mycology review on candida species in diabetics patients

1. Advanced Medical Mycology presentation on mini review
8/13/2020 1
epidemiology, pathogenesis, diagnosis, treatment and prevention of
cadidiasis in diabetic’s patient.
March, 2020
By Azanaw A.

2. Out line
➢ Introduction
➢ The statement of the problem
➢ Objective
➢ Epidemiology of Candidiasis
➢ virulence factor of Candidiasis
➢ Pathogenesis of Candidiasis
➢ DX, RX and prevention of Candidiasis
➢ Literature review
➢ search strategy
➢ Discussion
➢ Conclusion and Recommendation
➢ References
8/13/2020 2By Azanaw A.

3. Introduction
❖Candida is a fungus consisting of many species, but
only 17 species are reported to infect humans. These
species include
➢ Candida albicans,*
➢ Candida glabrata,
➢ Candida parapsilosis,
➢ Candida tropicalis*, Candida krusei*, Candida kefyr,
Candida guilliermondii, Candida lusitaniae, Candida
dubliniensis. (Wolff etal, Aliyu etal).
8/13/2020 3By Azanaw A.

4. Introduction …….
❖Candida species are commonly seen fungi that exist as
an element of normal flora in the skin, gastrointestinal
tract and reproductive tract of humans.
❖Fungal infections are generally opportunistic so the
pathogenesis and prognosis of candidial infections are
affected by:
➢ the host immune status and
➢ also differ greatly according to disease presentations.
(McPherson etal).
8/13/2020 4By Azanaw A.

5. Introduction …….
❖candida infection occurs when there are factors that can
facilitate the invasion of the tissues due to the weak
resistance of the host.
❖The factors that cause candidiasis are divided into two
➢ Endogenous ( pregnancy ,obesity, chronic disease like
DM).
➢ Exogenous ( climate, skin hygiene and contact with
patient) (Djuanda etal, Hammad MMtal).
❖ Candida species are a major cause of health care
associated BSI world wide(Guinea etal) .8/13/2020 5By Azanaw A.

6. Introduction …….
❖Systemic infections are commonly referred to as
candidemia and are one of the prominent co-infections in
immunocompromised patients such as those suffering
from DM (Chakravarthi S, etal.Ilkit M etal).
❖The presence of Candida yeasts in urine, known as
candiduria, is an indicator of infection or colonization of
the urinary tract by Candida species. This condition in
diabetic patients can be hazardous due to diminished
immune system response (Falahati M etal).
8/13/2020 6By Azanaw A.

7. Introduction …….
❖ Vulvovaginal candidiasis(VVC) is the most common
manifestation of genital candidiasis. VVC is diagnosed in
upto 40% of females with vaginal complaints (Deorukhkar
SC, etal).
❖ DM is a hyperglycemia disease characterized by absolute
absence of insulin or a relative decrease in cell insensitivity to
insulin (Wani MA etal).
❖ The metabolic status of DM patients provides the advantage
by fulfilling specific nutritional requirements and facilitating
the growth of fungi, especially Candida species (Nasreen S,
etal).
8/13/2020 7By Azanaw A.

8. Introduction………….
❖ Diabetic patients not only had a higher candidal carriage rate, but
also a variety of candidal species that were resistant to azole
antifungals.
❖ Oral candidal colonization is significantly associated with glycemic
control, type of diabetes, and salivary pH (AlAttas SA etal).
❖ The frequency of C. albicans is higher than non candida spp. in
diabetic patients with periodontitis and Candida infections are
observed at increased frequencies among subjects with high blood
sugar level (Al Mubarak S, etal).
8/13/2020 8By Azanaw A.

9. Statement of the problem
❖ Yeast naturally lives in the human body. Problems arise
when the yeast overgrows, causing a fungal infection.
❖ As a 2018 study which included data from over 300,000
people showed, person with type 1 or type 2 diabetes has a
higher risk of infection, including yeast infection, than a
person without the condition.
❖ In people with diabetes, symptoms can grow worse more
quickly than in other people. Also, infections can be harder
to treat (www.medicalnewstoday.com/articles).
8/13/2020 9By Azanaw A.

10. statement of the problem………..
❖ In the present study, there was also a significant statistical
difference between positive vaginal Candida culture and
type of diabetes mellitus (Faraji R etal).
❖ Candida pneumonia is a rare infection, and the majority of
cases are secondary to hematogenous dissemination
(Hakamifard A, etal).
❖ Candidiasis has emerged as an alarming opportunistic
infection with an increase in a number of patients among the
diabetics. It is estimated that as many as 75% of women
experience at least one episode of VVC during their lifetime
(Paul LG, etal ).8/13/2020 10By Azanaw A.

11. Statement of the problem ……
❖ So purpose of the mini review to show the burden of candidiasis in
DM patients and the correlation between glucose level with candidia
infection.
❖Objectives
➢ to practice how to search published data on candidasis infection in DM
patients using different searching tools like Google scholar, and Pub
med.
➢ To assess Epidemiology, pathogenesis, diagnosis, treatment and
prevention of candiaiasis.
➢ To assess the virulence factor of candidaisis in DM patient
8/13/2020 11By Azanaw A.

12. Epidemiology, pathogenesis,
diagnosis, treatment and prevention of candiaiasis
❖Epidemiology
➢ world wide
❖Superficial Candida rates ranged from 0%to 85 % while
invasive rates ranged from 0 % to 33% in Africa
(Omrani LP etal.).
❖Rates for candidiasis and candidemia are similar
throughout the world (Hidalgo JA etal).
8/13/2020 12By Azanaw A.

13. Virulence factor and Pathogenesis
❖Virulence factor
❖ Polymorphim
➢ Candida albicans is a polymorphic fungus that can grow
in several different forms, primarily yeast,
pseudohyphae, and hyphae.
➢ Several factors can cause a change in morphology, such
as pH differences, temperature changes, carbon dioxide
levels, starvation, and quorum sensing molecules (Mayer
FL, etal).
8/13/2020 13By Azanaw A.

14. Virulence factor and Pathogenesis
❖ Adhesins
➢ adhesion, the Als3 gene appears to the most important as it is
upregulated during an infection of oral and vaginal epithelial
cells. Also, it helps with biofilm formation by helping with
adhesion to each other (Roudbarmohammadi S, etal.)
❖ Invasins
➢ method of invasion is the active penetration of C. albicans into
host cells by an unknown mechanism involving hyphae
(Wächtler B, etal).
8/13/2020 14By Azanaw A.

15. Virulence factor and Pathogenesis
❖ Other virulence factors includes;
➢ Biofilm formation
➢ Secreted hydrolases
➢ Metabolic adaption (Xie Z, etal, Wächtler B, etal)
❖ Transmission
➢ Candida albicans is usually transmitted from mother to infant
through childbirth,
➢ Person to person acquired infections mostly happen in
hospital setting (Fanello S,).
8/13/2020 15By Azanaw A.

16. Virulence factor and Pathogenesis
❖ Candidiasis is caused by the abnormal growth in C. albicans,
which is usually due to an imbalance in the environment
❖ Several events can spark an imbalance. For example,
➢ Antibiotic use
➢ pregnancy
➢ uncontrolled diabetes and
➢ impaired immune system
❖ C. albicans are able to take advantage of the conditions then
colonization will occurred (emedicine.medscape.com/articl).
8/13/2020 16By Azanaw A.

17. Virulence factor and Pathogenesis
➢ Superficial infection
➢ Deep seated infection
➢ Disseminated infection
❖ Clinical features
➢ There are 3 major type of infections caused by Candida
albicans:
➢ oropharyngeal candidiasis
➢ vulvovaginal (genital) candidiasis
➢ and invasive candidiasis (candidemia)
8/13/2020 17By Azanaw A.

18. Diagnosis
❖ Oral and genital candidiasis is diagnosed in similar manners
by microscopy , culture and PCR (Blot SI etal).
➢ chlamydospore production on cornmeal Tween 80 agar
➢ Germ tube test
❖ Candidemia is primarily diagnosed by
➢ blood cultures
➢ Serologic marker (Roudbarmohammadi S etal).
8/13/2020 18By Azanaw A.

19. Treatment
❖candidiasis, the primary treatment for is fluconazole (a
triazole) daily.
❖For neutropenic patients, echinocandin or amphotericin B
is preferred (Pappas P, Kauffman C, etal.)
❖Candidemia patients are usually administered
fluconazole through IV but for critically ill patients,
echinocandin and lipid formulation amphotericin B are
again preferred(Nguyen MH etal.).
8/13/2020 19By Azanaw A.

20. Prevention
➢Keeping a healthy lifestyle
➢Good hygiene,
➢ proper nutrition,
➢ and careful antibiotic use
➢recurrent infections clotrimazole can be used
(http://www.prevention.com/health
conditions/candidiasis#Prevention)
8/13/2020 20By Azanaw A.

21. ❖ Particular Features of Candida sp. That Increase the
Incidence of Candidiasis in Diabetic Patients.
➢ Enzymatic Activity
❖ Several studies have established an association between
hydrolytic enzymes activity and an increase in the
pathogenic ability of Candida sp. (Bramono K etal ).
➢ Biofilm Formation
❖ Biofilms are communities of microorganisms embedded in
an extracellular matrix (Costerton JW, etal.).
8/13/2020 21By Azanaw A.

22. Development of a Candida sp. biofilm
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23. Hydrophobicity
❖In Candida spp., the adhesion phenomenon is mediated
by agglutinin like (Als) sequence proteins (Hoyer
LL,etal).
❖Als dependent cellular adhesion is connected with
increases in cell surface hydrophobicity (CSH) (Rauceo
JM etal.).
❖ The CSH of Candida sp. enhances virulence by
promoting adhesion to host tissues (Zakikhany K etal).
8/13/2020 23By Azanaw A.

24. Literature review
❖ DM is metabolic disorder that predisposes individuals to
fungal infections, including those related to Candida ssp.
due to an immunosuppressive effect on the patient.
❖ For instance the prevalence of cadidiasis from American
studies, USA (52%) from a total of 42 gingival samples in
diabetic patients with periodontitis. the most common spp.
Of Candida were C. albicans (38%), followed by C.
dubliniensis(9.5%), C. tropicalis (4.7%) and C.
glabrata(4.7%) (Al Mubarak S etal.).
8/13/2020 24By Azanaw A.

25. Literature review……………………..
❖ Another Study was conducted in Greek from total of 128 oral swabs
sample Candida albicans was the most frequently isolated species in
DM patients.
❖ The oral carriage of Candida spp. was significantly higher in diabetic
patients (Belazi M etal).
❖ A case control study conducted in Saudi Arabia that compared 150
diabetics (49 type 1, 101 type 2) with 50 healthy controls.
❖ Diabetics had a higher candidal carriage rate compared to controls.
❖ Candida albicans was the most frequently isolated species, but diabetics
had a variety of other candidal species present (Safia A etal…..)
8/13/2020 25By Azanaw A.

26. Literature review………………..
❖A Cross sectional study was conducted in Brazil among
717 with type 2 DM women.
❖ The diabetic group showed more symptomatic VVC and
RVVC = 66.66% than colonized 33.33% women, and
showed significantly more colonization, VVC and RVVC
than seen among the control (Gunther HPRM etal).
❖A study conducted in Malaysia among 30 DM patients.
60% of Candida species was found with overall species
were Candida albicans (Al Hafiz OM etal).
8/13/2020 26By Azanaw A.

27. Literature review………………..
❖ A study conducted in Iran among 100 diabetic women. The
frequencies of Candida species include Candida albicans 5%,
Candida glabrata 7%, Candidat ropicalis 4% and Candida
parapsilosis 4%. VVC was more prevalent in women without blood
glucose level control than ones with blood glucose level control
(Faraji R etal).
❖ Another study was conducted in Iran on 305 DM patients.
candiduria were 12.5% and the isolated species was Candida
glabrnta , 50%, C.albicans 31.6%, C. krusei 10.5%,C. tropicalis
5.3%, and C. kefyr, 2.6%(Falahati M etal).
8/13/2020 27By Azanaw A.

28. Literature review………………..
❖Studies conducted in Iran. A total of 113 swab sample
from patients with type 2 diabetes, 24 patients with type
1diabetes, and 105 healthy.
❖ The most commonly isolated species in both diabetics and
controls was Candida albicans.
❖ Of the tested antifungal drugs, the highest rate of
resistance was found against itraconazole, followed in
frequency by ketoconazole and fluconazole (Zomorodian K
etal).
8/13/2020 28By Azanaw A.

29. Literature review………………..
❖ A study conducted in Indian From total of 90 saliva sample , 30
with controlled type 2 diabetes, 30 with uncontrolled type 2
diabetes and 30 without diabetes.
❖ Candida CFUs were significantly higher in diabetic subjects, with
a significant and positive correlation with salivary glucose levels
(Balan P, etal).
❖ Another study was carried out in India. 30 cases of diabetic
patients and 30 cases of normal healthy individuals.
❖ significant increase in the candidal colonization was observed in
diabetic patients (Pallavan B,).8/13/2020 29By Azanaw A.

30. Literature review………………..
❖ A study conducted in Poland from total of 44 diabetic patients (27
patients with Type 1 DM and 17 with Type 2 DM) as well as 17
healthy. Candida spp. Populations in T1DM and T2DM subjects
were larger as compared to controls. However, no difference was
found between T1DM and T2DM (Gosiewski T, etal).
❖ A study was conducted in Ethiopia. A total of 422 diabetic
patients with asymptomatic and symptomatic UTI were
investigated for UTI. The overall prevalence of significant
candiduria in both groups was 8.3%. The most common species
were C albicans (42.0%), C glabrata (34.2%), and C
tropicalis(15.8%) (Yismaw G,) .8/13/2020 30By Azanaw A.

31. Search strategy/ method
❖A comprehensive literature search was done in PubMed,
Google Scholar, Science Direct, Databases using
keywords and Boolean operators (AND and OR)
combination.
❖The keywords used to search the mentioned databases
were “candidasias’’, “Diabetics mellitus’’, “oral
candidiasis’’, Candida Species “prevalence’’, “
Epidemiology’’, “year’’.
8/13/2020 31By Azanaw A.

32. Discussion
❖ The risk factors for oral candidal infection are complex, but
it is known that tongue lesions and immunosuppression
(e.g., diabetes mellitus) clearly influence oral Candida sp.
carriage and the upsurge of oral candidiasis.
❖ The causes influencing the higher incidence of oral
candidiasis in diabetic patients are presented in Table.docx
❖ Diabetes is a stated risk factor for periodontitis, which is the
sixth-leading complication of diabetes (Olczak Kowalczyk
D etal).
8/13/2020 32By Azanaw A.

33. Discussion
❖ C. albicans is the most common species isolated, followed by
C. glabrata in patients both with and without diabetes (Mnif
MF etal, Atabek ME etal)
❖ Around 10% to 15% of in-hospital urinary tract infections
(UTIs) are related to Candida sp. And the prevalence is still
increasing (Yismaw G etal)
❖ Catheter-associated candiduria is a common clinical finding
in hospitalized patients, especially in intensive care units
(Pfaller M etal)
8/13/2020 33By Azanaw A.

34. Conclusion and recommendations
❖ Diabetes mellitus is a severe metabolic chronic disease that is
most prevalent in developed and developing countries.
❖ The general immune compromised state with an often poor
glucose control often leads to secondary diseases in DM
individuals.
❖ Among the candidiasis, oral diseases are the most frequent
infections that occur in DM patients, as well as VVC and, more
seriously, systemic candidiasis.
❖ Final research should be conduct in Ethiopia on candidia in
infection in diabetic’s patient from different clinical specimen8/13/2020 34By Azanaw A.

35. Summary
❖Candida species are a major cause of health care
associated bloodstream infection (BSI) worldwide.
❖As a 2018 study which included data from over 300,000
people showed, a person with type 1 or type 2 diabetes
has a higher risk of infection.
❖This mini review showed that DM patients have an
increased susceptibility to Candida sp. infections which
aggravates in the cases of uncontrolled hyperglycemia.
8/13/2020 35By Azanaw A.

36. References
1. Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ. Fitzpatrick’s
dermatology in general medicine, 2 volumes. Transplantation. 2008;85(654).
2. Aliyu S, Enoch D, Abubakar I, Ali R, Carmichael A, Farrington M, et al.
Candidaemia in a large teaching hospital: a clinical audit. Journal of the
Association of Physicians. 2006;99(10):655-63.
3. Wahyuningsih R, Freisleben H-J, Sonntag H-G, Schnitzler P. Simple and rapid
detection of Candida albicans DNA in serum by PCR for diagnosis of invasive
candidiasis. Journal of clinical microbiology. 2000;38(8):3016-21.
4. McPherson R, Pincus M. Herry's Clinical Diagnosis and Management by
Laboratory Methods, twenty-second. Elsevier, Amsterdam; 2011.
5. Guinea J. Global trends in the distribution of C andida species causing candidemia.
Clinical Microbiology and Infection. 2014;20:5-10. .
8/13/2020 36By Azanaw A.

37. • Thank you for your attention !!!
8/13/2020 37By Azanaw A.