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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 2  |  Page : 190-194

Fungal isolates findings of sputum samples in new and previously treated cases of pulmonary tuberculosis in dr. soetomo hospital surabaya, Indonesia


1 Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
2 Department of Clinical Microbiology, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia

Date of Web Publication29-May-2020

Correspondence Address:
Soedarsono Soedarsono
Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Airlangga, Jl. Mayjen Prof. Dr. Moestopo No. 47, Surabaya 60131
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_1_20

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  Abstract 


Background: Fungal infections generally occur in immunosuppressive patients. Long-term tuberculosis (TB) treatment facilitates the occurrence of fungal infections, such as long-term antibiotics administration which is immunosuppressive agents and increases the opportunity of infections. Other factors may be correlated with fungal infection such as age, sex, malnutrition, smoking, diabetes mellitus, lung lesion severity, and the presence of multidrug-resistant TB. This study aims to identify and analyze the proportion of fungal isolates findings in the sputum of new and previously treated cases of pulmonary TB patients. Methods: This was an observational analytic study with a cross-sectional design of all pulmonary TB patients who were hospitalized in Dr. Soetomo Hospital Surabaya. Sputum samples were inoculated on Sabouraud's dextrose agar medium. The growth of visible colonies was identified by Lactophenol Cotton Blue staining using direct microscopy. Results: Fungal isolates were found in 148/193 (77%) pulmonary TB patients. Candida species was found 99% among 148 fungal positive culture. Candida albicans was the most common found fungal species (54.05%), followed by Candida sp (26.35%), Candida glabrata (10.13%), Candida krusei (5.4%), and Candida tropicalis (1.35%). Previously treated cases, sex, malnutrition, and smoking were variables correlated with fungal isolates finding with P value of 0.015, 0.006, 0.010, and <0.001, respectively. Conclusion: The proportion of fungal positive cultures in previously treated cases was higher than in new cases. C. albicans was the most common fungal species both in previously treated cases and new cases of pulmonary TB.

Keywords: Candida species, Mycobacterium tuberculosis, pulmonary fungal coinfection, pulmonary tuberculosis


How to cite this article:
Soedarsono S, Prasetiyo YD, Mertaniasih NM. Fungal isolates findings of sputum samples in new and previously treated cases of pulmonary tuberculosis in dr. soetomo hospital surabaya, Indonesia. Int J Mycobacteriol 2020;9:190-4

How to cite this URL:
Soedarsono S, Prasetiyo YD, Mertaniasih NM. Fungal isolates findings of sputum samples in new and previously treated cases of pulmonary tuberculosis in dr. soetomo hospital surabaya, Indonesia. Int J Mycobacteriol [serial online] 2020 [cited 2020 Jul 9];9:190-4. Available from: http://www.ijmyco.org/text.asp?2020/9/2/190/285218




  Introduction Top


Tuberculosis (TB) remains a global public health crisis causing 10 million and 1.2 million deaths in 2018 worldwide. Indonesia is one of the 30 countries with a high TB burden in the world and is in the 3rd rank after India and China with 845,000 TB cases or 316 cases per 100,000 populations in 2018.[1] Pulmonary TB is a chronic lung disease caused by Mycobacterium tuberculosis and characterized by lung damage along with caseation, necrosis, and fibrosis which lead the cavity formation. This cavity is rich in oxygen and necrotic tissue material so that it will become a growth site for several organisms including fungi.[2],[3]

Fungal infections and pulmonary TB generally occur in immunosuppressive patients.[4],[5] Long-term TB treatment by anti-TB drugs facilitates the occurrence of fungal infections, such as long-term antibiotics administration which is immunosuppressive agents and increase the opportunity of infections. Fungal infection may occurs in the early stage of TB disease, but doctors usually prescribe only anti TB drugs that cause patients to require more time for cure due to fungal infections coexistence.[6]

Fungal coinfection can be acquired primarily or secondarily in TB, immunodeficiency patients, chronic diseases such as diabetes mellitus (DM) or malignancy may worsen the primary disease.[3],[7] Bacteria can affect the growth and physiology of fungi, and fungi can also control the bacterial activity.[8] Various Candida species have long been associated with pulmonary TB and have assumed as emerging pathogens in TB patients.[9]Candida infections generally occur in immunosuppressive patients, especially in patients who have been treated with immunosuppressor, but TB infection might impair the host's immune system and increase the risk of invasive candidiasis in an immunocompetent patient.[10] Previous study reported that Aspergillus niger, A. fumigatus, Histoplasma capsulatum, and Cryptococcus neoformans are the main causes of infections affected by pulmonary TB.[6] A broad differential diagnosis was needed in patients with TB symptoms, especially in patients with negative for acid fast bacilli sputum smear, TB standard treatment failure cases, or patients with risk factors for fungal infection.[11] The diagnosis of the coexistence of pulmonary TB and fungal infections is also crucial to improve the treatment outcomes.

The coexistence of pulmonary TB and fungal infections will affect the treatment and increased mortality. Previous studies reported coinfection of TB with fungi is 12.3% in Iran,[12] 38%–49% in India,[13],[14] and 44.18% in Kenya.[15] The distinction between infection and colonization can be difficult.[16] A study about the data of fungal coexistence with M. tuberculosis in Indonesia is limited. This study aims to identify and analyze the proportion of fungal isolates in the sputum of new and previously treated cases of pulmonary TB patients.


  Methods Top


This was an observational analytic study with a cross-sectional design. Samples were collected from all pulmonary TB patients from March 2018 to February 2019, hospitalized in Dr. Soetomo Hospital Surabaya, which is the center of East Indonesia TB Referral Hospital. Sputum samples were taken from new and previously treated TB patients. New cases of pulmonary TB are patients who have never been treated for TB or have taken anti-TB drugs for <1-month or freshly diagnosed with TB. Previously treated TB cases of pulmonary TB are patients who have received 1-month or more anti-TB drugs in the past.[17] Previously treated cases are pulmonary TB patients from cases of treatment failure, after default, and relapse. The severity degree on chest X-ray was divided into mild, moderate, and severe. The severity was determined by using a scoring method adapted from Yan et al.[18] Underweight body mass index (<18.5) was considered as malnutrition. Exclusion criteria in this study were pulmonary TB patients with HIV, cancer, hospitalized in intensive care unit, neutropenia, liver disease, renal failure, and hematological disease. Sputum samples were inoculated on Sabouraud's dextrose agar medium supplemented with 50 mg/ml chloramphenicol. The inoculated specimens were incubated and observed at regular intervals for up to 4 weeks. The visible colonies were subcultured on Sabouraud's dextrose agar slants. The growth was identified by Lactophenol Cotton Blue staining using direct microscopy. Fungal species identification is according to the characteristic of morphology.[2],[14] SPSS 21.0 (SPSS 21.0 by IBM Corporation, New York, United States) was used for all statistical analyses. Statistical results were considered significant if the P < 0.05. This study was approved by the ethics committee in health research of Dr. Soetomo Hospital with ethical clearance number 0054/KEPK/II/2018 and has been approved on February 20, 2018.


  Results Top


A total of 193 pulmonary TB patients were included in this study from 68/193 (35%) previously treated cases and 125/193 (65%) new cases. [Table 1] shows the profile of pulmonary TB as the study subjects.
Table 1: Profile of study subjects

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Fungal were isolated in 148/193 (77%) patients, while 45/193 (23%) TB patients showed negative fungal isolate. History of previous TB treatment, sex, malnutrition, and smokers are correlated with fungal isolate findings, P value 0.015, 0.006, 0.010, and <0.001, respectively, as presented in [Table 2].
Table 2: Comparison of pulmonary tuberculosis with positive and negative fungal isolate findings

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Our study found 148 fungal species in pulmonary TB patients. Candida albicans is the most common fungal species in pulmonary TB patients with 80/148 (54.05%). Isolated fungal was found to be higher in the new cases of pulmonary TB as presented in [Table 3]. This may occur due to the high amount of new pulmonary TB cases in study subjects [Table 1].
Table 3: Fungal isolate finding proportion in pulmonary tuberculosis patients (n=148)

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  Discussion Top


Pulmonary TB patients in this study included 68/193 (35%) previously treated cases and 125/193 (65%) new cases. Fungal were isolated from 148/193 (77%) pulmonary TB patients. Fungal infection may occur in immunosuppressed patients like TB patients due to the long-term anti-TB administration. There was a significant difference in lung lesion severity between previously treated cases and new cases with a P = 0.024. Some bacilli can remain dormant and reactivate causing postprimary TB. A delay in the period time from the onset of symptoms to treatment initiation might contribute to a greater spread and progression of lung lesions. Severe lesions at the start of anti-TB treatment might lead to severe lesions after completion. Residual radiological lesions may persist even after successful treatment of TB.[19]

Pulmonary TB with co-morbid of DM in this study was 44/193 (28%), smokers were 66/193 (34%). DM is associated with an increased risk of TB. The long duration of DM is associated with the development of active TB and posttreatment reinfection of TB.[20],[21] DM is also correlated with the presence of fungal infection in pulmonary TB.[3] The prevalence of smokers may higher due to there is no data on passive smokers and previous history of smoking before diagnosed with TB. The prevalence of smoking among TB patients is 39.3% in Spain, 54.6% in China, 56% in South Africa, and 81.5% in India.[22],[23],[24],[25] Either active smokers and passive exposure to tobacco smoke are a risk factor for TB and risk for posttreatment relapse.[25],[26] Multidrug-resistant TB (MDR-TB) patients in this study were 30/193 (16%) consisted of 17 previously treated cases and 13 new cases. The previous history of TB treatment was a risk factor for DR-TB.[27],[28],[29]

In this present study, the previous history of TB treatment, sex, malnutrition, and smoking are variables correlated with positive fungal isolate finding in the sputum culture with P value of 0.015, 0.006, 0.010, and < 0.001, respectively. The proportion of fungal isolate findings in previously treated cases was higher than in new cases (86.8% vs. 71.2%). This was in accordance with the previous study that reported freshly diagnosed or untreated group was less associated with pulmonary mycoses.[30] The proportion of fungal positive culture in women was higher, compared to men (86% vs. 69.2%) and showed a significant difference with a P = 0.006. The previous study reported that pulmonary mycosis was more common in women compared to men (6% vs. 4%, P = 0.061),[31] being male was significantly correlated with fungal detection.[3]Candida coinfection was found in 62.5% of women patients and 29.4% men patients (P = 0.013).[5] Another study reported different result that >60% of men were found fungal culture positive, this due to their greater exposure to the surrounding.[6] Malnutrition was significantly correlated in this study with a P = 0.010. Previous studies also stated that malnutrition is one of the predisposing factors for fungal infections.[32],[33] An important and major risk factor for fungal infections is the use of broad-spectrum antibiotics that reduces the number of bacteria from microbiota and allows fungal growth leading to opportunistic infections.[34]

Of the 66 smokers, 39 of them (59.1%) were positive fungal culture, this was higher than the previous study by Osman et al., fungal positive cultures were found in 45.5% of smokers. Severe lung lesions, co-morbid of DM, and MDR-TB were not correlated with fungal infections in this study with P value of 0.184, 0.186, and 0.640, respectively. Other studies reported a different result, fungal infections are more common in DM, particularly those caused by Candida.[16] A significant correlation between fungal infections and MDR-TB, smoking, DM, and severity of X-ray finding. MDR-TB patients have a higher percentage of fungal infections, compared to fresh and relapse TB.[3] In this present study, MDR-TB was not correlated with fungal positive culture findings probably because the diagnosis of MDR-TB had just been confirmed and have not treated yet with MDR-TB regimen.

The positive fungal proportion in this study was 148/193 (77%). Candida species was found in 147/193 (76%) among all TB patients, this was higher than previous study in India which reported 60% Candida proportion in pulmonary TB patients. There is a considerable variation of 9–80% in positive fungal reported on the occurrence of Candida species in the sputum of pulmonary TB patients. This variation of fungal proportion may occur due to the change in the geographical distribution, genetic of the patients, sample size and type of culture media used.[30]

Candida species was found 99% and Stephanoascus ciferii was found only 1% among 148 positive fungal cultures in this present study. Another study reported Candida coinfection in 40% of pulmonary TB patients.[5]Candida species have been reported as the most common fungal agent isolated from the sputum of pulmonary TB patients and C. albicans is also the most common found in previous studies.[2],[5],[13],[14],[30],[31],[34] Another study reported Aspergillus spp. as the most predominant fungi, followed by C. albicans spp.[12] Various Candida species have long been associated with pulmonary TB and have assumed as an emerging pathogen in TB patients.[9]Candida infections generally occur in immunosuppressive patients, especially in patients who have been treated with immunosuppressors, but TB infection might impair the host's immune system and increase the risk of invasive candidiasis in an immunocompetent patient. C. albicans is the most prevalent fungal organism with the ability to causing infections, including slight mucocutaneous infection to invasive forms affecting the multiple organs.[10],[12]

C. albicans was the most common fungal isolate found in our study (54.05%), followed by Candida sp. (26.35%), Candida glabrata (10.13%), Candida krusei (5.4%), and Candida tropicalis (1.35%). Previous studies also reported C. albicans, C. glabrata, C. tropicalis, and C. krusei in their study of fungal prevalence among pulmonary TB patients.[2],[5],[7],[30],[31] Generally, study of Candida species from blood culture using corn meal tween agar method found Candida parapsilosis as the most common fungi, followed by C. tropicalis and C. albicans.[35]C. tropicalis is the new opportunistic pathogen causing infection in patients with preexisting lung disease. C. tropicalis has a greater capacity than C. albicans to invade the deep tissues of the immunocompromised host.[2]


  Conclusions Top


The proportion of fungal positive cultures in previously treated cases was higher than in new cases with 86.8% versus 71.2%. Sex, malnutrition, and smoking were also the variables correlated with positive fungal culture in pulmonary TB patients. C. albicans was the most common fungal species.

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Conflicts of interest

There are no conflicts of interest.



 
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