| Marital Status | |||||
| Single | 255 (21.3) | 51 (4.25) | 204 (17.0) | 200 (16.66) | 55 (4.58) |
| Married | 580 (48.3) | 64 (5.33) | 516 (43.0) | 191 (15.91) | 389 (32.42) |
| Separated/Divorced/ Widowed | 365 (30.4) | 83 (6.92) | 282 (23.5) | 262 (21.83) | 103 (8.58) |
| Total | 1200 (100) | 198 (16.5) | 1002 (83.5) | 653 (54.4) | 547 ( 45.58) |
| *Figures in brackets represent percentage prevalence of each group | |||||
The distribution of different fungal isolates among various clinical samples is found on Table 2.
Table 2: Species distribution of different fungal isolates.| Fungal isolates | No of isolates no (%) | Prevalence (%) |
|---|---|---|
| A. niger | 68 | 7.5 |
| A. fumigatus | 128 | 14.1 |
| A. flavus | 38 | 4.2 |
| Candida spp | ||
| Candida albicans | 458 | 50.4 |
| C. tropicalis | 90 | 10 |
| C. krusei | 20 | 4.4 |
| C. glabrata | 21 | 2.3 |
| Cryptococcus spp | ||
| C. neoformans | 18 | 2 |
| C. gat | 13 | 1.4 |
| Penicillium spp | ||
| Penicillium marneffei | 17 | 1.9 |
| Fusarium spp | ||
| Fusarium solani | 10 | 1.1 |
| Fusarium oxysporum | 7 | 0.8 |
| Total | 908 | 100 |
and Penicillium 1.9% (17) species which were isolated from skin specimen only. The highest number of clinical specimen screened was urine with the prevalence of 6.70% (141) in HIV positive patients 6.70% (141) and HIV negative patients 14.29% (301) followed by oropharyngeal swab 4.80% (101) and 15.19% (320) from HIV positive and negative individuals respectively. The least clinical specimen was skin scraping with the prevalence of 6.74% (142) from HIV positive patients and 2% (42) from HIV negative patients (Table 3).
Table 3: Distribution of different fungal isolates among various clinical samples.| Clinical Sample | No. of the clinical sample from patients (%) | No. of the clinical sample from HIV positive patients (%) | No. of the clinical sample from HIV negative patients (%) | Fungal organisms isolated | Fungal organisms (%) |
|---|---|---|---|---|---|
| Oropharyngeal swab | 421 (20.0) | 101 (4.80) | 320 (15.19) | Candida spp | 168 (18.5) |
| Sputum specimen | 385 (18.3) | 92 (4.37) | 293 (13.91) | Aspergillus spp | 72 (7.9) |
| Candida spp | 85 (9.4) | ||||
| Cryptococcus spp | 7 (0.8) | ||||
| Blood specimen | 343 (16.3) | 144 (6.84) | 199 (9.45) | Candida spp | 177 (19.5) |
| Cryptococcus spp | 10 (1.1) | ||||
| Stool specimen | 331 (15.7) | 60 (2.85) | 271 (12.87) | Aspergillus spp | 5 (0.6) |
| Candida spp | 31 (3.4) | ||||
| Urine specimen | 442 (21.0) | 141 (6.70) | 301 (14.29) | Aspergillus spp | 88 (9.7) |
| Candida spp | 74 (8.1) | ||||
| Cryptococcus spp | 14 (1.5) | ||||
| Skin specimen | 184 (8.7) | 142 (6.74) | 42 (2.0) | Aspergillus spp | 69 (7.6) |
| Candida spp | 74 (8.1) | ||||
| Fusarium spp | 17 (1.9) | ||||
| Penicillium spp | 17 (1.9) | ||||
| Total | 2106 (100) | 680 (32.3) | 1426 (67.7 | 908 (100) | |
| *Figures in brackets represent percentage prevalence of each group | |||||
Nine hundred and eight organisms were isolated. Differences in the isolation rate were statistically significant. Candida albicans had the highest frequency 50.4% (458) followed by Aspergillus fumigatus 14.1% (128). Others include Cryptococcus neoformans 2.0% (18) and Penicillium marneffei 1.9% (17). The organism with the lowest frequency was Fusarium oxysporum 0.8% (7). In this study, out of a total of 2106 clinical specimens screened, Candida spp. was the most prevalent organism isolated from all the specimens; oropharyngeal swab 18.5% (168), sputum 9.4% (85), blood 19.5% (177), stool 3.4% (31), urine 8.1% (74) and skin 8.1% (74) followed by Aspergillus and Cryptococcus species. The organisms with the least prevalent rate were Fusarium 1.9%(17)
Weight loss was the most frequent clinical presentation from patients with a prevalence rate of 4.33% (52) in males and females 6.0% (72), followed by an oral ulcer. Neck rigidity was the least clinical presentation recorded (Table 4).
Table 4: Frequency of Clinical Presentation in relation to sex.
| Clinical Presentation | No. of participants Examined (%) | Male No. (%) | Female No. (%) |
|---|---|---|---|
| Weight loss | 124 (10.3) | 52 (4.33) | 72 (6.0) |
| Oral ulcer | 120 (10.0) | 50 (4.17) | 70 (5.83) |
| Fever | 118 (9.8) | 50 (4.17) | 68 (5.67) |
| Headache | 117 (9.8) | 51 (4.25) | 66 (5.5) |
| Loss of appetite | 109 (9.1) | 42 (3.5) | 67 (5.58) |
| Cough | 100 (8.3) | 38 (3.16) | 62 (5.16) |
| Dyspnea | 101 (8.4) | 43 (3.58) | 58 (4.83) |
| Diarrhea | 94 (7.8) | 26 (2.16) | 68 (5.67) |
| Neck rigidity | 89 (7.4) | 41 (3.41) | 48 (4.0) |
| Others | 129(10.8) | 64 (5.33) | 65 (5.42) |
| Asymptomatic | 99 (8.3) | 39 (3.25) | 60 (5.0) |
| *Figures in brackets represent percentage prevalence of each group. | |||
The system involvement in patients in relation to sex is presented on Table 5. The Gastrointestinal Tract (GIT) was mostly affected.The prevalence rate in male is 11.83% (142) and in female 14.75% (177) followed by the respiratory tract with male prevalence rate of 12.33% (148) and female 12.92% (155).The least was the skin with the prevalence rate of 2.5% (30) in male and in female 4.25% ( 51).
Cases of known diagnosis before visiting the hospital were 710 (59.20%) while a new diagnosis was 490 (40.8%). Those currently receiving ART 702 (58.5%) were higher than those who were not yet on ART 498 (41.5%). However, patients who have received ART for more than 24 weeks were more 450 (64.1%) than those who have received for just 24 weeks 252 (35.9%).
Table 5: System Involvement in Patients| System | No. of Patients (%) | Male No. (%) | Female No. (%) |
|---|---|---|---|
| Gastrointestinal Tract (GIT) | 319(26.58) | 142(11.83 | 177(14.75) |
| Respiratory | 303(25.25) | 148(12.33 | 155(12.92) |
| Central Nervous System | 258(21.50) | 108(9.0) | 150(12.5) |
| Colorectal | 142(11.83) | 61(5.08) | 81(6.75) |
| Genitourinary | 97(8.08) | 41(3.41) | 56(4.67) |
| Skin | 81(6.75) | 30(2.5) | 51(4.25) |
| Total | 1200(100) | 530(44.2) | 670(55.8) |
| *Figures in brackets represent percentage prevalence of each group. | |||
| HIV Status on Admission | No. of Patients | HIV +ve | HIV -ve |
|---|---|---|---|
| Known | 710 | 119 (9.9) | 591 (0.5) |
| New Diagnosis | 490 | 79 (6.6) | 411 (34.3) |
| Total | 1200 | 198 (16.5) | 1002 (83.5) |
| Currently Receiving ART | |||
| No | 498 | 124 (10.3) | 374 (31.2) |
| Yes | 702 | 74 (6.2) | 628 (52.3) |
| Total | 1200 | 198 (16.5) | 1002 (83.5) |
| Duration of ART | |||
| >24Weeks | 490 | 131 (10.9) | 319 (26.6) |
| < 24Weeks | 252 | 33 (2.8) | 219 (18.3) |
| Total | 702 | 198 (16.5) | 1002 (83.5) |
| *Figures in brackets represent percentage prevalence of each group. | |||
In this study, the number of patients who had fungal infections was more in HIV positive patients than in HIV negative individuals. This could be attributed to the fact that HIV infection reduces the immunity; CD4 count, in patients and leaves them susceptible to opportunistic infections, mostly fungal infections. This was similar to the results of other studies done by Chen, et al, (2013) and Maurya, et al., (2013) in Northern Taiwan and Northern India respectively, who reported that Oropharyngeal Candidosis (OPC) is an opportunistic fungal infection that is commonly found in HIV-infected patients [17,18]. However, the number of females 35% (450) who had fungal infections and subsequently positive to HIV were more compared to males 119.4% (233). Furthermore, majority of the patients who had fungal infection and subsequently HIV positive belonged to 30-39 years in the ratio of (3.43: 1), the most productive age group of the country, showing a female preponderance with a male to female ratio of (2.88:1; 3.59:1). Again, this is consistent with studies on HIV patients in India and Iran [19,20]. The preponderance of females may be due to the vulnerabilities created by the unequal cultural, social and economic status of the genders [21,22] or due to anatomical variations. Males give out while females receive during sexual acts making it more likely for the females to be infected [22].
Candida species 67.1% (609) were the most prevalent fungi isolated followed by Aspergillus spp. 25.8% (234) and Cryptococcus species 3.4%(31). This observation is similar to the studies of Jahromi, et al. [23], Pagano, et al. [24], Kashyap, et al. [25] and Parmar, et al. [26]. Similarly, Candida species (18.5%) was the most common organism isolated from oropharyngeal specimen making oropharyngeal candidiasis the most common opportunistic fungal infection. This is in line with other studies [27, 28]. The occurrence of oral candidiasis is recognized as an indicator of immune suppression and is often found in HIV infected patients with CD4 counts fewer than 200 cells/µL [29, 30]. C. albicans has been reported as the most pathogenic of Candida species [31-33].
Also, the present study highlighted that the prevalence of Candida species was significantly higher (ρ value, P ≤ 0.05) in the HIV positive study group as compared to the HIV negative control group. This is similar to the results of other studies [17, 18]. In sputum specimen, Candida species 9.4% (85) predominates followed by Aspergillus species 7.9% (72). The least prevalent specie was Cryptococcus 0.8% (7).However, there was low prevalence of fungal infection in sputum compared to our study which is in line with Bharathi et al. [36,37]. According to the Ochiabuto et al. [38], a total of six different fungal isolates were recorded in their study from sputum specimens, with C. albicans isolates the highest. Among the Candida species, C. glabrata (7%) was isolated in this study. The report also stated that C. glabrata was also isolated [39,40]. Based on the site of sample collection, the Candida species (91.4%) was the most common pathogen isolated from hospitalized subjects followed by Cryptococcus species (3.74%). Prevalence of Candida infection was higher although a lot of variation in the prevalence and incidence of candidemia has been reported in different places in India varies from 1.6% to 6.9% [41-42]. In the stool specimen, Candida spp.prevalence rate was 3.4% (31) and Aspergillus spp. 0.6% (5) were isolated in this study, indicating that these yeasts can survive in the extreme conditions of the gastrointestinal tract. Recent studies have demonstrated an incidence of fungemia caused by Aspergillus spp between 2.3% and 5.34% in the USA and Europe, respectively [43]. In the urine specimen, Candida spp. 8.1%(74) Aspergillus spp. 9.7%(88) and Cryptococcus spp. 1.5%(14) were isolated in this study. A point prevalence survey done in 228 hospitals from 29 European countries stated that 9.4% of nosocomial Urinary tract infections were caused by Candida spp. and Aspergillus spp., though minimal. Depending on the population examined, Candida is reported in up to 44% of urine samples sent for culture. Two retrospective analyses were done in Israel and Italy found much lower rates (varying between 0 and 1.4%) in urine cultures [44].
Aspergillus species were isolated from sputum 7.9% (72), stool 0.6% (5), urine 9.7% (88) and skin specimen 7.6% (69). Aspergillus exposure is universal, though invasive aspergillosis is rare in general, it is commonly found in immunocompromised cases like in HIV infection [45]. According to Bharanthi et al. [46] out of 13 specimens isolated, A. fumigatus was isolated in 6 specimens; A. niger was isolated in another 6 specimens and A. flavus in one specimen. Since the findings of this study correlate significantly with the previous report stated, Aspergillus species could be said to be the second most prevalent species in HIV patients. Sturt [47] revealed that Aspergillus was cultured from the sputum of 45 patients with HIV, but only 5 patients were not infected with Aspergillus species. In a separate study of 40 AIDS patients with cultures of Aspergillus species, 24 of the cultures represented colonization. This finding suggests that the detection of Aspergillus by sputum culture, even in patients with advanced HIV infection, is equivalent to documenting invasive disease requiring antifungal therapy.
Cryptococcus neoformans was isolated from three specimens (sputum, blood, and urine) in this study. This finding is similar to that of a study carried out in Cameroon where C. neoformans had a rate of 2.04% in HIV patients [48]. C. neoformans was also isolated from 5 samples out of 100 samples from HIV patients in India [49]. This means that its prevalence is low in most localities. Cryptococcosis is an AIDSdefining illness, WHO stage IV and caused by Cryptococcus neoformans. It is an opportunistic fungal infection, often seen in the immunocompromised. It is the second commonest opportunistic infection after tuberculosis in South East Asia In this study, the prevalence was slightly above the WHO estimate. Studies done by many researchers have placed the CD4 T+ cells at the manifestation of Cryptococcus disease at < 100 cell/mm3. This research work corroborated this, as all the study specimens showed CD4< 100 cells/mm3.
Penicillium marneffei was the third most common fungi isolated in this study. Penicilliosis is the third common opportunistic infection in patients with AIDS [51]. It is believed to hasten the emergence of AIDS and is always associated with low CD4 count typically less than 100 cells/μl [36]. It is very pathogenic and can mimic tuberculosis with 50% cases resulting in cough, dyspnea, and hemoptysis. According to an earlier study,by Bharanti and Usha, Penicillium marneffei was isolated from HIV positive individuals whose CD4 counts were less than 100 cells/μl [52].
Similar low incidences of Penicilliosis in HIV positive patients from Africa have been reported by Iroezindu et al. [53] (1.25%) and Alli et al. [54] (3.2%). The main reason for the low prevalence of Penicillium marneffei infection in Nigeria is the unavailability of high-quality diagnostic laboratories and low yield specimens, as bronchoalveolar lavage is not performed in most hospitals [53].
More so, the findings of Xiao et al.[29], revealed the prevalence of Penicillium marneffei (1.4%) to be almost similar to our findings (1.9%). He also reported that P. marneffei within an osteolytic lesion in an HIV-negative person is a rarely reported diagnosis. This patient’s corticosteroid treatment for subacute thyroiditis, which affected the patient’s immune function, possibly increased her chance of infection. The symptoms that lead to the diagnosis of P. marneffei infection are often non-specific and it tends to be regularly misdiagnosed. Cases of P. marneffei in non-HIV-infected patients are rare and other reports have shown that there are different clinical manifestations between HIV-positive and HIV-negative patients.
Presence of weight loss, oral ulcers, loss of appetite and neck rigidity seen in this study constitute clinical features of oral thrush and esophageal candidiasis. These features affect oral intake and and significantly affect the quality of life of such patients and are considered important markers of clinical disease progression and immunosuppression [54]. As seen with other studies [55], majority of the HIV positive patients in this study presented with more of these symptoms that HIV negative petients at the time of recruitment .However, according to Kaur et al., [56], the most common system involvement in clinical infection of HIV was Gastrointestinal (GI) and Respiratory tract which is similar to this study. This study revealed that cases of the number of HIV patients before visiting the hospital were more than patients screened at the point of visiting the hospital. Similar results were also observed in the work Bharanthi, et al. [57] that more patients are aware of their HIV status.Moreso, those currently receiving ART were higher than those who were not yet on ART. However, patients who have received ART for more than 24 weeks were more than those who have received for just 24 weeks. This finding is consistent with previous reports from various countries. Ceballos et al., [58], in their studies of 154 patients who were on ART for a minimum of 6 months, reported a 30% reduction in the prevalence of fungal colonisation.
This study has revealed that HIV positive and Negative patients are often affected with fungal infections in COOUTH, Anambra State, Nigeria. This may have contributed to impaired immune system in patients and development of AIDS in HIV infected patients. The researchers have recommended the constant monitoring; treatment, and evaluation of the fungal infection in the area and in other Teaching Hospitals in the country should be encouraged. Also, both viral load and CD4 cell count monitoring be used in monitoring the risk of opportunistic infection (OI) and treatment failure. These can be used to significantly improve the life expectancy of patients living with HIV and fungi infections. Sharing of unhygienic personal belongings with the infected patients and intimate association with pet animals could increase the mode of transmission. However, HIV/AIDS and fungi infections awareness campaigns among people in Anambra State must be given a particular attention to specific issues on their transmission, risk factors and management and starting antiretroviral treatment as soon as possible, and sustaining it as part of everyday routine, is the best way of ensuring that the immune system stays strong.
