Candida in Pulmonary Tuberculosis

VP Baradkar, M Mathur, K Wanjari, S Kumar

Abstract
In recent years, fungal infections are on the rise, due to various predisposing factors, such as
patients on steroids, long term administration of antibiotics, HIV infection and many of them
have basic pulmonary diseases like tuberculosis, which may also alter the course of the disease.
Hence this study was undertaken to find out the prevalence of Candida species in cases of
pulmonary tuberculosis. One hundred diagnosed cases of pulmonary tuberculosis were in-
cluded in the study, from August 2006 – August 2007. Sputum samples were processed by KOH
10% preparation, Gram’s staining, Nigrosin (10%) staining, and were cultured on Sabouraud’s
Dextrose agar (SDA) slants. The Candida species were isolated and diagnosed by standard
mycological procedures. Out of the 100 cases studied, significant growth of Candida species
was present in 26 cases (26%), the commonest isolates were Candida albicans (24%), followed
by Candida tropicalis and Candida parapsilosis in one case each.

Introduction tuberculosis and positive by Ziehl Neelsen

I n the recent years, there is a continuous
growing interest for the diagnosis of
mycoses.1 - 5 Most of the individuals affected
with mycoses have a history of receiving
antibiotics and/ or corticosteroids, other
immunodeficiency like AIDS and majority of
them have severe pulmonary diseases like
tuberculosis. When host resistance is lowered,
these unrecognized opportunistic fungi may
affect the progress of disease or may even
become fatal. 6 - 9 Hence, there is need to
consider the possible importance of these
saprophytic organisms, when they are found
repeatedly and evidently from the sites of
infection. The present study was therefore
undertaken to find out the prevalence of
Candida species in pulmonary tuberculosis.
Material and Methods
100 diagnosed cases of pulmonary
tuberculosis, with clinical presentation of
Department of Microbiology, Lokmanya Tilak
Municipal Medical College and General Hospital, Sion
Mumbai - 400 022.
smear for acid fast bacilli, were randomly
selected. The study was conducted in the
Department of Microbiology, L.T.M.M.C and
L.T.M.G.H, Sion from August 2006-August
2007.
Early morning sputum sample was
collected in a sterile container. Direct smear
examination of sputum was done by 10%
KOH, 10% Nigrosin and Gram staining. For
culture, a loopful of specimen was inoculated
on two sets of Sabouraud’s Dextrose agar
(SDA), one with 0.04 mg/ml chloramphenicol,
0.5 mg/ml cycloheximide and one without
chloramphenicol and cycloheximide. The SDA
slants were observed daily for the presence
of growth. If there was no growth for 4 weeks,
they were discarded. Evaluation of the
amount of growth was done by Kahanpaa et
al.10 Criteria for diagnosis of candidiasis in
present study were 1) heavy growth of candida
i.e. more than 30 colonies in the culture.
2) presence of budding yeast cells, pus cells
along with pseudohyphae in Gram stained
smears. Identification of Candida species was

52 Bombay Hospital Journal, Special Issue, 2009

done by germ tube test, growth pattern on
Cornmeal agar and sugar assimilation tests.
Results
Out of the 100 cases of pulmonary
tuberculosis, Candida species was isolated in
26 cases (26%). In 10 cases there was scanty
growth of Candida species on SDA but the
primary smears showed only budding yeast
cells, without pus cells and pseudohyphae
suggesting colonization and these cases were
reported as “ non-significant fungal growth”.
Candida albicans was the commonest species
isolated in 92.31% (24/26) cases, followed by
Candida tropicalis and Candida parapsilosis
in one case each 3.25% (1/26). No other
species of candida like Candida krusei or
Candida pseudotropicalis was reported in the
study.
Discussion
There is a considerable variation of 9% to
80% in incidence reported in the literature
on the occurrence of Candida species in
sputum of patients with pulmonary
tuberculosis.1-8 Jain et al9 from India, reported
isolation in 23.57% of cases. Our findings are
comparable with this study. Out of the 26
commonest isolate was Candida albicans in
92.31% (24/26) cases, followed by Candida
tropicalis and Candida parapsilosis in one case
each 3.25% (1/26). No other species of Candida
like Candida krusei in 2 (2.9%) and Candida
parapsilosis in 6 (8.7%) out of 69 cases.
Pandalai et al7 found Candida krusei i n 2
(2.9%) and Candida parapsilosis in 6 (8.7%)
out of 69 cases. Grower et al3 noted Candida
tropicalis in 4(4%) and Candida parapsilosis
in 2 (2%) in their series of 100 cases. Khanna
et al6 reported Candida krusei in 2 (1.8%) and
Candida albicans var stellatoidea in 2 (1.8%)
out of 110 patients. The relationship of
isolation of Candida species with the extent
Bombay Hospital Journal, Special Issue, 2009
of lesion was studied in the present study.
The growth of candida was independent of
fresh and partially treated pulmonary cases.
Schwarting and Skinner 10 and Jainsketal 9
showed similar findings. Khanna et al6 were
of the opinion that positivity of fungi in
pulmonary tuberculosis was related to the
chronicity of pulmonary disease, which was
not observed in our study as well as Jain et
al. 9 More studies are needed in India to
correlate the prevalence of Candida species
with the duration of illness and chronicity of
cases and specially with multidrug resistant
cases.
References
1. Chakravarty SC, Randhawa HS, Ray BK,
Vishanathan R. Candida species in the throat
swab culture of normal people and in sputum of
patients with bronchopulmonary disease. Cal Med
J 1960; 57 : 127-32.
2. Gonzaez- Mendoza A, Bojalil LF. The incidence of
Candida albicans in sputum of tuberculous
patients. Amer Rev Tuber C 1958; 77 : 543-45.
3. Grower S, Junnarkar RV. Mycological flora in
sputum of patients suffering from
bronchopulmonary diseases. Ind J Med Sci 1965;
19 : 823-27.
4. Helms P. The occurrence of Candida albicans in
sputum in Denmark. J Clin Path 1956; 9 : 372-73.
5. Kahanpaa A. Bronchopulmonary occurrence of
fungi in adults. Acta Pathol Microbiol Scand 1972;
80 B : 1-113.
6. Khanna BK, Nath P, Ansari AH. A study of mycotic
flora of respiratory tract in pulmonary
tuberculosis. Ind J Tuberc 1977; 24 : 159-62.
7. Shome SK, Upreti HB, Singh MM, Pamra SP.
Mycoses associated with pulmonary tuberculosis.
Ind J Tuberc 1976; 23 : 64-68.
8. Chander J. Text Book of Medical Mycology edition.
9. Jain SK, Agarwal RL, Sharma DA, Agarwal MM.
Candida in pulmonary tuberculosis. J Postgrad
Med 1982; 28 : 24-29.
10. Schwarting VM, Skinner CE. Candida in sputum
of patients with tuberculosis. Mycopathol 1994; 4
: 349-55.
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