|Year : 2014 | Volume
| Issue : 2 | Page : 99-102
Candida associated diarrhea in human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) patients and their correlation with CD4+ T lymphocyte counts
Abhijit Sarkar, Kamki Yompe, Ng Brajachand Singh
Department of Microbiology, Regional Institute of Medical Sciences, Imphal, Manipur, India
|Date of Web Publication||18-Sep-2014|
Dr. Abhijit Sarkar
Rose Valley Enclave, Flat no. C-I-1, Bardowali, P.O-A.D. Nagar, Tripura West, Agartala - 799 003
Source of Support: None, Conflict of Interest: None
Context: Gastrointestinal opportunistic infections occur very frequently in human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) patients and diarrhea is one of the common clinical presentations among these patients. Candida spp. have also been implicated as a causative agent of chronic diarrhea in HIV-infected patients. Aims: This study was carried out to determine the prevalence of fungal pathogen among HIV/AIDS patients presented with diarrhea and their correlation with CD4+ T lymphocyte counts. Settings and Design: This cross-sectional study was conducted in the Department of Microbiology, RIMS, Imphal. Materials and Methods: A total of 158 stool samples were examined, out of which 108 were from HIV-positive patients with diarrhea (study group) and 50 from HIV-positive patients without diarrhea (control group). Specimens were examined by direct microscopy and culture in Sabouraud's dextrose agar. The CD4+ T lymphocyte count of patient was also recorded. Statistical Analysis Used: Data were analyzed by using Statistical Package for the Social Sciences (SPSS) version-16 software. P predictive value) value <0.05 was considered significant. Results: Confluent growth of Candida spp. was detected in stool samples of 28.7% patients with diarrhea and 12% patients without diarrhea. Association between the isolation of Candida spp. and diarrhea was found to be significant (P = 0.01). Isolation of Candida spp. was inversely correlated with CD4+ T lymphocyte count. Conclusion: Intestinal candidiasis must be held in mind as a cause of HIV/AIDS-associated diarrhea, particularly in patient with low CD4+ T lymphocyte count.
Keywords: AIDS, Candida, CD4+T lymphocyte, Diarrhoea, HIV
|How to cite this article:|
Sarkar A, Yompe K, Singh N. Candida associated diarrhea in human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) patients and their correlation with CD4+ T lymphocyte counts. J Med Soc 2014;28:99-102
|How to cite this URL:|
Sarkar A, Yompe K, Singh N. Candida associated diarrhea in human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) patients and their correlation with CD4+ T lymphocyte counts. J Med Soc [serial online] 2014 [cited 2020 May 29];28:99-102. Available from: http://www.jmedsoc.org/text.asp?2014/28/2/99/141092
| Introduction|| |
Human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) ranks among the most dreaded disease afflicting mankind, causing dysfunction of both the limbs of the immune system, resulting in overwhelming and fatal opportunistic infections. 
By the end of 2010, about 34 million people were infected with HIV/AIDS globally.  In India, infected person were estimated to be 32.9 lakhs.  In Manipur, the prevalence of HIV/AIDS is high (1.40%). 
Because of a progressive decline in their immunological response, patients with HIV infection are extremely susceptible to variety of common as well as opportunistic infections.  Gastrointestinal infections are very common in patients with HIV infection or AIDS. Diarrhea is a frequent clinical manifestation of these infections.  HIV-related diarrhea is multi-factorial. The etiological spectrum of enteric pathogens causing diarrhea includes bacteria, parasites, fungi, and viruses. 
Candida spp. are opportunistic pathogen of humans.  Gastrointestinal candidiasis has been recognized more commonly in recent years due to malnourishment, widespread use of antibiotics, chemotherapeutic agents, and prolonged survival of immunocompromized hosts. Candida has been implicated as a diarrhoeogen in elderly receiving antibiotics or with severe illnesses.  Recently, Candida spp. have been implicated in the etiology of chronic diarrhea HIV-infected patient. 
The identification of Candida spp. as a causative agent of diarrhea is important since a number of efficacious antifungal therapies are available. Some studies found that resolution of antibiotic-associated diarrhea in elderly patients with intestinal overgrowth of candida, after treatment with nystatin. 
Therefore, the present study was conducted in Regional Institute of Medical Sciences, Imphal, to find out the prevalence of Candida-associated diarrhea in HIV-infected individuals in Manipur with a goal to provide guidance to physician for better treatment and management of HIV-associated diarrhea.
Aims and objects
To determine the prevalence of Candida spp. among HIV/AIDS patients with diarrhea and their correlation with CD4+ T lymphocyte counts.
| Materials and Methods|| |
This cross-sectional study was conducted in the Department of Microbiology, RIMS in collaboration with the Department of Medicine, RIMS, Imphal, Manipur from November 2010 to October 2012. In this study, diarrhea was defined as having three or more loose bowel movements within a 24-hour period. In this study, a total of 158 stool samples from serologically diagnosed HIV-positive patients were collected. Out of which 108 samples were from the patients with diarrhea (study group) and 50 samples were from the patients without diarrhea (control group). The patients were recruited from Anti retroviral therapycenter of RIMS, fluorescence-activated cell sorter (FACS) count center of RIMS, attended/admitted patient in the RIMS hospital for the treatment of diarrhea with HIV/AIDS and patient referred to RIMS by different non-governmental organization (NGO) and Community Care Centers.
A detailed clinical history regarding the age, sex, marital status, education, onset, duration and nature of diarrhea, status of ART, and other medication of the patient were recorded in a predesigned proforma.
Samples were collected in a sterile wide mouth container and processed as soon as possible. If delay longer than 2 hour was anticipated, collections of specimens were done in Cary-Blair medium for Candida analysis.  Examination of stool sample was carried out by direct microscopy using normal saline and 10% potassium hydroxide (KOH) preparation. Stool samples were inoculated in duplicate into Sabouraud's dextrose agar (SDA) with chloramphenicol 0.05 gm/L and were incubated one at 25°C and another at 37°C for 7 days. The cultures were examined after 48-72 hours and thereafter every alternate day. Stool were also processed for the isolation of bacterial and parasitic pathogens. 
In this study, presence of pseudohyphae or yeast form on microscopy together with heavy to confluent yeast like growth on culture (medium sized, cream colored, smooth and pasty colonies), not associated with any other bacterial and parasitic pathogens was considered positive for Candida spp.
Further confirmation was done by observing colony morphology, blastospores, chlamydospores, pseudohyphae, or hyphae.
Estimation of CD4+ T lymphocyte count was done by using FACS count system (Becton-Dickinson Immuno Cytometry).
Data analysis was performed by using SPSS version-16 software. Different characteristics of study of the participants were described using percentage, range and mean as appropriate. Significance was tested by using Pearson's Chi-square test and Spearman's correlation coefficient test. P value <0.05 was considered as significant.
| Results|| |
In our study, the majority of the patients were in the age-group of 30-39 years. In this age-group, male were 36 (33.33%) while female were 17 (15.74%). The mean age of the study group was 37.27 years.
In the present study, Candida spp. was isolated in 31 (28.7%) patients with diarrhea (study group) and in the patient without diarrhea (control group) Candida spp. was isolated in 6(12%) patients (P = 0.01). No candida was detected in 77 (71.3%) patients with diarrhea and 44 (88%) patients without diarrhea. This finding was statistically significant [Table 1].
|Table 1: Distribution of Candida spp. isolated among study and control groups|
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In the study group, most of the patients (42.6%) who presented with diarrhea (case) CD4+ T lymphocyte count was cell below 200 cells/μl while in the 30% of patients who presented without diarrhea (control) CD4+ T lymphocyte count was above 500 cells/μl. The mean CD4+ count in case and control were 272.68 cells/μl and 406.52 cells/μl, respectively [Table 2].
|Table 2: Distribution of CD4+ T lymphocyte counts among study and control groups|
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We observed that the isolation rate of Candida spp. decreases as the CD4+ T lymphocyte count increases among the study group patients, so there is a negative correlation (r = −0.4) between CD4+ T lymphocyte counts and the isolation of Candida spp. and this finding was found statistically significant (P = 0.001), [Table 3].
|Table 3: Correlation between CD4+ T lymphocyte count and isolation of Candida spp. in the study group (n = 108)|
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| Discussion|| |
Numerous opportunistic infections occur in HIV/AIDS patients due to suppression of the immune system. It is universally recognized that gastrointestinal infection is one of the most common infection in HIV/AIDS patients. This largely manifests with diarrheal symptoms leading to life threatening complications.
This study documents the prevalence of Candida spp. in HIV/AIDS patients with diarrhea and their correlation with CD4+ T lymphocyte counts.
In our study, we have observed a preponderance of male patients (63.9%) in comparison to females (36.1%), [Table 4]. Our finding is consistent with other published reports of opportunistic infections in HIV infected and AIDS patients where male subject are more often the victims of this disease than their female counterparts probably due to their high risk behavior (Vyas N et al. , Sherpa U et al.).
Yeasts and fungi, especially Candida spp., are present in the feces of healthy individuals. Candida is known to be pathogenic in gastrointestinal tract of patients with depressed immunity, but its role in diarrhea is not widely accepted. Candida spp. on many occasions was the only organisms isolated from the intestinal tract of HIV patients with diarrhea and have been implicated in the etiology of chronic diarrhea and colitis in patients infected with HIV/AIDS. 
In our study, Candida spp. were the only fungi isolated with 28.7% in HIV/AIDS patients with diarrhea while it was isolated in 12% in HIV/AIDS patients without diarrhea. Our study showed that there was significant association between the isolation of Candida spp. and diarrhea (P = 0.01). Other studies also reported similar prevalence of Candida spp. (Uppal B et al. , Rossit ARB et al.
Isolation of Candida spp. were inversely correlated with CD4+ T lymphocyte count. So possibility of intestinal candidiasis as a cause of HIV/AIDS-associated diarrhea must be held in mind, particularly in patients with chronic diarrhea and low CD4+ T lymphocyte counts.
However, in this study, no attempt was made to isolate the viral and mycobacterium.
| Conclusion|| |
This study provides important information about the prevalence of Candida spp. causing diarrhea in HIV/AIDS patients. Confluent growth of Candida spp. was observed in stool samples of 31 (28.7%) patients with diarrhea; and in these samples, no other pathogenic organism was found, so intestinal candidiasis must be held in mind as a cause of HIV/AIDS associated diarrhea, particularly patient with low CD4+ T lymphocyte count.
However, further studies are necessary to obtain more understanding of the spectrum of enteric pathogens in HIV/AIDS patients with diarrhea. This will help in the proper clinical management and reducing the morbidity and mortality of patients with HIV/AIDS in Manipur.
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[Table 1], [Table 2], [Table 3], [Table 4]