Mycopathologia (2009) 167:8187 DOI 10.

1007/s11046-008-9153-9

Frequency of Candida spp. in the Oral Cavity of Brazilian HIV-Positive Patients and Correlation with CD4 Cell Counts and Viral Load
G. N. Back-Brito A. J. Mota T. C. Vasconcellos S. M. R. Querido A. O. C. Jorge A. S. M. Reis I. Balducci Cristiane Yumi Koga-Ito

Received: 19 November 2007 / Accepted: 10 August 2008 / Published online: 10 September 2008 Springer Science+Business Media B.V. 2008

Abstract The aim of this study was to evaluate the prevalence of Candida spp., and particularly C. dubliniensis, among oral isolates from Brazilian HIVpositive patients correlating these results with CD4 cell counts and viral load. Forty-ve individuals (23 female and 22 male) diagnosed as HIV-positive by ELISA and Western-blot, under anti-retroviral therapy for at least 1 year and without oral candidosis signals were included in the study. The control group was constituted by 45 healthy individuals, matched to the test group in relation to age, gender, and oral conditions. Oral rinses were collected and the

G. N. Back-Brito T. C. Vasconcellos S. M. R. Querido A. O. C. Jorge C. Y. Koga-Ito (&) Department of Oral Biosciences and Diagnosis, dos Campos Dental o Jose Laboratory of Microbiology, Sa o Paulo State University (UNESP), Av. School, Sa Longo, 777 Sa dos o Jose Engenheiro Francisco Jose Campos, Sao Paulo, Brazil e-mail: [email protected] A. J. Mota ba University Laboratory of Genetics, Vale do Para dos Campos, Sao Paulo, Brazil o Jose (UNIVAP), Sa A. S. M. Reis Medical School Day Hospital, Sa dos o Jose Taubate Campos, Sao Paulo, Brazil I. Balducci dos Campos Dental School, Sa o Jose o Biostatistics, Sa dos Campos, o Jose Paulo State University (UNESP), Sa Sao Paulo, Brazil

identication was performed by phenotypic tests. The existence of C. dubliniensis among the isolates was analyzed using a validated multiplex PCR assay. Candida spp. were detected at signicantly higher number in the oral cavity of HIV-positive patients in relation to the controls (P = 0.0008). C. albicans was the most frequently isolated species in both groups. In the HIV group, C. glabrata, C. lipolytica, C. krusei, C. guilliermondii, and C. parapsilosis were also identied. In the control group, we additionally identied C. tropicalis and C. dubliniensis. Two isolates (1.9%, 2/108) from control individuals were identied as C. dubliniensis and this species was not veried in the HIV group. Candida spp. counts were statistically lower (P = 0.0230) in the oral cavity of patients with low viral load (\400 copies/mm3). Candida spp. counts did not differ statistically among groups with different levels of CD4 cells counts (P = 0.1068). Keywords Candida spp. Candida dubliniensis HIV Oral microora

Introduction The oral cavity is inhabited by more than 700 microbial species and many intrinsic and extrinsic factors affect the composition, metabolic activity, and pathogenicity of the highly diversied oral microora [1, 2]. Oral microora is remarkably stable in health

123

82

Mycopathologia (2009) 167:8187

subjects, but signicant changes may occur during serious systemic disease and its treatment [1]. Over the past decades, there has been a signicant increase in the prevalence of fungal infections caused by Candida species. This fact has been correlated mainly to the use of broad-spectrum antibacterials, corticosteroids, anti-tumoral agents, oral contraceptives, and increase in the number of immunocompromised patients [3]. In patients with AIDS, bone marrow transplantation, and aggressive anti-neoplasic therapy, Candida is cited as an important cause of mortality and morbidity [4]. Oral candidosis occurs in more than 95% of AIDS patients and it is considered as an important marker of the disease and its progression. The prevalence of oral candidosis in HIV-positive patients seems to be correlated to the severity of immunological dysfunction [5, 6]. Alterations in saliva secretion and composition during the infection by HIV may alter the defense mechanisms of the host, and inuence the adherence and colonization by Candida [1]. By studying the salivary composition in HIV-positive patients Lin et al. [5] observed reduction in the anti-Candida activity and salivary ow. Studies on the pathogenicity of isolates from HIVpositive and HIV-negative individuals are controversial. Higher proteinase activity and increased pathogenicity to rats have already been described [1]. On the other hand, Costa et al. [7] did not observe any difference between proteinase production by C. albicans isolated from HIV-positive and HIV-negative children. Previous studies focused on the correlation of Candida oral presence and clinical variables in HIVpositive patients, and the results were not conclusive. Higher counts of Candida were observed among patients with low CD4 counts [7, 8]. Li et al. [9] concluded that CD4 counts under 200 cells/mm3 can be considered as a risk factor for the development of candidosis. On the other hand, other authors [1012] did not observe correlation between the presence of Candida and CD4 lymphocyte counts. The occurrence of oral candidosis at initial stages of AIDS is common, particularly when CD4 cells count is low (400700 cells/mm3) [5]. Regarding viral load, the studies also show inconclusive results. Some authors observed higher counts in patients with higher viral load [8, 10]. Other

authors did not report correlation between these two variables [7, 11, 12]. Candida dubliniensis, rstly described at Ireland, shares many phenotypic features with C. albicans and has been more frequently isolated from HIVpositive patients [13]. More recent studies revealed the presence of this species in several parts of the world [13, 14]. Milan et al. [15] evaluated 108 Brazilian patients with AIDS and oropharyngeal candidosis and reported that three of them were positive to C. dubliniensis. About 5.4% individuals positive to this species among HIV-negative and HIV-positive patients with erithematous oral candidosis was observed by Chavasco et al. [16]. Subgingival samples from HIV-positive Brazilian children were also analyzed and 5.7% of these individuals were positive to C. dubliniensis [17]. Considering the lack of agreement regarding the presence of Candida and the clinical variables, and the few data on the epidemiology of C. dubliniensis in Brazil, the aim of this study was to evaluate the prevalence of Candida spp., mainly C. dubliniensis, among oral isolates from Brazilian HIV-positive patients and to correlate these results with data on CD4 cell counts and viral load.

Materials and Methods This study was approved by the Local Ethics Committee (protocol number 012-PH/CEP). Forty-ve individuals (23 female and 22 male), aged from 22 to 66 years, HIV-positive diagnosed by ELISA and conrmed by Western-blot, under treat Medical School ment at the Day Hospital of Taubate o Paulo State) or Medical Specialities Center (Sa (ARE), and under anti-retroviral therapy for at least 1 year were included in the study. Out of the total, 43% of the patients were under highly active antiretroviral therapy (HAART) and the other patients were treated only with protease inhibitor. For the control group, 45 healthy individuals aged from 23 to 66 years, and with similar conditions in relation to age, gender, prosthesis use, and oral conditions to the HIV-positive individuals were o selected among the patients under treatment at Sa dos Campos Dental School. Jose Patients with diabetes mellitus or other systemic diseases, pregnant women, smokers, denture

123

Mycopathologia (2009) 167:8187

83

or orthodontic device users, and individuals under treatment with antimicrobials/antifungals during the last 60 days that preceded the sampling or with lesions of oral candidosis were excluded. Recent data on CD4? lymphocyte counts and viral load, antiretroviral use, and antimicrobial use were obtained from the medical records. Sampling from each individual was performed by oral rinses in buffered phosphate saline (PBS, 0.1 M, pH 7.2) for 1 min [18]. The samples were centrifuged for 10 min at 8,000g and the supernatant was discharged. Then, 2.5 ml of PBS was added to the pellet. Dilutions of 10-1 and 10-2 in PBS were obtained and an aliquot (0.1 ml) of each suspension was plated on Sabouraud dextrose agar supplemented with chloramphenicol (0.1 mg/ml of the culture medium). Plates were incubated at 37C for 48 h. After this period, characteristic colonies were counted and the number of colony-forming units per milliliter (CFU/ml) was obtained. Two colonies representative of each morphology observed in the plate were submitted to microscopic conrmation, and were transferred to tubes containing Sabouraud dextrose agar. Tubes were incubated for 48 h at 37C and after this period, they were maintained at 4C until identication. Phenotypic identication included germ tube formation in bovine serum, growth in corn meal-Tween 80 agar, fermentation, and assimilation of carbohydrates [19, 20]. Isolates phenotypically identied as C. albicans or C. dubliniensis were submitted to molecular identication. These isolates were analyzed by a multiplex polymerase chain reaction (PCR) procedure, according to the methodology proposed by Donnely et al. hn et al. [22], with modications. [21] and Ma Briey, the isolates were plated on Sabouraud dextrose agar and incubated for 24 h at 37C. Then, a single colony was transferred to 75 ll of zymoliase (Sigma, St. Louis, USA) solution (0.5 mg/ml in 1 M sorbitol buffer). Tubes were maintained at 95C for 10 min. After this period, samples were centrifuged at 8,000g at 4C for 15 min and the supernatant was kept on ice until the PCR analyses. For PCR, two pairs of primers were used: two universal primers, Uni-f: 50 -GCATATCAATAAGC GGAGGAAAA-30 and Uni-r: 50 -GGTCCGTGTTTC AAGACG-30 ; and two C. dubliniensis-specic ones, DUBF Act-f: 50 GTATTTGTCGTTCCCCTTTC-30

e DUBR Act-r: 50 -GTGTTGTGTGCACTAACGTC30 . The amplication was carried out in 10 ll nal volume containing ve picomoles of each, 5.0 ll of PCR Master Mix (Promega), 3.2 ll ultra-pure water, and 1 ll of DNA template. Cycling conditions consisted of 3 min at 95C followed by 30 cycles of 30 s at 95C, 30 s at 58C, 60 s at 72C, followed by 72C for 10 min. In all reactions, C. albicans (ATCC 18804) and C. dubliniensis (CD33) were included as control. Amplication products were separated by electrophoresis through 2% (w/v) agarose gels containing 25 lM ethidium bromide and visualized on a UV transilluminator (Foto/UV 26, Fotodyne Inc.). A DNA ladder of 100 pb (Gibco, BRL) was used as molecular size standard. The gels were photographed for analysis and documentation (DC290 Kodak photo documentation system). Analysis of Data Counts of yeasts from HIV and control groups were compared statistically by ANOVA, MannWhitney test (5%). The presence of Candida in the oral cavity of HIV patients was evaluated in relation to CD4 lymphocytes counts and viral load by KruskalWallis test (ANOVA) (5%). For this purpose, the patients were classied into three subgroups according to the counts of CD4 lymphocytes (cells/mm3) (\200, 200500, and [500), based on the guidelines for anti-retroviral therapy for adults and adolescents [23]. Also, they were divided into subgroups according to viral load (\400, 40020,000, and [20,000 copies/ml of serum) [24].

Results Thirty-three HIV-positive patients (73.3%) and 21 individuals from the control group (46.6%) yielded positive Candida cultures. Candida spp. were detected at signicantly higher number in the oral cavity of HIV-positive patients (median value = 860 CFU/ml and interquartile range = 3250 CFU/ml) in relation to the controls (median value = 0 CFU/ml and interquartile range = 480 CFU/ml) (P = 0.0008) (Fig. 1). Candida albicans was the most frequently isolated species in both groups. In the HIV group, C. glabrata, C. lipolytica, C. krusei, C. guilliermondii, and

123

84
20000 15000

Mycopathologia (2009) 167:8187 Table 2 Values of median and interquartile ranges obtained for Candida spp. counts (UFC/ml) according to CD4? lymphocytes counts (cells/mm3) and viral load (copies/ml of serum) Subgroups Median Interquartile range KW P

CFU/mL

10000 5000 0 Control HIV

CD4? lymphocyte counts (cells/mm3) \200 200500 [500 \400 [20,000 % 1,060 920 710 34 2,340 5,692 2,639 3,795 1,770 5,130 5,160 7.5425 0.0230* 0.5648 0.1068

Fig. 1 Oral counts of Candida spp. (colony-forming units per milliliter; CFU/ml) obtained for the control and HIV groups Table 1 Number and frequency of Candida species among the isolates recovered from HIV-positive patients group and control group Species HIV-positive n C. albicans C. tropicalis C. glabrata C. dubliniensis C. lipolytica C. krusei C. guilliermondii C. parapsilosis Total isolates 131 41 3 0 2 1 1 1 180 % 72.8 22.8 1.8 0 1.1 0.5 0.5 0.5 100 Control n 86 20 0 2 0 0 0 0 108

Viral load (copies/ml) 40020,000 1,490

KW, KruskalWallis statistics test; P, P-value associated with statistics test * Statistically signicant difference

79.6 18.5 0 1.9 0 0 0 0 100

C. parapsilosis were also identied. In the control group, C. tropicalis and C. dubliniensis were also found. Two isolates (1.9%, 2/108) from different control individuals were identied as C. dubliniensis (Table 1). The values of median and interquartile ranges for Candida counts according to CD4 lymphocytes counts and viral load are shown in Table 2. The presence of Candida in the oral cavity of HIV patients was evaluated in relation to CD4 cells counts and viral load by KruskalWallis test (ANOVA) (5%). Candida spp. counts were statistically lower (P = 0.0230) in the oral cavity of patients with low viral load (\400 copies/mm3). Candida spp. counts did not differ statistically among HIV positive patients subgroups with different levels of CD4 cells counts (P = 0.1068). Discussion The study group included 45 HIV-positive patients, 48.8% male and 51.2% female. Although some

studies did not demonstrate association between the presence of Candida in relation to gender [10, 25], we avoided bias by having a sex-balanced sample. Also, with the same purpose, the design of the study included control individuals matched to the HIVpositive groups regarding age, gender, and oral conditions (use of dentures or orthodontic devices). All patients included in the study were under treatment, 43% were under HAART and the other patients were treated with protease inhibitor. It was not possible to have a xed therapy protocol for all patients because the treatment strategy would change according to the CD4? lymphocyte level and viral load, and other relevant clinical variables, such as the occurrence of opportunistic diseases and adverse reactions to the medication. The HAART is correlated to lower occurrence of oral diseases and promotes the inhibition of viral replication, redistribution and restoration of immunity, resulting in an increase in CD4? cell counts. Moreover, protease inhibitors may show anti-Candida activity by inhibiting the protease of this microorganism [1, 26, 27]. Despite this, previous studies reported no correlation between yeast counts and the adopted anti-retroviral therapy [1012]. Regarding to the sampling method adopted, the design of the study was based upon a previous study that compared several methodologies and concluded that oral rinse can be considered the most reliable sampling procedure to detect the oral

123

Mycopathologia (2009) 167:8187

85

presence of yeasts, Staphylococcus aureus and coliforms [18]. Several studies reported higher frequency of Candida isolation from the oral cavity of HIVpositive patients in relation to control individuals [8, 1012, 25] and our study conrms these previous reports. Candida albicans was the most frequently isolated species (72.7%), and this nding is in accordance with the previous studies of HIV [7, 8, 1012, 28]. The comparison among the frequency of Candida isolation in the present study with previous studies is complicated due to different inclusion and exclusion criteria and sampling [26, 29] methods. A previous study carried out under similar conditions reported the isolation of Candida spp. from 61.9% of HIVpositive adults, [10] a value lower than our nding nchez-Vargas et al. [12] found a value (73.3%). Sa (74.5%) closer than ours although the sampling was carried on with swabs. Among the control group, 46.6% were positive for Candida in the oral cavity and this result falls in the range reported previously (2575%) [12, 29]. The association between the clinical variables of HIVpositive patients and the oral level of Candida spp. has been frequently discussed; however, the results are still controversial. This fact may be affected by the sampling methodologies, as discussed before, and also by the variability in the methods to measure the CD4? lymphocyte count and viral load. In our study, no association between counts of Candida and CD4 lymphocytes was observed and this result is in accordance with the previous reports [1012, 30]. On the other hand, some studies [7, 8] reported higher frequency of yeast isolation associated with reduced CD4 cell counts. Regarding the viral load, we observed signicantly lower counts in patients with lower viral load (\400 copies/ml). No association between the yeast population and viral load was found by others [10 12]. Our data suggest that viral load might be a more reliable risk factor for the occurrence of candidosis than the CD4? lymphocyte count. Candida dubliniensis has been initially associated with oropharyngeal candidosis in HIV-positive patients, in particular, among those who have recurrent occurrence of oral candidosis; however, it has also been isolated from HIV-negative individuals [16, 31]. Previous studies comparing phenotypical

methods for identication of C. dubliniensis, found no single method highly reliable for unanbiguous differentiation of this species from C. albicans [22, 32]. Culture media used for the differentiation between C. albicans and C. dubliniensis were useful for phenotypical screening, but the denitive identication still requires genotyping techniques [21, 22]. Consequently, we used a multiplex PCR to identify C. dubliniensis in this study [22, 23]. This methodology has been largely used in studies from several parts of the world [15]. In the present study, out of 108 isolates from the control group, two (1.9%) were identied as C. dubliniensis. Interestingly, these isolates were only obtained from HIV-negative individuals. Reports on the isolation of C. dubliniensis from the oral cavity of control individuals are very variable and ranged from 0% [12, 28], 0.7% [32], 3.5% [33] to 13.33% [34]. Mosca et al. [34] isolated 8.3% of C. dubliniensis from the oral cavity of adolescents with orthodontic devices, and reported that oral infections by this species can also occur among healthy individuals. Other non-albicans species isolated were C. tropicalis and C. glabrata. These data were also observed by Sant Ana et al. [35]. The prevalence of nonalbicans species represented only 34.9% of Candida species isolated from the HIV group. Also, this group showed a more abundant recovery of Candida species. This can be considered as an important datum, since infections caused by C. albicans, such as candidemia, generally have best prognosis when compared to diseases caused by non-albicans species [36]. Within the limits of this study, we concluded that HIV group showed higher prevalence of Candida spp., in particular, among those with high viral load. C. dubliniensis was isolated at low frequency only from control individuals.
Acknowledgement The authors would like to thank Dr. F. G. brega for suggestions and experimental support, and No ` Pesquisa do Estado de Sa o de Amparo a o PauloFundac a FAPESP (2004/14088-8; 2004/12381-6) for nancial support.

References
1. Samaranayake LP, et al. Fungal infections associated with HIV infection. Oral Dis. 2002;8(Suppl 2):15160. 2. Aas JA, Paster BJ, Stokes LN, Olsen I, Dewhirst FE. Dening the normal bacterial ora of the oral cavity. J Clin

123

86 Microbiol. 2005;43:572132. doi:10.1128/JCM.43.11. 5721-5732.2005. Eggimann P, Garbino J, Pittet D. Epidemiology of Candida species infections in critically ill non-immunossupressed patients. Lancet Infect Dis. 2003;3:658720. Coleman DC, Rinaldi MG, Haynes KA, Rex JH, Summerbell RC, Anaissie EJ, et al. Importance of Candida species other than Candida albicans as opportunistic pathogens. Med Mycol. 1998;36:15665. Lin AL, et al. Salivary anticandidal activity and saliva composition in a HIV-infected cohort. Oral Microbiol Immunol. 2001;16(5):2708. doi:10.1034/j.1399-302x.2001.0160052 70.x. Al-Abeid HM, Khaled HA, Elkarmi AZ, Hamad MA. Isolation. characterization of Candida spp. in Jordanian cancer patients: prevalence, pathogenic determinants, and antifungal sensitivity. Jpn J Infect Dis. 2004;57:27984. Costa EMB, et al. Heterogeneity of metallo and serine extracellular proteinases in oral clinical isolates of Candida albicans in HIV-positive and healthy children from Rio de Janeiro, Brazil. FEMS Immunol Med Microbiol. 2003; 38(2):17380. doi:10.1016/S0928-8244(03)00145-7. Capoluongo E, et al. Heterogeneity of oral isolates of Candida albicans in HIV-positive patients: correlation between candidal carriage, karyotype and disease stage. J Med Microbiol. 2000;49(11):98591. Li SY, et al. Molecular epidemiology of long-term colonization of Candida albicans strain from HIV-infected patients. Epidemiol Infect. 2006;134(2):26596. doi: 10.1017/S0950268805004905. Campisi G, Pizzo G, Milici ME. Candidal carriage in the oral cavity of human immunodeciency virus-infected subjects. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;93(3):2816. doi:10.1067/moe.2002.120804. Barchiesi F, Maracci M, Radi B, Arzeni D, Baldassarri I, Giacometti A, et al. Point prevalence, microbiology and uconazole susceptibility patterns of yeast isolates colonizing the oral cavities of HIV-infected patients in the era of highly active antiretroviral therapy. J Antimicrob Chem. 2002;50:9991002. doi:10.1093/jac/dkf233. nchez-Vargas LO, et al. Oral isolates colonyzing Sa infecting human immunodeciency virus-infected and healthy persons in Mexico. J Clin Microbiol. 2005;43(8): 415962. doi:10.1128/JCM.43.8.4159-4162.2005. Sullivan DJ, Moran GP, Pinjon E, Al-Mosaid A, Stokes C, Vaughan C, et al. Comparison of the epidemiology, drug resistance mechanisms, and virulence of Candida dubliniensis and Candida albicans. FEMS Yeast Res. 2004;4: 36976. Alves SH, Milan EP, Branchini ML, Nishimura K, Fukushima K, Oliveira LO, et al. First isolation of Candida dubliniensis in Rio Grande do Sul, Brazil. Diagn Microbiol Infect Dis. 2001;39:1658. doi:10.1016/S0732-8893(01)00 220-6. Milan EP, Laet SantAna P, Melo ASA, Sullivan DJ, Coleman DC, Lewi D, et al. Multicenter prospective surveillance of oral Candida dubliniensis among adult Brazilian human immunodeciency virus-positive and AIDS patients. Diagn Microbiol Infect Dis. 2001;41:29 35. doi:10.1016/S0732-8893(01)00290-5.

Mycopathologia (2009) 167:8187 16. Chavasco JK, Paula CR, Hirata MY, Aleva NA, Melo CE, Gambale W, et al. Molecular identication of Candida dubliniensis isolated from oral lesions of HIV-positive and o Paulo, Brazil. Rev Inst Med HIV-negative patients in Sa Trop Sao Paulo. 2006;48(1):126. doi:10.1590/S0036-466 52006000100005. 17. Portela MB, Souza IPR, Costa EMMB, Hagler AN, Soares RMA, Santos ALS. Differential recovery of Candida species from subgingival sites in human immunodeciency virus-positive and healthy children from Rio de Janeiro, Brazil. J Clin Microbiol. 2004;42(12):59257. doi:10.1128/ JCM.42.12.5925-5927.2004. 18. Samaranayake LP, et al. A comparison or oral rinse and imprint sampling techniques for detection of yeast, coliform and Staphylococcus aureus carriage in the oral cavity. J Oral Pathol. 1986;15:3868. doi:10.1111/j.1600-0714. 1986.tb00646.x. 19. Sandven P. Laboratory identication and sensitivity testing of yeast isolates. Acta Odontol Scand. 1990;48:2736. doi: 10.3109/00016359009012731. 20. Williams DW, Lewis MAO. Isolation and identication of Candida from the oral cavity. Oral Dis. 2000;6:311. 21. Donnely SM, Sullivan DJ, Shanley DB, Coleman DC. Phylogenetic analysis and rapid identication of Candida dubliniensis based on analysis of ACT1 intron and exon sequences. Microbiology. 1999;145:187182. hn B, Stehr F, Scha fer W, Neuber K. Comparison of 22. Ma standard phenotypic assays with a PCR method to discriminate Candida albicans and Candida dubliniensis. Mycoses. 2005;46:5561. doi:10.1111/j.1439-0507.2004.01054.x. 23. Center for disease control and prevention. Reported CD4? T-lymphocyte results for adults and adolescents with HIV/ AIDS33 states, 2005. HIV/AIDS Surveillance Supplemental Report. 2005;11(2):131. 24. Center for disease control and prevention. Guidelines for using antiretroviral agents among HIV-infected adults and adults and adolescents. Recommendations of the panel of clinical practices for treatment of HIV. Morb Mortal Wkly Rep. 2002;nRR-7:164. 25. Nittayananta W, Jealeae S, Winn T. Oral Candida in HIVinfected heterosexuals and intravenous drug users in Thailand. J Oral Pathol Med. 2001;30(6):34754. doi: 10.1034/j.1600-0714.2001.300604.x. 26. Gonc alves LS, et al. Association of T CD4 lymphocyte levels and chronic perodontitis in HIV-infected brazilian patients undergoing highly active anti-retroviral therapy: clinical results. J Periodontol. 2005;76(6):91522. doi: 10.1902/jop.2005.76.6.915. 27. Perezous LF, et al. Colonization of Candida species in denture wearers with emphasis on HIV infection: a literature review. J Prosthet Dent. 2005;93(3):28893. doi: 10.1016/j.prosdent.2004.11.015. 28. Jabra-Rizk MA, Falkler WA, Enwoncu CO, Onwujekwe DI, Merz G, Meiller TF. Prevalence of yeast among children in Nigeria and the United States. Oral Microbiol Immunol. 2001;16:3835. doi:10.1034/j.1399-302X.2001. 160611.x. 29. Koga-Ito CY, Lyon JP, Vidotto V, Resende MA. Virulence factors and antifungal susceptibility of Candida albicans isolates from oral candidosis patients and control

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

123

Mycopathologia (2009) 167:8187 individuals. Mycopathologia. 2006;161:21923. doi: 10.1007/s11046-005-0001-x. Tsang CSP, Samaranayake LP. Oral yeasts and coliforms in HIV-infected individuals in Hong Kong. Mycoses. 2000;43(78):3038. doi:10.1046/j.1439-0507.2000.005 84.x. Ahmad S, Khan Z, Mokaddas E, Khan ZU. Isolation and molecular identication of Candida dubliniensis from nonhuman immunodeciency virus-infected patients in Kuwait. J Med Microbiol. 2004;53:6337. doi:10.1099/ jmm.0.05315-0. Gugnani HC, Becker K, Fegeler W, Basu S, Chattopadhya D, Baveja U, et al. Oropharyngeal carriage of Candida species in HIV-infected patients in India. Mycoses. 2003;46:2818. doi:10.1046/j.1439-0507.2003.00896.x. Blignaut E, Messer S, Hollis RJ, Pfaller MA. Antifungal susceptibility of South African oral yeast isolates from

87 HIV/AIDS patients and healthy individuals. Diagn Microbiol Infect Dis. 2002;44:16974. doi:10.1016/S0732. 08893(02)00440.6. n J. 34. Mosca CO, Moragues MD, Brena S, Rosa AC, Ponto Isolation of Candida dubliniensis in a teenager with denture stomatitis. Med Oral Patol Oral Cir Bucal. 2005; 10:2531. 35. SantAna PL, et al. Multicenter brazilian study of oral Candida species isolated from AIDS patients. Mem Inst Oswaldo Cruz. 2002;97(2):2537. doi:10.1590/S0074.02 762002000200019. 36. Bodey GP, et al. The epidemiology of Candida glabrata and Candida albicans fungemia in immunocompromised patients with cancer. Am J Med. 2002;112(5):380385. doi:10.1016/S0002-9343(01)01130-5.

30.

31.

32.

33.

123

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.