Al-Ammari et al (2019): Fungal Pathogens in RTIs November 2019 Vol. 22(8)

PREVALENCE OF FUNGAL PATHOGENS AMONG Abbas M. AL-Ammari1*, Anaam Fuad Hussain2, Thuraya Kadhim Ismael3 1. Biology Department, College of Science, Diyala University, Iraq. 2. Biotechnology Department, College of Science, Diyala University, Iraq. 3. Iraqi Ministry of Health and Environment, Diyala Health Environment, Baquba Teaching Hospital, Iraq

Corresponding author E-mail: [email protected]

ABSTRACT One-third of infections associated mortality is caused by respiratory diseases. Among these accounting, fungal respiratory infections are largely unrecognized. Although treatment, most invasive fungal infections stilled responsible forhigh mortality. Fungal spores typically enter the by inhalation, the spores reach lung through the bloodstream and cause fungal . Inside the alveoli, the fungal spores travel throughout intracellular spaces and also passage to adjacent alveoli through connecting pores. One hundred twenty specimens including bronchoalveolar lavage, sinus, and sputum (40 specimens each) were randomized collected from patients with respiratory problems who attended Baquba Teaching Hospital for a period 7 months.Fungal cultures were performed using primary culture onto Sabouraud´s dextrose agar containing chloramphenicol which incubated at 28ºC for 1-2 weeks. The positive results were identified using standard conventional methods. Candida species reportedalmost fungal pneumonia isolated from bronchoalveolar lavage and sinus sites, with a percentage 28.6% and 26.7%, respectively. Whilst, Aspergillus fumigates was the almost fungal isolates from sputum specimens, with a percentage 24%. Young and adult groups were most percentage infected with Candida species (35.7% and 21.1%), respectively. Whilst old aged were most infected with A. fumigates (23.8%) The findings concluded that Candida species and Aspergillusfumigates reported the highest frequency of fungal pneumonia infections.

Keywords: Fungal pneumonia, Candida species, Aspergillus fumigates,Respiratory tract infections How to cite this article: Al-Ammari AM, Hussein AF, Ismael TK (2019): Prevalence of fungal pathogens among respiratory tract infections, Ann Trop & Public Health; 22(8): S227. DOI: http://doi.org/10.36295/ASRO.2019.22085

INTRODUCTION Immunocompromised patient is faced with threat of suppression in due to different reasons such as (chemotherapy , AIDS, diabetes, organs transplant and auto immune diseases) (1)

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Al-Ammari et al (2019): Fungal Pathogens in RTIs November 2019 Vol. 22(8)

One-third of infections associated mortality are caused by respiratory diseases. Among these accounting, fungal respiratory infections are largely unrecognized. Although treatment, most invasive fungal infections stilled responsible forhigh mortality(2,3).Endemic or opportunistic fungi are causes of pulmonary fungal problems. The fungal pathogens are capable to cause opportunistic diseasesin particular in personswhose suppression in immune systems(4). Many of soil-inhabiting fungal genera including (Aspergillus, Blastomyces, Coccidioides, Candida, Cryptococcus, Histoplasma, and Penicillium) which are primarily inflicting and considered to besystemic or opportunistic pneumonia problems(5).Fungal diseases are most increasingly in nosocomial setting. Distribution the spores of fungi are more than 50,000 spores \m3 of air loaded during the fungal season(6,7).Fungal spores are typically enter the lung by inhalation, the spores reach lung through the bloodstream and cause fungal pneumonia. Inside the alveoli, the fungal spores travel throughoutintracellular spaces and also passage to adjacent alveoli through connecting pores. The immune system is respond by sendingWBCs for attacking fungal spores as foreign bodies(8). A studyrevealed thatcertain present in the high percentage in bronchial and sinonasalcultures, even in healthy individuals(9).Fungal pneumonia is more commonly as colonization in both of upper and lower airway allergic diseases particularly in patients with allergic , , chronic rhinosinusitis and . The recognition between colonization and is not easy. Therefore, the treatment is initiated associated with an increase in adverse events and costs. On the other hand, fungal pneumonia are associated with high percentageof mortality in those cases where treatment initiation is delayed (10).

MATERIALS AND METHODS One hundred twenty specimens were collected from randomized patients with respiratory problems who attended Baquba Teaching Hospital for a period7 months.Patients´ age was ranged from 1 to 70 years old. The specimens including bronchoalveolar lavage, sinus, and sputum (40 specimens each). The volume of collected specimenswas approximatelybetween 2-6 ml.Fungal cultures were performed on fresh specimens using primary culture onto Sabouraud´s dextrose agar containing chloramphenicol which incubated at 28ºC for 1-2 weeks. The positive results were identified using standard conventional methods such as Czapic agar, malt yeast agar, potato carrot agar, potato carrot agar, Chrom agar, Tweens assimilation tests, germ tube test, API 20C system, colony morphology and microscopic findings(11).

RESULTS Out of one hundred twenty specimens had been included in this survey, the percentages of fungal isolated from respiratory infections were35%, 37.5% and 62.5%, respectively (Table 1).

Table 1: Percentage of fungal pneumoniaaccording tospecimen sites Specimens Bronchoalveolar Sinus Sputum Total lavage ©Annals of Tropical Medicine & Public Health S228

Al-Ammari et al (2019): Fungal Pathogens in RTIs November 2019 Vol. 22(8)

Results No (%) No(%) No(%) No (%) Positive 14 (35%) 15 (37.5%) 25(62.5%) 54(45%) Negative 26 (65%) 25 (62.5%) 15(37.5%) 66(55%) Total 40(100%) 40 (100%) 40 (100%) 120(100%)

Percentage of fungal isolates: Candida species reportedalmost fungal pneumonia isolated from bronchoalveolar lavage and sinus sites, with a percentage 28.6% and 26.7%, respectively. Whilst, Aspergillus fumigates was the almost fungal isolates from sputum specimens, with a percentage 24% (Table 2).

Table 2: Percentage of fungal isolates according to infection sites Sites Bronchoalveolar Sinus Sputum Total lavage Results No(%) No (%) No (%) No (%) Absidia species 1 (7.1%) 0(0.0%) 0(0.0%) 1(1.9%) Alternaria species 0(0.0%) 0(0.0%) 1(4%) 1(1.9%) Aspergillus falvus 2 (14.3%) 2 (13.3%) 1(4%) 5(9.3%) Aspergillus fumigates 3(21.4%) 1 (6.7%) 6(24%) 10 (18.5%) Aspergillus niger 0(0.0%) 1 (6.7%) 2(8%) 3(5.6%) Candida species 4(28.6%) 4 (26.7%) 5(20%) 13 (24.1%) Cladosporium species 0(0.0%) 0(0.0%) 1(4%) 1(1.9%) Cryptococcus neoformans 2(14.3%) 2(13.3%) 4(16%) 8(14.8%) Fusarium species 0(0.0%) 1 (6.7%) 1(4%) 2(3.7%) Mucor species 1(7.14%) 2(13.3%) 1(4%) 4(7.4%) Rhizopus species 0(0.0%) 0(0.0%) 1(4%) 1(1.9%) Rhodotorula species 1(7.14%) 0(0.0%) 1(4%) 2(3.7%) Penicillium species 0(0.0%) 2(13.3%) 1(4%) 3 (5.65) Total 14 (100%) 15 (100%) 25 (100%) 54 (100%)

Male patients were more infected with fungal pneumonia than females. Candida species reported asa highly infections with fungal pneumonia infection, with a percentage (21.9%)(Table 3).

Table 3: Percentage of fungal pneumonia isolates according to sex groups concerning specimens Male Female Specimens Source Total Results No (%) No(%) (No) No (%) Absidia species 1 (3.1%) 0(0.0%) Bronchoalveolar lavage 1(1.9%) Alternaria species 1 (3.1%) 0(0.0%) Sputum 1(1.9%) Bronchoalveolar lavage (2) 5(9.3%) ©Annals of Tropical Medicine & Public Health S228

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Aspergillus falvus 2(6.3%) 3 (13.6%) Sinus (2)Sputum (1) Bronchoalveolar lavage (3) 10 (18.5%) Aspergillus fumigates 6(18.8%) 4 (18.2%) Sinus (1)Sputum (6) Aspergillus niger 3(9.4%) 0(0.0%) Sinus (1)Sputum (2) 3(5.6%) Bronchoalveolar lavage (4) 13 (24.1%) Candida species 7 (21.9%) 6(27.3%) Sinus (4)Sputum (5) Cladosporium species 1 (3.1%) 0(0.0%) Sputum (1) 1(1.9%) Bronchoalveolar lavage (2) 8 (14.8%) Cryptococcus neoformans 4 (12.5%) 4(18.2%) Sinus (2)Sputum (4) Fusarium species 2(6.3%) 0 (0.0%) Sinus (1)Sputum (1) 2(3.7%) Bronchoalveolar lavage (1) 1(3.1%) 4(7.4%) Mucor species 3 (13.6%) Sinus (2)Sputum (1) Rhizopus species 1(3.1%) 0(0.0%) Sputum (1) 1(1.9%) Bronchoalveolar lavage (1)Sputum Rhodotorula species 1(3.1%) 1(4.6%) 2(3.7%) (1) Penicillium species 2 (6.3%) 1(4.6%) Sinus (1)Sputum (1) 3 (5.65) Bronchoalveolar lavage (14) 54 (100%) Total 32(100%) 22 (100%) Sinus (15)Sputum (25)

Upon stratification of patients´ age, young and adult groups were most infected with Candida species, with a percentage 35.7% and 21.1%, respectively. Whilst old aged were most infected with A. fumigates (23.8%) (Table 4).

Table 4: Percentage of fungal pneumonia isolates according to age groups concerning specimens Age groups Young Adult Old Sample Source Total Results No (%) No(%) No (%) (No) No(%) Absidia species 0(0.0%) 1(5.3%) 0(0.0%) Bronchoalveolar lavage 1(1.9%) Alternaria species 0(0.0%) 0(0.0%) 1(4.8%) Sputum 1(1.9%) Bronchoalveolar lavage (2) Aspergillus falvus 1 (7.1%) 2 (10.5%) 2(9.5%) 5(9.3%) Sinus (2)Sputum (1) Bronchoalveolar lavage (3) Aspergillus fumigates 2 (14.3%) 3(15,8%) 5(23.8%) 10(18.5%) Sinus (1)Sputum (6) Aspergillus niger 0(0.0%) 1(5.3%) 2(9.5%) Sinus (1)Sputum (2) 3(5.6%) Bronchoalveolar lavage (4) Candida species 5 (35.7%) 4(21.1%) 4(19.1%) 13(24.1%) Sinus (4)Sputum (5) Cladosporium species 1 (7.1%) 0(0.0%) 0(0.0%) Sputum (1) 1(1.9%) Bronchoalveolar lavage (2) Cryptococcus neoformans 2 (14.3%) 3(15,8%) 3(14.3%) 8 (14.8%) Sinus (2)Sputum (4) ©Annals of Tropical Medicine & Public Health S228

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Fusarium species 0(0.0%) 1(5.3%) 1(4.8%) Sinus (1)Sputum (1) 2(3.7%) Bronchoalveolar lavage (1) Mucor species 1 (7.1%) 2 (10.5%) 1(4.8%) 4(7.4%) Sinus (2)Sputum (1) Rhizopus species 0(0.0%) 1(5.3%) 0(0.0%) Sputum 1(1.9%) Bronchoalveolar lavage (1) Rhodotorula species 1 (7.1%) 1(5.3%) 0(0.0%) 2(3.7%) Sputum (1) Penicillium species 1 (7.1%) 0(0.0%) 2(9.5%) Sinus (1)Sputum (1) 3 (5.65%) Bronchoalveolar lavage(14) Total 14 (100%) 19(100%) 21(100) 54 (100%) Sinus (15)Sputum (25)

DISCUSSION Many studies showed that fungi were isolated from respiratory samples in both of immunocompetent and immunocompromised patients (12,13).This study has highlighted the potential for fatal fungal respiratory disorders. According to the data that are detailed in table (2).Candida genus was almost fungal infection founded in bronchoalveolar lavage and sinus specimens, with a percentage 28.6% and 26.7%, respectively. Whilst, in sputum specimens, A. fumigates was the almost percentage isolates among other pneumonia fungi (24%). Fungal pneumonia wasmore infected among males than females. Candida species reported the highest infection, with a percentage (21.9%).These results agree with (14, 15) and disagree with (16) who revealed that A. fumigates was most isolated from fungal respiratory infections. Dissemination of fungal spores in air loading of many places and different virulence factors such as biofilm formation capable this yeast to be most fungal isolated fromrespiratory tract infections. Table (4) showed that young and adult groups were most infected with Candida species, with a percentage 35.7% and 21.1%, respectively. Whilst old aged were most infected with A. fumigates (23.8%).There are no studies to compare our results with it. Immunity status of the most infected age groups may be play an important role to discuss the recent findings.

CONCLUSION These findings concluded that a high frequency of fungal pneumonia infections, in particular with Candida species and Aspergillusfumigatuswhich be risk factor for immunocompromised patients

ACKNOWLEDGMENT Wewould like to express most acknowledgment toall membersof the respiratory unit at Baquba teaching hospital.

ETHICAL CLEARANCE

The Research Ethical Committee at scientific research by ethical approval of both environmental and health and higher education and scientific research ministries in Iraq

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Al-Ammari et al (2019): Fungal Pathogens in RTIs November 2019 Vol. 22(8)

CONFLICT OF INTEREST

The authors declare that they have no conflict of interest.

FUNDING: Self-funding

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