Introduction
Esophageal Candidiasis (EC) is an active common resourceful infection in humans with lower immunity, for example- Human immunodeficiency virus (HIV) infection, diabetes mellitus. Sometime we can also see esophageal candidiasis in healthy human beings without any immunosuppressive disease. There are certain predisposing factors responsible for esophageal candidiasis in a healthy individual. Esophageal diseases such as non-infectious esophagitis or achalasia are also the cause of development of esophageal candidiasis.1 Candidiasis is frequently fungal disease found in individuals affecting mucosa, nails and other parts. It is spread by various species of Candida like Candida albicans. The disease may be severe or long-lasting, external or deep and their clinical manifestations are varied according to the site of involvement. It is very rarely found as disease and mainly seen as secondary infection in immunocompromised patients. 2 Uses of antibiotic drugs, corticosteroids and immunosuppresses for longer time are also including with the risk of candidiasis. In the year 1990 the addition of novel era of oral antifungal drug has been recognized as an important agent for treatment of patients suffering from candida infection. Fluconazole is recommended as the effective drug for treatment of esophageal candidiasis. 3 Esophageal candidiasis is the infection developed by the colonization of candida species mainly in the lower third of esophagus, as a result of whitish plaques related to oral thrush. 1 that is especially visible in the extreme or in long lasting HIV contamination. almost, 90% of AIDS (Acquired Immunodeficiency Syndrome) sufferers get affected from oropharyngeal or esophageal candidiasis consistent with the colonization of the species at the infectious site.1 Fluconazole is the preference for EC due to the fact fluconazole is commonly secured and has permits the quick clinical response and can be digested at any gastric pH. 3
Materials and Methods
A prospective observational study was carried out for one year in the Teerthanker Mahaveer medical college & research center (TMMC&RC) Moradabad from January 2020 to December 2020. A total of 4,256 upper gastrointestinal endoscopy performed, Out of which 73 endoscopy results was similar to features suggestive of esophageal candidiasis were taken for Candida species isolation and their antifungal sensitivity test to fluconazole. All the patients included in the study were informed regarding the same and informed consent was taken. The collected sample was further processed for culture on Sabouraud Dextrose agar (SDA). Isolated colonies were identified based on cultural characteristics, gram stain for the appearance of budding yeast cells with or without pseudohyphae, growth on chromogenic medium (CHROMagar), Germ tube test for the differentiation of Candida albicans and NAC.2
All species of candida were tested for antifungal susceptibility by disc diffusion method on Mueller Hinton Agar (MHA) supplemented with 2% Glucose and 0.5 mg Methylene blue. 4 The antifungal disc used was Fluconazole (25μg). The antifungal susceptibility of the isolates were interpreted as sensitive (S) and resistant (R) as per the clinical and laboratory standards institute (CLSI) standards. 5
Result
Total 4256 patients referred to UGI endoscopy at the endoscopy unit, 73(1.7%) had found whitish plaques adhered to esophageal mucosa resembling to esophageal candidiasis. Most affected age group from this disease was found 41-60 years (48%).
Bar diagram showing age-group wise distribution of the disease
Out of 73(1.7%) samples, the isolated Candida species were C.albicans 50(68.5%), C.glabrata 08(11%), C.parapsilosis 8(11%), C.dubliniensis 04(5.4%), C.tropicalis 02(2.7%), C.krusei 01(1.4%).
Discussion
Candida species are the most common cause of fungal infections, leading to a range of life-threatening, invasive to non-life threatening mucocutaneous diseases. The species are endogenous in nature and are usually responsible for opportunistic infections. In addition, there is an increased incidence of Candidiasis due to the use of various broad spectrum antibiotics, immunosuppressive drugs and corticosteroids. Prevalence rate of Esophageal candidiasis in our research center was 1.7% nearly similar to Underwood JA et al. (2003) 6 who found 1.17% prevalence rate and another study conducted between March 2006 to April 2007 by Wilheim et al (2009) 7 found 1.5% prevalence rate of esophageal candidiasis. The dissimilarity of this result was found in the study conducted by KLIEMANN et al. (2008), 8 who found 0.74% prevalence rate. There are various reports showing increasing rate of resistant towards fluconazole specially NAC species which permits its careful use as a prophylactic agent in hospitals.
All 73 samples included in this study were found positive with esophageal candidiasis. In which 50(68.5%) patients sample has found Candida albicans, which is commonly found infectious strain of the candida and rest of the samples 23(31.5%) were found Non-albicans Candida, respectively C.glabrata 11%, C.parapsilosis 11%, C.dubliniensis 5.4%, C.tropicalis 2.7% and C.krusei was 1.4%, while Shafi FT et al. (2015) 9 found in his study that Candida albicans was frequent isolated strain (64%). Another study conducted by Nadagir SD et al. (2008) 10 in Karnataka, they found C.albicans and NAC percentage was 66.6% and 33.3% respectively. It may be due to various epidemiologic factors. Candida species are frequently found in hospital environment, food, surfaces, in most cases prior colonization has been shown. In our study the most affected age group for EC was 41-60 years (35.5%), this report was in concordance with the study conducted by Lakshmy et al. 11 where higher number of patients were from the age group of 41-60 years (71.4%), while only 40.0% patients were in the age group of < 50. Similar findings have been reported in studies by Jayachandran AL et al. 12 who reported in their study that most affected age group from Candidiasis were 41-60 years (35.5%). This can be because of attributed to the various co-morbid symptoms and health problems to this age group. This study also shows the results that Candidiasis is more diagnosed in male more than females.
As an overall result for this study we reported that there was 73 samples conducted in this study in which we found 56(76.7%) samples was sensitive to antifungal fluconazole and 15(20.6%) samples showing resistance to fluconazole, rest 2(2.7%) was found intermediate to that particular drug. In addition to this result we define every strain that there were only 50(68.5%) samples found as Candida albicans. In which out of 50, 38 (76%) samples found sensitive to fluconazole and 10(20%) samples shows resistance to fluconazole, rest 2(4%) found intermediate. Our finding is also agreement with the corresponding study conducted by Khadka S et al. 13 in 2017, they found 71.5% C.albicans sensitive to fluconazole and 17.9% was resistance to fluconazole and 10.8% were shows SDD. According to another study conducted in our institute by Ahamad I et al. 14 in 2019, they found higher resistance 36.11% in C.albicans for fluconazole. This pattern of resistance is in agreement with the findings of Dutta V et al. (2015). 15 Who found 23% C. albican showing resistant pattern for antifungal fluconazole. In our study we found 23 NAC species in which Candida glabrata showing resistance in 2(25%) samples out of 8 and same results shown for C.parapsilosis 2(25%) samples out of 8. Further results are C.tropicalis which is showing 0% resistance and 100% sensitivity to fluconazole. C.krusei that is reporting 100% resistance and last one is C.dubliniensis that shows 100% sensitive pattern regard fluconazole. The major cause of showing resistance pattern might be widespread use of fluconazole in various clinical problems.
Conclusion
The present study provided the latest information regarding the “speciation of candida species in patients with esophageal candidiasis and their antifungal sensitivity pattern to antifungal fluconazole” in our hospital. Esophageal Candidiasis is an emerging significant problem in patients coming in endoscopy unit. This study will also provide an opportunity to prevent infection by effective measures like awareness of esophageal candidiasis. Treatment can be initiated at an early stage leading to reduction in complications and associated health issues. This study further gives an opportunity to fight this disease untidily by clinicians and microbiologists, to validate clinical presentation of esophageal candidiasis and to understand the relation between clinically suspected and laboratory confirmed cases.
The record for increased resistance pattern to fluconazole incorporates a major concerning on the morbidity, management of those patients and need to be some various treatments. Treatment can be initiated at an early stage leading to reduction in complications and associated health issues regarding esophageal candidiasis.
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