Oropharyngeal Candidiasis Research Articles

Azole Resistance in Candida albicans Isolates from Oropharyngeal Candidiasis is Associated with ERG11 Mutation and Efflux Overexpression

Background: Azole resistance rates are rising in Candida species. Fluconazole is one of the most important antifungal drugs used in candidiasis treatment. Objectives: We identified the molecular mechanisms of fluconazole resistance of Candida albicans oropharyngeal candidiasis (OPC) isolates obtained from head and neck cancer patients, a study carried out between 2018 and 2020. Methods: One hundred and twenty-five C. albicans clinical isolates were collected. Antifungal susceptibilities were determined by the CLSI- M27-A3 method. The ERG11 gene was amplified and sequenced to discover SNP mutation. Moreover, real-time PCR was carried out to measure the mRNA levels of ERG11, CDR1, CDR2, and MDR1. Results: Resistance to fluconazole was found in 15 C. albicans isolates. Amino acid substitutions E266D and D116E were observed in resistant, sensitive dose-dependent (SDD), and susceptible C. albicans isolates. K128T, G465S, A114S, Y257H and V488I were in relation to fluconazole resistance. D504A, P375A, W520C, G59S, and V51L were novel substitutions detected in the isolates; except for D504A, other mutations were observed only in resistance isolates. The expression levels of CDR2, CDR1, MDR1, and ERG11 were increased compared to susceptible isolates, respectively. Conclusions: ERG11 mutation was the principal mechanism for fluconazole resistance in C. albicans isolated from oropharyngeal candidiasis patients, and caspofungin can be used as the effective antifungal substance in fluconazole resistance situation for C. albicans infection.

Distribution and antifungal susceptibility profiles of Candida species isolated from people living with HIV/AIDS in a public hospital in Goiânia, GO, Brazil.

Oropharyngeal candidiasis (OPC) is the most common opportunistic fungal infection of the oral cavity and is a significant clinical problem, particularly in immunocompromised individuals, such as people living with HIV/AIDS (PLWHA). Although Candida albicans is the most frequent pathogen, at least 30 species capable of causing infection have been described. Identifying the infecting organism is necessary because the species respond differently to therapy, and antifungal susceptibility testing is important to determine the appropriate treatment. This study aimed to determine the epidemiological, clinical, and mycological profiles of OPC in hospitalized PLWHA. Clinical samples were collected from 103 PLWHA with suspected candidiasis admitted to the Hospital Estadual of Doenças Tropicais/Hospital Anuar Auad of Goiania, Goias, Brazil, for 14months. Candida species were identified using phenotypic microbiological techniques and molecular analysis performed by PCR using species-specific primers. The antifungal susceptibility pattern of the isolates against the six antifungal agents was determined using the broth microdilution method. Here, female individuals were the most affected by OPC, presenting a higher risk of oral colonization by Candida spp. The main clinical manifestation was pseudomembranous candidiasis. The number of cases of candidiasis was 87.3% (90/103), with C. albicans being the most common species, followed by C. tropicalis and C. glabrata. In the susceptibility pattern, non-albicans Candida showed higher resistance to than C. albicans. The fast and accurate identification of Candida spp. is very important to identify therapeutic agents for the treatment of oral candidiasis in PLWHA.

Tragacanth and xanthan gum natural polymers for formulation of clotrimazole mucoadhesive gel

Clotrimazole is an antifungal agent, widely used in vulvovaginal and oropharyngeal candidiasis. Currently available clotrimazole (especially vaginal) dosage forms, have some limitations, including: leakage, messiness and low residence time, which leads to poor patient compliance. Therefore, in this study, a clotrimazole mucoadhesive gel has been developed as a suitable strategy due to their high water content, increased local retention time, lubrication and patient compliance. Xanthan gum and tragacanth with different portions were utilized as natural mucoadhesive gel forming polymers. Gel formulations were subjected to physico-chemical evaluations including gel viscosity, FTIR spectroscopy, spreadability, scanning electron microscopy (SEM) images of hydrogel chains, and release kinetic. Results demonstrated that among 8 developed formulas, formulation F1 showed the appropriate properties including controlled drug release (63.13% in 6h) with higuchi release kinetic, higher mucoadhesion (77.71 dyne cm-1) and drug content (94.47%) and relatively low spreadability (3.5 cm) which is suitable for local drug delivery. FTIR spectroscopy revealed there is not incompatibility between clotrimazole and other excipients in formulations. Combination of natural polysaccharides can form a proper mucoadhesive gel matrix for delivery of synthetic or natural drugs.

Ethnobotanical study of medicinal plants utilized in the management of candidiasis in Northern Uganda

BackgroundThe emergence of resistant Candida species to antifungal drugs has led to resurgence in herbal usage globally. However, little is known about anti-candida plants. This study explored ethnomedicinal plants as treatment option for candidiasis in Pader, Northern Uganda.MethodsA cross-sectional survey of potential anti-candida plants was conducted using questionnaires, focus group discussions and field observations in March 2022. Sixty-three respondents were selected by snowball technique. The frequencies of respondents/responses were analyzed, associations of respondents’ socio-demographics with indigenous knowledge of herbal usage established by Chi-square (χ2) test using SPSS 27. Informant Consensus Factor was computed to establish level of agreement on herbal usage, and thematic analysis done for focus group discussions.ResultsCandidiasis is still common and troublesome in Pader. All herbalist had equal chances of receiving and treating candidiasis patients irrespective of herbalist’s gender, age, education level, occupation, marital status and religion (p > 0.05). About 39.7% of herbalists received candidiasis patients weekly (p < 0.01). All herbalists had knowledge on candidiasis. Death (56.8%) and discomfort (36.8%) were the major health risks of oropharyngeal candidiasis (OPC) and vulvovaginal candidiasis (VVC), respectively. A total of 32 potential anti-candida plant species in 18 families were identified. Families of Fabaceae (9 species) and Asteraceae (5 species) had most plant species. Trees (50.0%) and herbs (43.8%) were the dominant life forms. The commonest plants by frequency of mention were: Momordica foetida (26), Sansevieria dawei (20), Khaya anthotheca (15), Piliostigma thonningii (10), Clerodendrum umbellatum (7), Hallea rubrostipulata (5) and unidentified plant, ‘Agaba/daa layata’ in Acholi dialect (5). Plant parts mainly used were roots (56.3%) and stem barks (15.6%) harvested majorly by cutting (46.9%) and uprooting (12.5%). Most respondents (females, 95%) preferred herbal to western medication (p < 0.01) due to its perceived effectiveness. There was high consensus among herbalists on herbal remedies for OPC and VVC (FIC = 0.9).Conclusions Pader communities have diverse indigenous knowledge on candidiasis and prefer herbal medicines to orthodox treatment for candidiasis. However, the herbalists use unsustainable harvesting techniques like uprooting whole plants and cutting main roots. Hence, the need to document such indigenous knowledge before being lost for community usage and scientific validation.

Synergistic Antifungal Analysis of Carica papaya Leaf and Solanum melongena Peel Ethanolic Extracts Against Candida albicans

Infectious diseases are responsible for most mortalities and morbidities globally. They are estimated to cause 17 million deaths annually. Candida albicans is a microflora found in mucous membranes of the gastrointestinal tract and vagina. Though a commensal organism, it can cause either oropharyngeal or vaginal candidiasis in immunocompromised states. It thus, is a common opportunistic infection especially in patients living with HIV/AIDS. Management of candidiasis requires use of antifungal agents but some are costly or drug-resistant. Therefore, there is need for exploration of novel and affordable treatment modalities. Medicinal plants offer alternative therapeutic modalities. Against this backdrop, we sought to evaluate synergistic antifungal activity of ethanolic extract of Carica papaya leaves and Solanum melongena fruit peel against Candida albicans. Ethical approval was sought from School of pharmacy, Kabarak University Research Ethics Committee (KUREC) and National commission for science, technology, and innovation (NACOSTI). Experimental research design was employed. Green leaves of Carica papaya were obtained from the school’s herbarium while the eggplant fruit was purchased from Nakuru town market. The sample plants were dried and powdered. Phytochemical analysis was carried out and antifungal activity evaluated via disk diffusion method. Phytochemical studies showed presence of tannins, alkaloids and flavonoids in both plants. Anthraquinone glycosides were absent in both samples. Carica papaya and Solanum melongena ethanolic extracts respectively showed activity against Candida albicans at different concentrations with zones of inhibition of 8.34mm and 7.98mm, respectively, at the highest concentrations. S. melongena extracts showed a lower zone of inhibition against Candida albicans compared to C. papaya extracts. Combined ethanolic extracts of Solanum melongena and Carica papaya showed higher activity at all concentrations than individual extracts, implying synergism between the two plant extracts. The difference in zones of inhibition was significant at different concentrations(P&lt;0.05). Conclusion: The study findings have demonstrated that Carica papaya and Solanum melongena extracts have remarkable antifungal activity against Candida albicans. This makes them potential efficacious antifungal agents against Candida albicans.

Lung Injury in COVID-19 and Pneumocystis Pneumonia. Similarities and Differences

In the regions with the high prevalence of HIV infection, it is necessary to perform differential diagnosis of lung injury caused by COVID-19 and pneumocystis pneumonia.The main complaints in COVID-19 and pneumocystis pneumonia are similar and include dyspnea, weakness, cough, fever, and ground glass radiographic syndrome. However, sputum production was more common in pneumocystis pneumonia. The most important differences were frequent anosmia in COVID-19 and its absence in pneumocystis pneumonia, frequent detection of oropharyngeal candidiasis in pneumocystis pneumonia which was not seen in COVID-19.Serum hepcidin concentration has a high diagnostic potential and indicates a greater likelihood of COVID-19 than pneumocystis pneumonia at values ≤ 768.044 pg/ml (ROC AUC 0.977; p &lt; 0.001).

“Antifungal Susceptibility Pattern of Oropharyngeal Candidiasis in Cancer Patients”

Introduction: Fungal infections like oral candidiasis is prevalent in cancer patients as their immune systems were compromised.Material and Methods: 377 cancer patients who were clinically diagnosed with oropharyngeal candidiasis were included in the study. Isolation and identification of Candida species was based on standard microbiological procedures. CLSI (2021) recommendations were followed when determining antifungal susceptibility.Results: Among the total 377 cases included, the highest number of instances was reported in those aged 41 to 50 years (30.23%). Candida albicans (21.98%) was the most frequent followed by Candida tropicalis (18.84%), Candida prapsilosis (17.80%). Monomicrobial growth was observed in 77.63% patients whereas polymicrobial growth was observed in 22.36% patients. Candida albicans (24.59%) and Candida tropicalis (20.49%) were the most frequent isolates among patients who underwent chemotherapy while Candida albicans (40%) and Candida Parapsilosis (26.66%) were the most frequent isolates among patients undergoing radiotherapy. Miconazole was found to be more susceptible than Fluconazole, Itraconazole, Clotriconazole among the antifungals.Conclusion: Due to the risk of a systemic infection, it is important to recognise candidiasis as soon as possible for the clinical management of seriously unwell cancer patients. It may also aid the clinician in selecting antifungals for empirical treatment.

S2781 Crohn’s Disease Presenting as Oropharyngeal Candidiasis

Introduction: Oral lesions are easily visualized and often a sign of systemic disease. One such entity, oropharyngeal candidiasis, is a frequent finding in immunocompromised patients. Oropharyngeal candidiasis as a presenting finding in Crohn’s disease (CD) is exceedingly rare. We present the case of newly diagnosed CD manifesting with oropharyngeal candidiasis in the absence of any other immunosuppressing conditions. Case Description/Methods: A 38-years-old male with no prior medical history presented to the hospital with 1 week of sore throat, white discoloration of the oral cavity, and odynophagia. On review of systems, he also reported intermittent abdominal pain, episodic hematochezia, and a 20lb unintentional weight loss over the past several months. He took no medications and denied any high-risk sexual behavior. On physical exam, his oropharyngeal cavity was coated with white plaques on the buccal mucosa, tongue base, and palate, consistent with a clinical diagnosis of oropharyngeal candidiasis. Initial blood work was remarkable for a leukocytosis of 15,000 and CRP of 15. His HIV serology, EBV (IgG, IgM), and autoimmune workup (ANA, Anti-dsDNA) were negative. Stool multiplex PCR assay and stool ova and parasites were negative as well. His fecal calprotectin was 2399 ug/g. Computed tomography scan of the abdomen and pelvis showed pan-colitis. He subsequently underwent upper and lower endoscopy revealing innumerable ulcers with white exudate on the oropharynx and multiple ulcers throughout the colon. Biopsies demonstrated severe colitis, cryptitis, and crypt abscesses, and a diagnosis of CD was made. The patient started high dose steroids in conjunction with anti-fungal medications and had rapid resolution of all symptoms. Discussion: Oropharyngeal candidiasis is commonly seen in patients with a recent use of antibiotics, steroids, and immunocompromised states. In patients with CD, it is almost exclusively related to the use of steroids, biologics, or other immunosuppressant medications. Oropharyngeal candidiasis as a presenting symptom in CD is extremely rare with only one case being reported in the medical literature. Our case highlights the importance of keeping a broad differential in patients presenting with oropharyngeal candidiasis, but seemingly without typical risk factors.Figure 1.: Ulcers seen during the colonoscopy procedure.

The IL-20RB receptor and the IL-20 signaling pathway in regulating host defense in oral mucosal candidiasis.

Pseudomembranous candidiasis (thrush), erythematous candidiasis, and fungal esophagitis are infections of the barrier mucosa of the upper gastrointestinal tract. The majority of these infections are caused by Candida albicans, an opportunistic fungal pathogen that frequently exists as a harmless commensal on mucosal surfaces lining the gastrointestinal tract. Oral infections are initiated in the superficial stratified squamous epithelium, in which keratinocytes are the most abundant host cells and are the initial points of contact with C. albicans present in saliva. Intrinsic features of oral keratinocytes are likely to play important roles in host defense and tissue homeostasis in oral candidiasis. One understudied pathway that may be important for modulating oral candidiasis is the IL-20 cytokine signaling pathway that employs keratinocyte IL-20RB receptors as ligands for IL-19, IL-20, and IL-24. We report that production of human oral keratinocyte il24 mRNA and protein are stimulated during co-culture with C. albicans. To test the role of the IL-20 family signaling pathway in oral candidiasis, Il20rb-/- mice (lacking the IL-20RB receptor) were compared to wild-type mice in a murine model of oropharyngeal candidiasis. Fungal burdens and percent loss in body weight were determined. Despite comparable fungal burdens, the Il20rb-/- mice exhibited less weight loss over the course of their infection compared to the B6 mice, suggestive of reduced overall disease consequences in the mutant mice. Interference with IL-20 family cytokine signaling may be useful for augmenting the ability of the host to defend itself against pathogens.

A gut-oral microbiome-driven axis controls oropharyngeal candidiasis through retinoic acid.

A side effect of antibiotics is outgrowth of the opportunistic fungus Candida albicans in the oropharynx (oropharyngeal candidiasis, OPC). IL-17 signaling is vital for immunity to OPC, but how the microbiome impacts antifungal immunity is not well understood. Mice in standard specific pathogen-free (SPF) conditions are resistant to OPC, whereas we show that germ-free (GF) or antibiotic-treated mice are susceptible. Oral type 17 cells and IL-17-dependent responses were impaired in antibiotic-treated and GF mice. Susceptibility could be rescued in GF mice by mono-colonization with segmented filamentous bacterium (SFB), an intestine-specific constituent of the microbiota. SFB protection was accompanied by restoration of oral IL-17+CD4+ T cells and gene signatures characteristic of IL-17 signaling. Additionally, RNA-Seq revealed induction of genes in the retinoic acid (RA) and RA receptor-α (RARα) pathway. Administration of RA rescued immunity to OPC in microbiome-depleted or GF mice, while RAR inhibition caused susceptibility in immunocompetent animals. Surprisingly, immunity to OPC was independent of serum amyloids. Moreover, RAR inhibition did not alter oral type 17 cytokine levels. Thus, mono-colonization with a component of the intestinal microflora confers protection against OPC by type 17 and RA/RARα, which act in parallel to promote antifungal immunity. In principle, manipulation of the microbiome could be harnessed to maintain antifungal immunity.

S1.1d Risk factors associated with oropharyngeal candidiasis in COVID-19 patients: a case control study

S1.1 Controversies in the clinical management of invasive candidiasis in critically ill patients, September 21, 2022, 11:00 AM - 12:30 PM ObjectivesWith the emergence and spread of the coronavirus disease-19 (COVID-19) in the world, humans have been faced with the biggest challenge in health care systems in recent decades. The aim of the present study is to identify risk factors associated with oropharyngeal candidiasis (OPC) in COVID-19 patients.MethodsThe total number of confirmed COVID-19 patients was 218 (105 participants as cases who experienced OPC and 113 participants as controls without any evidence of OPC). The questionnaire used in this study consists of demography data, treatment strategy, clinical and laboratory data, and underlying diseases to collect information at the time of clinical OPC and follow them until the end of hospitalization.ResultsPseudomembranous candidiasis (77/105, 73.3%) was the most prevalent form of OPC in case patients. The majority of cases (58.1%) and control (58.4%) groups were male. Increasing age of COVID-19 patients (P = .03) and length of hospitalization (P = .016) were significantly associated with OPC. Diabetes (P = .003), solid tumor (P = .019), and hypertension (P = .000) were the most common underlying conditions. Use of dentures (P = .003) and poor oral hygiene (P = .000) were related to OPC in case groups. Therapy with chloroquine (P = .012), IVIG (P = .001), diuretics (P = .000), and corticosteroid pulse therapy (P = .000) were significantly associated with the development of OPC in case patients.ConclusionIt is reasonable to consider that old age, length of hospitalization, poor oral hygiene, corticosteroid usage, diabetes, solid tumor, and hypertension may predispose to the development of OPC in COVID-19 patients.

P048 Antifungal susceptibility and mechanism of azole resistance in Candida albicans clinical isolates from oropharyngeal candidiasis patients in Iran

Poster session 1, September 21, 2022, 12:30 PM - 1:30 PM ObjectivesOropharyngeal candidiasis (OPC) is the most frequent opportunistic fungal infection in head and neck cancer patients. This study was done to investigate the azole susceptibility of Candida albicans (C. albicans) from oropharyngeal candidiasis (OPC) patients and to determine the relationship between ERG11 gene mutations in these isolates and azole resistance.MethodsA total of 324 clinical isolates of Candida species were collected. Identification of the oral clinical samples was determined by culturing on CHROMagar, carbohydrate assimilation and ITS sequencing methods. Azole susceptibility was tested in vitro in microdilution studies. The ERG11 genes of 42 isolates of C. albicans were amplified and sequenced.ResultsOf the 324 isolates collected, 44.75% (145 isolates) were C. albicans. ERG11 gene was sequenced in 42 isolates. In total, 14 missense mutations were detected in ERG11 genes from 42 isolates. Among them, A945C and T495A substitutions were most prevalent and were known to cause fluconazole resistance.ConclusionsA total of 14 mutations in the ERG11 gene were identified in azole-resistant C. albicans isolates, which indicated a possible relation with the increase in resistance to azole drugs and the recurrence of oropharyngeal candidiasis. Finding more mutations and relevance requires studies with a higher number of samples.

P496 Effect of fluconazole prophylaxis in prevention of local fungal infections in patients of head and neck cancers receiving chemo-radiotherapy

Poster session 3, September 23, 2022, 12:30 PM - 1:30 PMObjectivesTo ascertain, in head and neck cancer patients receiving chemo-radiotherapy, the efficacy of fluconazole prophylaxis in1. Reducing the incidence of oropharyngeal fungal infections2. Reducing the incidence of severe i.e., grade 3 and 4 oropharyngeal mucositisMethodsA total of 66 cases of Stage III or IV squamous cell carcinoma of the oral cavity or oropharynx who were candidates for radical chemo-radiotherapy (CCRT) were randomly assigned between arm A (study arm) and arm B (control arm) using computer-generated algorithms. Both arms received conventionally fractionated radiation (66-70 Gy) with concurrent weekly intravenous cisplatin (40 mg/m2) along with standard measures of oropharyngeal hygiene. In addition, arm A received Tab Fluconazole 100 mg/d administered per oral after lunch from initiation to the completion of radiotherapy, while arm B received Tab Fluconazole 100 mg/d, if fungal infections appeared, for a period of 7-14 days.Weekly clinical examination for oro-pharyngeal candidiasis was done. Throat swabs for microbiological assessment of fungal colonization were done before treatment (zero week), during second and sixth week of CCRT, and 4 weeks after the completion of CCRT, and if any clinical suspicion of fungal infection was present.ResultsProportion of patients who developed fungal infection during treatment was significantly lower in group A—6/33 patients as compared with group B—27/33 patients (18.18% vs. 69.70% respectively, P-value < .0001). Candida albicans was detected in 7 patients (31.82%) while non-albicans Candida was detected in 15 patients (68.18%). Candida parapsilosis, C. tropicalis, C. krusei, and C. glabrata were detected. A total of 3 infected patients (75%) in group A were resistant to fluconazole but showed sensitivity to voriconazole, posaconazole, and caspofungin B. While in group B, 3/18 infected patients (16.66%) showed resistance to fluconazole and these were sensitive to voriconazole, amphotericin B, posaconazole, and caspofungin B. Mean week of onset of fungal infection in group A was 5.5 weeks which was significantly higher as compared with group B of 4.48 weeks (P-value = .029).Proportion of patients who developed grades 3/4 mucositis was significantly lower in group A as compared with group B of 54.55% vs. 81.82% respectively (P-value = .017). Median week of onset of grade 3/4 mucositis in group A was 5.5 weeks which was significantly higher as compared with group B of 5 weeks. (P-value = .029).Proportion of patients with treatment completion was significantly higher in group A as compared with group B—84.85% vs. 60.61% respectively (P-value = .027). Mean number of days needed for treatment completion in group B was 57.55 days which was significantly greater as compared with group A of 50.68 days (P-value =. 033). Median treatment gap in group B was 10 days which was significantly higher as compared with group A of 4 days (P-value = .003).See Figures below.ConclusionTab fluconazole 100 mg prophylaxis in head and neck cancer patients receiving chemo-radiation isAn effective way to reduce fungal infections, ideal prophylaxis beginning at the fourth week.An effective way to reduce the severity of radiation-induced oral mucositis—thereby translating into reduced morbidity, treatment interruptions, and overall treatment time, which have been shown to impact prognosis favorably.

P350 Oropharyngeal candidiasis in HIV infected patients: associated risk factors and antifungal susceptibility testing of candida species by disc diffusion method

Poster session 3, September 23, 2022, 12:30 PM - 1:30 PM ObjectivesTo isolate and identify Candida species by the standard microbiological method.To estimate the frequency of oral Candidiasis according to age, sex, and other factors [CD4 + count, ART, tobacco consumption, diabetes, upper respiratory tract infection (URTI), recent antibiotic consumption] in HIV-positive patients.To determine the Antifungal Susceptibility pattern of the Candida species by Disc Diffusion Method.MethodologyA hospital-based cross-sectional study was conducted for 6 months in the Department of Microbiology of Sukraraj Tropical and Infectious Disease Hospital, Kathmandu, Teku, Nepal. A total of 408 HIV-positive patients attending the ART center of the hospital of different age and sex were included in the study. Study variables like CD4 + count, tobacco consumption, diabetes, URTI, and recent antibiotic consumption were noted.Standard microbiological guidelines were followed for the oral swab collection and transportation. Specimen was seeded on SDA agar plates (SDA with chloramphenicol and cycloheximide). Preliminary identification of the Candida was done on the basis of colony characteristics, gram staining, and germ tube test. Further for the speciation of Candida species, HiCrome™ Candida Differential Agar (HImedia, India) was applied where on the basis of coloration and colony morphology speciation was done. Similarly, Cornmeal Agar (Dalmau plate culture technique) and sugar Fermentation test were applied to confirm the Candida species.Muller-Hinton agar supplemented with 2% glucose and 0.5 μg/ml methylene blue dye (GMB) medium was used to perform the antifungal susceptibility testing of Candida isolates. Antifungal susceptibility testing (AST) of isolates was performed and interpreted according to Clinical and Laboratory Standards Institute (CLSI) M44-A document. Candida albicans ATCC 90028 was taken as the reference strain. All the data were entered in Microsoft excel and Chi-square was used to find out the association between the frequency of oral candidiasis and study variables.ResultsAmong 408 studied subjects, 225 (55.1%) were males and 183 (44.9%) were females. Of the participants, 116 (28.4%) had regular tobacco smoking habit, diabetes 10 (2.5%), URTIs 30 (7.4%), antibiotic consumption 44 (10.8%) and ART use 394 (96.6%). The CD4 + cell count of respondents ranged from 12 - 2425 cells/mm³. Candida albicans 53 (81.5%) was the most frequently encountered species followed by C. tropicalis 3 (4.6%), C. krusei 2 (3.1%), C. glabrata 1 (1.5%) and 6 (9.2%) other Candida species. A total of 26 patients had CD4+ ≤200 cells/mm3 and 39 patients had CD4+ >200 cells/mm3. There was no significant association in the occurrence of oral candidiasis among males and females (P = .966), tobacco consumption (P = .051), ART use (P = .188), diabetes (P = .722). Whereas, there was a significant association between oral Candida carriage and CD4 + cell count ≤ 200 cells/mm3 (P <.001), URTI (P = .029), and recent antibiotic consumption (P = .002). Amphotericin B was the most potent antifungal followed by voriconazole, itraconazole, and conversely fluconazole the most resistant.Conclusion Candida albicans was the common species isolated in our study. Candida Chrome Agar can be used as a routine media for rapid identification and Candida speciation. AST needs to be done routinely to know the susceptibility pattern of isolates and initiate proper treatment of patients. Since oral yeast colonization was associated with low CD4 + count (<200 cells/mm3). Thus, oral lesions can serve as early markers for HIV infection.

Arid5a Mediates an IL-17-Dependent Pathway That Drives Autoimmunity but Not Antifungal Host Defense.

IL-17 contributes to the pathogenesis of certain autoimmune diseases, but conversely is essential for host defense against fungi. Ab-based biologic drugs that neutralize IL-17 are effective in autoimmunity but can be accompanied by adverse side effects. Candida albicans is a commensal fungus that is the primary causative agent of oropharyngeal and disseminated candidiasis. Defects in IL-17 signaling cause susceptibility to candidiasis in mice and humans. A key facet of IL-17 receptor signaling involves RNA-binding proteins, which orchestrate the fate of target mRNA transcripts. In tissue culture models we showed that the RNA-binding protein AT-rich interaction domain 5A (Arid5a) promotes the stability and/or translation of multiple IL-17-dependent mRNAs. Moreover, during oropharyngeal candidiasis, Arid5a is elevated within the oral mucosa in an IL-17-dependent manner. However, the contribution of Arid5a to IL-17-driven events in vivo is poorly defined. In this study, we used CRISPR-Cas9 to generate mice lacking Arid5a. Arid5a -/- mice were fully resistant to experimental autoimmune encephalomyelitis, an autoimmune setting in which IL-17 signaling drives pathology. Surprisingly, Arid5a -/- mice were resistant to oropharyngeal candidiasis and systemic candidiasis, similar to immunocompetent wild-type mice and contrasting with mice defective in IL-17 signaling. Therefore, Arid5a-dependent signals mediate pathology in autoimmunity and yet are not required for immunity to candidiasis, indicating that selective targeting of IL-17 signaling pathway components may be a viable strategy for development of therapeutics that spare IL-17-driven host defense.

Receptor-kinase EGFR-MAPK adaptor proteins mediate the epithelial response to Candida albicans via the cytolytic peptide toxin, candidalysin

Candida albicans (C. albicans) is a dimorphic commensal human fungal pathogen that can cause severe oropharyngeal candidiasis (oral thrush) in susceptible hosts. During invasive infection, C. albicans hyphae invade oral epithelial cells (OECs) and secrete candidalysin, a pore-forming cytolytic peptide that is required for C. albicans pathogenesis at mucosal surfaces. Candidalysin is produced in the hyphal invasion pocket and triggers cell damage responses in OECs. Candidalysin also activates multiple MAPK-based signaling events that collectively drive the production of downstream inflammatory mediators that coordinate downstream innate and adaptive immune responses. The activities of candidalysin are dependent on signaling through the epidermal growth factor receptor (EGFR). Here, we interrogated known EGFR-MAPK signaling intermediates for their roles mediating the OEC response to C. albicans infection. Using RNA silencing and pharmacological inhibition, we identified five key adaptors, including growth factor receptor-bound protein 2 (Grb2), Grb2-associated binding protein 1 (Gab1), Src homology and collagen (Shc), SH2-containing protein tyrosine phosphatase-2 (Shp2), and casitas B-lineage lymphoma (c-Cbl). We determined that all of these signaling effectors were inducibly phosphorylated in response to C. albicans. These phosphorylation events occurred in a candidalysin-dependent manner and additionally required EGFR phosphorylation, matrix metalloproteinases (MMPs), and cellular calcium flux to activate a complete OEC response to fungal infection. Of these, Gab1, Grb2, and Shp2 were the dominant drivers of ERK1/2 activation and the subsequent production of downstream innate-acting cytokines. Together, these results identify the key adaptor proteins that drive the EGFR signaling mechanisms that underlie oral epithelial responses to C. albicans.

Tocilizumab induced immunosuppression in a case of adult-onset still’s disease: are these newer biologics double edged sword?

Adult-onset still’s disease (AOSD) is a rare multisystemic inflammatory disorder of unknown etiology characterised by high spiking fever, evanescent skin rash, arthralgias, arthritis, neutrophilic leucocytosis. Initial treatment strategy includes use of hands-on drugs like non-steroidal anti-inflammatory drugs, low dose corticosteroids, conventional DMARDs. But as the disease progresses to severe form, targeted and biologic DMARDs could be the option for management. Interleukin-6 being one among the many cytokines involved in the pathogenesis of AOSD, has made itself a target for the treatment of refractory cases. Tocilizumab, a recombinant humanized anti IL-6 monoclonal antibody, is one such biologic drug available in the market that has proven its therapeutic efficacy in several clinical trials. We are presenting a case of 37-year-old female patient, known case of AOSD for 4 years. Patient was initially maintained on low dose corticosteroid and conventional DMARD like hydroxychloroquine and methotrexate. Flare ups of the disease warranted the use of tocilizumab and tofacitinib in this patient. After clinical as well as pathological improvement with tocilizumab 2 years before, signs of immunosuppression were observed when tocilizumab was reintroduced for the treatment. Patient suffered from acute pyelonephritis, septicemia, shock, oropharyngeal candidiasis and bronchitis which could be owned to immunosuppressive action of tocilizumab. One can reduce the chances of infection and other adverse effects by careful periodic monitoring of various laboratory parameters like total W.B.C., total platelet count and liver enzymes. Cautious selection of the patient is needed for the treatment with newer biologic agents.

A comparative study on the production of extracellular hydrolytic enzymes of C. albicans and non-albicans Candida species isolated from HIV+/AIDS patients and healthy individuals.

Oropharyngeal candidiasis is the most prevalent opportunistic fungal infection in patients with human immunodeficiency virus (HIV) as well as other immunodeficiency disorders, which is caused by various Candida species, mostly Candida albicans. Studies have shown that Candida isolates differ in their pathogenicity. These variations are attributed to virulence factors, host characteristics, and the target tissue. This study aimed to determine and compare the secretion of hydrolytic enzymes in C. albicans and non-albicans Candida species isolated from HIV+/AIDS patients and healthy individuals. Samples were taken from 201 patients with HIV and 118 healthy individuals. The samples were identified by macroscopic, phenotypic, and molecular methods, and virulence factors were subsequently measured. Statistical differences in enzymatic activity of various Candida isolates were calculated (P<0.0001). In total, 95 samples (47.20%) from patients and 46 samples (38.90%) from healthy individuals were positive for the growth of different Candida species. There were 39 (41.10%) and 36 (78.30%) C. albicans in patients and healthy individuals, respectively, as well as 56 (58.90%) and 10 (21.70%) non-albicans species in patients and healthy subjects, respectively. All the enzymes produced by Candida species enzymes were at low, medium, and high levels. Hemolysin activity in Candida species isolated from patients was significantly higher, compared to healthy individuals. Moreover, the activity of all C. albicans enzymes in patients was significantly higher than other Candida species. The C. albicans isolated from HIV-positive individuals secreted higher amounts of exoenzymes, and can cause oropharyngeal candidiasis and become a source of candidiasis for the host.

Niclosamide-loaded nanoparticles disrupt Candida biofilms and protect mice from mucosal candidiasis.

Candida albicans biofilms are a complex multilayer community of cells that are resistant to almost all classes of antifungal drugs. The bottommost layers of biofilms experience nutrient limitation where C. albicans cells are required to respire. We previously reported that a protein Ndu1 is essential for Candida mitochondrial respiration; loss of NDU1 causes inability of C. albicans to grow on alternative carbon sources and triggers early biofilm detachment. Here, we screened a repurposed library of FDA-approved small molecule inhibitors to identify those that prevent NDU1-associated functions. We identified an antihelminthic drug, Niclosamide (NCL), which not only prevented growth on acetate, C. albicans hyphenation and early biofilm growth, but also completely disengaged fully grown biofilms of drug-resistant C. albicans and Candida auris from their growth surface. To overcome the suboptimal solubility and permeability of NCL that is well known to affect its in vivo efficacy, we developed NCL-encapsulated Eudragit EPO (an FDA-approved polymer) nanoparticles (NCL-EPO-NPs) with high niclosamide loading, which also provided long-term stability. The developed NCL-EPO-NPs completely penetrated mature biofilms and attained anti-biofilm activity at low microgram concentrations. NCL-EPO-NPs induced ROS activity in C. albicans and drastically reduced oxygen consumption rate in the fungus, similar to that seen in an NDU1 mutant. NCL-EPO-NPs also significantly abrogated mucocutaneous candidiasis by fluconazole-resistant strains of C. albicans, in mice models of oropharyngeal and vulvovaginal candidiasis. To our knowledge, this is the first study that targets biofilm detachment as a target to get rid of drug-resistant Candida biofilms and uses NPs of an FDA-approved nontoxic drug to improve biofilm penetrability and microbial killing.

Adverse reactions and cardiac arrhythmias related to antiretroviral use in patients with HIV/AIDS

Introduction: AIDS is an advanced clinical manifestation of human immunodeficiency virus (HIV) infection. These patients have improved with antiretroviral drugs; but there is an increased risk of toxicity and cardiac disease, including cardiac arrhythmias. Objective: To clinically characterize patients with HIV/AIDS who presented adverse reactions due to the consumption of antiretroviral, as well as to estimate the prevalence ratio of cardiac arrhythmias. Method: Descriptive and cross-sectional study, which made possible the clinical characterization and the relationship of ART with general adverse reactions, including cardiac arrhythmias, in the General Clinical-Surgical Teaching Hospital Dr. “Juan Bruno Zayas Alfonso” in the period 2018-2020. Results: Adverse reactions related to oropharyngeal candidiasis were marked, representing 80%. Antiretroviral treatment was very unfavorable for Scheme I, with 66.6% of adverse reactions. Esophagus-gastritis and cardio toxicity marked the differences, with 28 (53.8%) and 14 (55.8%) respectively. The ratio between patients with cardiac arrhythmias versus those without arrhythmias is reasonably higher in those who consumed antiretroviral compared those who did not consume it. Conclusion: Adverse reactions in patients with HIV/AIDS continue to be a health problem in our territory, demonstrating the relationship between adverse reactions and antiretroviral treatment with Cuban generics, especially due to gastrointestinal effects and cardiac arrhythmias. The drug-disease interaction results a complex but indisputably frequent process in patients with HIV/AIDS.