Abstract

Background: Fungi are eukaryotic species that live in the form of yeast and molds. They are eukaryotic, but they have a cell wall. It is possible to distinguish mycosis into four types; skin, subcutaneous, systemic and opportunistic.

Objectives: To determine the frequency of the most common fungal infection.

Methods: This retrospective study was performed in histopathology department of King Edward Medical University by reviewing previous records. The study was performed during November 2020 to May 2021. 1295 were the biopsies with chronic nonspecific inflammation. 34 biopsies were diagnosed with superadded fungal infection. These patients were those who presented to outdoor, general surgery, plastic surgery, maxillofacial, burn, eye unit and ICU.

Results: In our study, 18 (52.9%) patients were males and 16 (47.1%) were females, the total patients with fungal infection were 34. 23 out of 34 (67.6%) patients were diagnosed with mucormycosis, the second most frequent fungal infection reported was Candidiasis with a frequency of 5 out of 34 (14.7%), and then aspergillosis with a frequency of 4 (11.8%).

Conclusion: It is concluded that the most frequent fungal infection reported in Mayo Hospital is Mucormycosis, keeping the PAS stain as the

gold standard, with a frequency of 23 out of 34, and a percentage of 67.6%.

INTRODUCTION

Fungi are eukaryotic species that live in the form of yeast and molds. They are eukaryotic, but they differ from plants and animals because, unlike plants, they have a cell wall. The fungal cell wall is made up of chitin, so fungi are resistant to such drugs [1]. In comparison to human cell membranes that contain cholesterol, the fungal cell membrane contains ergosterol [2]. Two forms of fungi exist; yeast and molds. Yeasts are single cells and create asexual budding. Molds form a mycelium and are long filaments (hyphae). Some hyphae form transverse walls, that is, aseptate hyphae, while others form nonseptate hyphae. Candida Albicans is a part of the natural flora of humans [3]. In the processing of essential fungi are used [4]. The development of granulomas is the response to infection with several fungi [5].

It is possible to distinguish mycosis into four types; skin, subcutaneous, systemic, and opportunistic [6]. Pulmonary pathogens include Histoplasma capsulatum and Aspergillus fumigatus [7]. Opportunistic mycoses are due to fungi that in most immunocompetent individuals do not cause disease but can induce disease in those with compromised host defences [8].

The cause of cryptococcal meningitis is cryptococcus neoformans. Often predisposed to fungal infection are patients with immunosuppression, poorly controlled diabetes, burns, neutropenia, HIV and pancreatitis [9]. Occupational exposures are associated with blastomycosis. Renal transplantation, a major cause of mortality and morbidity is invasive fungal infections [10].

Mucor and Rhizopus are saprophytic molds, causing mucormycosis. They proliferate in the walls of the blood vessels, particularly the sinuses, intestines or lungs, causing necrosis and tissue infarction. Diabetic patients are prone to rhinocerebral mucormycosis, in which hyphae are produced by mold spores in the sinuses that infiltrate the blood vessels that supply the brain. Fungal meningitis and bloodstream infections are less common than skin and lung infections and can be lethal. As the signs of yeast infection may be identical to those of other illnesses, there is often a delay in diagnosis as well as treatment [11].

Gomori Methenamine Silver, GMS and Periodic Acid- Schiff, PAS are the two most common stains used for fungus identification [12, 13].

According to the Journal of Clinical Medical Research 2015, in solid organ transplant recipients, average mortality due to invasive fungal infections varies from 25% to 80% [14].

The survey in Egypt in June 2017 found that the most prevalent infection was onychomycosis (64.8 percent of cases), and tinea capitis (17.6 percent) [15].

In Korea, the annual prevalence of all-type mycosis increased from 6.9% in 2012 to 7.4% in 2017, based on the National Health Insurance of South Korea data. The prevalence of dermatophytosis was highest (5.2%) among the particular classes, followed by opportunistic mycosis (1.7%) and superficial mycosis (0.2%) [16].

The majority of aspergillus infections (78 percent) are restricted to the lungs [17]. In 45 percent and 39 percent of cases, CNS involvement and disease confined to the lungs were observed among cryptococcosis cases, respectively [18]. Disseminated multi-organ infections include blastomycosis, coccidioidomycosis, and histoplasmosis [19].

Vegetable material trauma is thought to be a particular threat to fungal infection of the cornea [20]. AML and ALL patients developed candidaemia at incidence rates of 2-3% and 4-5%, respectively, in an Italian study [21]. Invasive candidiasis in premature neonates is widespread [22].

The objective of this study is to find the frequency of fungal infections in patients in whom symptoms of infection are nonspecific; there is often a delay in proper diagnosis and treatment. The histological diagnosis will be confirmed by PAS stain, taken as gold standard thus identifying the most common infectious fungal organisms in our patients.

METHODS

This was a retrospective descriptive study which was conducted at the histopathology department, of Kind Edward Medical University. The duration of the study was six months from November 2020 to May 2021. 5987 is the total number of specimens submitted to the pathology department within six months. 1295 were the biopsies with chronic nonspecific inflammation.

34 biopsies were diagnosed with superadded fungal infection. These patients were those who presented to outdoor, general surgery, plastic surgery, maxillofacial, burn, eye unit and ICU. After history, examination and baseline investigations biopsy was done with informed consent. Biopsies were submitted to the pathology department and after processing slides were prepared. Hematoxyllin and eosin stains were done, and for further confirmation and categorization periodic acid-Schiff stain was performed. Data was analyzed using SPSS version 20.

RESULTS

In our study, out of 34 patients, 18 (52.9%) were male and 16 (47.1%) were female (Table 1). The biopsies were taken from different organs and parts of the body which included the head and neck, lungs, cheeks, maxilla, palate, sinus, leg, foot, nasalcavities and necrotic patch on the extremities. Mucormycosis turned out to be the most common fungal infection in Mayo Hospital with a frequency of 23 out of 34(67.6%) (Fig. 1). After Mucormycosis, the second most frequent fungal infection reported to candidiasis with a frequency of 5 out of 34 (14.7%), and then aspergillosis with the frequency of 4 (11.8%) (Fig. 2). 2 out of 34 (5.8%) have concurrent two fungal infections (mucormycosis with candida and mucormycosis with aspergillosis) (Table 1).

Table 1: Percentage of most common fungal infections in patients presenting to the pathology department at KEMU.

DISCUSSION

Mucormycosis has been reported as the most dangerous and frequent fungal infection. Mucormycosis, associated with high morbidity and mortality, is an angio-invasive fungal infection. Sometimes, diagnosis is delayed, and illness continues to develop rapidly.

In patients with diabetes mellitus, the rhino-cerebral type of mucormycosis is most commonly seen, whereas pulmonary mucormycosis is most commonly Pakistan’s reported data documenting rates of fungal infections in general and particular populations has been checked and used where appropriate. Estimates, in the LIFE approach, were made for the entire population or particular populations at risk. An estimated 3,280,549 (1.78%) of the 184,500,000 people in Pakistan are affected by a severe fungal infection, omitting all cutaneous infections, oral candidiasis and allergic fungal sinusitis, which we were unable to estimate. Seen in patients with haematological malignancy [23].

Candidemia (21/100,000) and mucormycosis (14/100,000) rates are estimated to be very high compared to other countries and are based on data from India. Owing to the high TB burden, chronic pulmonary aspergillosis rates are estimated to be high (39/100,000). The estimate for invasive aspergillosis was around 5.9/100,000. Fungal keratitis, with an approximate prevalence of 44/100,000, is also problematic in Pakistan. Pakistan is likely to have a high rate of many life-threatening or visually-threatening fungal infections. [24].

According to Severe Fungal Infections in Pakistan 2017, Candidemia mortality rate ranges from 23 to 52% in Karachi studies and 24% in a neonatal intensive care unit (ICU) (Patients with upper gastrointestinal disease and prolonged ICU stay have a higher proportion of intra-abdominal candidiasis), with about 25,830 cases of mucormycosis from Pakistan using a prevalence of 0.14/1000 population and 38% mortality, yearly, 2,821,440 women of reproductive age suffer from recurrent the burden of reproductive tract infection in urban women in Pakistan reports vaginal candidiasis as the second most common genital infection, with a prevalence of 7–12% [25].

Study limitations are outsourcing of samples for diagnosis, so we lose a lot of data regarding the actual load of fungal infection prevalent at our setup.

CONCLUSION

It is concluded that the most frequent fungal infection in Mayo Hospital is reported to be Mucormycosis, keeping the PAS stain as the gold standard, with a frequency of 23 out of 34, and a percentage of 67.6%. Rest important and

Frequency of the Most Common Fungal Infection...

common fungal infections were reported to be candidiasis, aspergillosis and combinations of mucormycosis and candidiasis, and mucormycosis and aspergillosis.

ETHICAL APPROVAL

Ethical approval was obtained from the Institutional Review Board of King Edward Medical University (KEMU), Lahore (REF letter No. 863/RC/KEMU, Dated: 14/11/2020). All procedures performed in studies involving human participants were following the ethical standards of the institutional and/ or national research committee and the Helsinki Declaration.

CONSENT FOR PUBLICATION

Written informed consent was taken from the participants.

AVAILABILITY OF DATA

All data in hard and soft form is available.

FUNDING

Declared none.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

ACKNOWLEDGEMENTS

Declared none.

AUTHORS’ CONTRIBUTION

Topic was decided and H&E stain diagnosis were made by Dr. Safeena Sarfraz.

Collection of data it’s compiling and material collection was done by Myra Shahid.

Reporting of PAS stain was done by Dr. Rabia Shahid (msfarooq).

Suspected cases of fungal infection were also sent by Dr. Maryam Raana and Dr. Quratul Ain.

Statistical data was helped by Dr. Fizza Jahangir.

REFERENCES

DOI: https://doi.org/10.1002/9781118321492

contexts. Res Microbiol 2015; 166(7): 564-9.

DOI:     https://doi.org/10.1016/j.resmic.2014.12.007       PMID:

25634072

DOI:https://doi.org/10.1016/s1473-3099(17)30309-2       PMID:

28774699

DOI: https://doi.org/10.1111/myc.12251 PMID: 25346218

DOI: https://doi.org/10.1093/jac/dkz041 PMID: 31222314

DOI:     https://doi.org/10.1007/978-1-4939-6515-1_2     PMID:

27837497

DOI:      https://doi.org/10.1007/s10096-017-2919-6        PMID:

28161741

DOI: https://doi.org/10.1016/j.mycmed.2017.01.005 PMID: 28188051

DOI: https://doi.org/10.1111/liv.13981 PMID: 30276951

DOI: https://doi.org/10.1111/myc.13201 PMID: 33075162

DOI:      https://doi.org/10.1007/s12602-014-9176-0        PMID:

25362524

DOI: https://doi.org/10.1111/myc.12753 PMID: 29453860

53-67.

DOI:        https://doi.org/10.1111/1469-0691.12041         PMID:

23137137

DOI:        https://doi.org/10.1111/1469-0691.12040         PMID:

23137136

DOI:       https://doi.org/10.1186/s40064-016-2926-6       PMID:

27536540

DOI: https://doi.org/10.1016/j.cmi.2015.10.020 PMID: 26551838

DOI: https://doi.org/10.1111/ced.12593 PMID: 25683452

DOI: https://doi.org/10.1093/jbcr/iraa148 PMID: 32844184