Epidemiology, laboratory diagnosis and clinical aspects of fungal pulmonary infections in 384 patients hospitalized in pulmonary units in Guilan province, Iran

  • Zahra Rafat Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
  • Seyed Jamal Hashemi Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran AND Food Microbiology Research Center, Tehran University of Medical Sciences, Tehran, Iran
  • Keyhan Ashrafi Department of Medical Microbiology, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
  • Iraj Nikokar Medical Biotechnology Research Center, School of Paramedicine, Guilan University of Medical Sciences, Rasht, Iran
  • Alireza Jafari Urology Research Center, Razi Hospital, Guilan University of Medical Sciences, Rasht, Iran
  • Abbas Rahimi Foroushani Department of Statistics and Epidemiology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
  • Behrad Roohi Department of Medical Mycology, Mazandaran University of Medical Sciences, Sari, Iran
  • Zeinab Borjian Boroujeni Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
  • Niki Najar-Shahri Medical Biotechnology Research Center, School of Paramedicine, Guilan University of Medical Sciences, Rasht, Iran
Keywords:
Bronchoalveolar lavage;, Sputum;, Candidiasis;, Fungal respiratory infections;, Invasive pulmonary aspergillosis;, Galactomannan antigen

Abstract

Background and Objectives: The respiratory tract is the most common site for developing fungal infections. People who have a weakened immune system are more susceptible to respiratory system involvement with fungi. Fungal infections of the respiratory tract are largely unrecognized and their true burden is elusive. Therefore, the aim of the current study was to evaluate the clinical spectrum, demographic characteristics, risk factors, and etiology of fungal respiratory infections in 384 patients hospitalized in pulmonary units of Razi hospital, Guilan province, Iran.
Materials and Methods: A total of 384 lung specimens (192 Bronchoalveolar lavages (BAL) and 192 sputa) were obtained from patients who met the inclusion criteria. All samples were analyzed by direct microscopy and culture. Fungal identification was accomplished by internal transcribed spacer (ITS) and beta-tubulin sequencing. Also, in patients suspected to invasive pulmonary aspergillosis BAL specimens were tested for galactomannan (GM) antigen. According to the host factors (clinical symptoms, radiology findings and predisposing factors which were defined as inclusion criteria), and the positive results in direct examination, culture and serology (GM for aspergillosis) the infection was confirmed.
Results: Fungal respiratory infection was confirmed in 137 cases (35.67%) including 86 (62.77%) males and 51 (37.23%) females and the highest prevalence of infection was found in the age group of 46-72 years (n=75, 54.74%). Cough (n=129, 94.16%), dyspnea (n=111, 81.02%), purulent sputum (n=85, 62.04%) and weight loss (n=77, 56.2%) were the predominant symptoms. Tuberculosis (n=34, 24.81%), taking chemotherapy regimen (n=30, 21.89%) and diabetes mellitus (n=27, 19.70%) were the predominant underlying conditions. Candida albicans (37.22%) and Candida tropicalis (21.89%) represent the two most commonly isolated species in the current study. Furthermore, according to revised EORTC/MSG (2008) definitions for invasive fungal infections, from 5 cases of pulmonary aspergillosis, 2 (40%) cases of probable invasive pulmonary aspergillosis (IPA) and 3 (60%) cases of possible IPA were diagnosed.
Conclusion: According to the results of this study, infected infants with congenital CMV infection could identify at early stage by testing Guthrie cards (within 21 days of life). Furthermore, since there is a lack of CMV knowledge in our population, educating and effective counseling by obstetricians/ gynecologists to the pregnant women are recommended.

References

1. Topely, Wilsons (2005). Microbiology and microbial infections. 10nd ed. Hodder Arnold Publisher. London, UK.
2. Wilson LS, Reyes CM, Stolpman M, Speckman J, Allen K, Beney J. The direct cost and incidence of systemic fungal infections. Value in Health 2002; 5:26-34.
3. Panda B. Fungal infections of lungs: the emerging scenario. Indian J Tuberc 2004; 51:63-69.
4. Lacey J (1981). The aerobiology of conidial fungi. In: Biology of conidial fungi. ED, Academic Press. 1st ed. Austin, Texas, UK, pp. 373-416.
5. Roeder A, Kirschning CJ, Rupec RA, Schaller M, Korting HC. Toll-like receptors and innate antifungal responses. Trends Microbiol 2004; 12:44-49.
6. Jahromi SB, Khaksar AA. Deep-seated fungal infections in immunocmpromised patients in Iran. Iran J Allergy Asthma Immunol 2005; 4:27-32.
7. Smith JA, Kauffman CA. Pulmonary fungal infections. Respirology 2012; 17:913-926.
8. Sole A, Morant P, Salavert M, Peman J, Morales P. Aspergillus infections in lung transplant recipients: risk factors and outcome. Clin Microbiol Infect 2005; 11:359-365.
9. Tripathy U, Yung GL, Kriett JM, Thistlethwaite PA, Kapelanski DP, Jamieson SW. Donor transfer of pulmonary coccidioidomycosis in lung transplantation. Ann Thorac Surg 2002; 73:306-308.
10. Cheesbrough M (2006). District laboratory practice in tropical countries. 2nd ed. Cambridge university press. Norfolk, England.
11. Collee TG, Mackie TJ, McCartney JE (1996). Mackie & McCartney practical medical microbiology. 14nd ed. Harcourt Health Sciences. Churchill Livingstone, New York.
12. Abe M, Ogawa Z, Tanuma H, Kume H. [Study of mycological examination methods in clinical laboratories--specimen pretreatment and isolation]. Nihon Ishinkin Gakkai Zasshi 2009; 50:235-242.
13. Procop GW, Koneman EW (2016). Koneman’s Color Atlas and Textbook of Diagnostic Microbiology. E. W. Koneman, 7nd ed, Lippincott Williams & Wilkins, Philadelphia.
14. Agarwal S, Manchanda V, Verma N, Bhalla P. Yeast identification in routine clinical microbiology laboratory and its clinical relevance. Indian J Med Microbiol 2011; 29:172-177.
15. Lai C, Hsu H, Lee L, Hsueh P. Assessment of Platelia Aspergillus enzyme immunoassay for the diagnosis of invasive aspergillosis. J Microbiol Immunol Infect 2007;40: 148-153.
16. Harju S, Fedosyuk H, Peterson KR. Rapid isolation of yeast genomic DNA: Bust n'Grab. BMC Biotechnol 2004; 4: 8.
17. Yeates C, Gillings M, Davison A, Altavilla N, Veal D. Methods for microbial DNA extraction from soil for PCR amplification. Biol Proced Online 1998; 1:40-47.
18. Reischer GH, Lemmens M, Farnleitner A, Adler A, Mach RL. Quantification of Fusarium graminearum in infected wheat by species specific real-time PCR applying a TaqMan Probe. J Microbiol Methods 2004; 59:141-146.
19. Badiee P. Evaluation of human body fluids for the diagnosis of fungal infections. Biomed Res Int 2013; 2013: 698325.
20. De Pauw B, Walsh TJ, Donnelly JP, Stevens DA, Edwards JE, Calandra T, et al. Revised definitions of invasive fungal disease from the European organization for research and treatment of cancer/invasive fungal infections cooperative group and the national institute of allergy and infectious diseases mycoses study group (EORTC/MSG) consensus group. Clin Infect Dis 2008; 46:1813-1821.
21. Fauci AS, Morens DM. The perpetual challenge of infectious diseases. N Engl J Med 2012; 366:454-461.
22. Brown GD, Denning DW, Gow NA, Levitz SM, Netea MG, White TC. Hidden killers: human fungal infections. Sci Transl Med 2012; 4:165rv13.
23. Basiri Jahromi SH, Khaksar AA. Respiratory fungal infections in specimens referred to the Pasteur Institute of Iran, 1994-2001. Res Med 2004; 28:265-268.
24. Roohani AH, Fatima N, Shameem M, Khan HM, Khan PA, Akhtar A. Comparing the profile of respiratory fungal pathogens amongst immunocompetent and immunocompromised hosts, their susceptibility pattern and correlation of various opportunistic respiratory fungal infections and their progression in relation to the CD4+ T-cell counts. Indian J Med Microbiol 2018; 36:408-415.
25. Ahmed M, Farghaly A, Raafat R, Abd Elsattar W. Study of the prevalence and pattern of fungal pneumonias in respiratory intensive care units. Egypt J Bronchol 2019; 13:545-550.
26. Gavazzi G, Krause K-H. Ageing and infection. Lancet Infect Dis 2002; 2:659-666.
27. Rafiee S, Besharat S, Jabbari A, Golalipour F, Nasermoaadeli A. Epidemiology of tuberculosis in northeast of Iran: a population-based study. Iran J Med Sci 2009; 34:193-197.
28. Fontalvo DM, Jiménez Borré G, Gómez Camargo D, Chalavé Jiménez N, Bellido Rodríguez J, Cuadrado Cano B, et al. Tuberculosis and fungal co-infection present in a previously healthy patient. Colomb Med 2016; 47:105-108.
29. Joos L, Tamm M. Breakdown of pulmonary host defense in the immunocompromised host: cancer chemotherapy. Proc Am Thorac Soc 2005; 2:445-448.
30. Ramirez LC, Dal Nogare A, Hsia C, Arauz C, Butt I, Strowig SM, et al. Relationship between diabetes control and pulmonary function in insulin-dependent diabetes mellitus. Am J Med 1991; 91:371-376.
31. Spahr J, Weiner D J, Stokes DC, Kurland G (2019). Pulmonary disease in the pediatric patient with acquired immunodeficiency states. In: Kendig's Disorders of the Respiratory Tract in Children. Elsevier. pp. 923-943.
32. Zarrinfar H, Saber S, Kordbacheh P, Makimura K, Fata A, Geramishoar M, et al. Mycological microscopic and culture examination of 400 bronchoalveolar lavage (BAL) samples. Iran J Public Health 2012; 41: 70-76.
33. Zanganeh E, Zarrinfar H, Rezaeetalab F, Fata A, Tohidi M, Najafzadeh MJ, et al. Predominance of non-fumigatus Aspergillus species among patients suspected to pulmonary aspergillosis in a tropical and subtropical region of the Middle East. Microb Pathog 2018; 116:296-300.
34. Hedayati MT, Mayahi S, Denning DW. A study on Aspergillus species in houses of asthmatic patients from Sari City, Iran and a brief review of the health effects of exposure to indoor Aspergillus. Environ Monit Assess 2010; 168: 481-487.
35. Dykewicz CA. Summary of the guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients. Clin Infect Dis 2001; 33:139-144.
36. Verweij PE, Stynen D, Rijs A, De Pauw BE, Hoogkamp-Korstanje J, Meis J. Sandwich enzyme-linked immunosorbent assay compared with Pastorex latex agglutination test for diagnosing invasive aspergillosis in immunocompromised patients. J Clin Microbiol 1995; 33:1912-1914.
37. Pagano L, Caira M, Candoni A, Offidani M, Fianchi L, Martino B, et al. The epidemiology of fungal infections in patients with hematologic malignancies: the SEIFEM-2004 study. Haematologica 2006; 91:1068-1075.
38. Ozçelik T, Ozkalemkaş F, Kocaeli H, Altundal Y, Ener B, Ali R, et al. Successful treatment of neuroaspergillosis in a patient with acute lymphoblastic leukemia: role of surgery, systemic antifungal therapy and intracavitary therapy. Mikrobiyol Bul 2009; 43:499-506.
39. Herbrecht R, Letscher-Bru V, Oprea C, Lioure B, Waller J, Campos F, et al. Aspergillus galactomannan detection in the diagnosis of invasive aspergillosis in cancer patients. J Clin Oncol 2002; 20:1898-1906.
40. Sulahian A, Tabouret M, Ribaud P, Sarfati J, Gluckman E, Latgé JP, et al. Comparison of an enzyme immunoassay and latex agglutination test for detection of galactomannan in the diagnosis of invasive aspergillosis. Eur J Clin Microbiol Infect Dis 1996; 15:139-145.
Published
2020-07-31
How to Cite
1.
Rafat Z, Hashemi SJ, Ashrafi K, Nikokar I, Jafari A, Rahimi Foroushani A, Roohi B, Borjian Boroujeni Z, Najar-Shahri N. Epidemiology, laboratory diagnosis and clinical aspects of fungal pulmonary infections in 384 patients hospitalized in pulmonary units in Guilan province, Iran. Iran J Microbiol. 12(4):353-363.
Section
Original Article(s)