ASSESSMENT OF SYSTEMIC FUNGAL INFECTION IN DIABETIC PATIENTS ATTENDING ENUGU STATE UNIVERSITY TEACHING HOSPITAL PARKLANE ENUGU, NIGERIA.

ASSESSMENT OF SYSTEMIC FUNGAL INFECTION IN DIABETIC PATIENTS ATTENDING ENUGU STATE UNIVERSITY TEACHING HOSPITAL PARKLANE ENUGU, NIGERIA.

ABSTRACT

Opportunistic invasive fungal infections are emerging health challenges worldwide. This occurs mostly among immunocompromised patients such as Diabetics, Cancer patients with chemotherapy induced neutropenia, transplant recipients receiving immunosuppressive therapy and Human immunodeficiency (HIV) infected patients.  The aim of this was to assess systemic fungal infection in diabetic patients and the specific objectives was to assess occurrence of systemic fungal infections in diabetic patients, risk factors for systemic fungal infections in diabetic patients and to assess the relationship between fasting blood sugar (FBS) and systemic fungal infections.  A structured questionnaire was used to obtain information on the demographic and risk factors from the subjects. The diabetic patients were recruited from the diabetic clinics; Enugu State University Teaching Hospital (ESUTH) Parklane, Enugu.  They were informed of the study and those that voluntarily agreed to participate signed informed consent form.  Ethical approval was obtained from the Ethical Committee of the hospital.  Sputum samples were collected from the patients and analyzed mycologically.  The samples were cultured on Sabouraud dextrose agar with actidione and brain heart infusion agar fortified with 5% sheep red blood cells.  Those with fungal growth were identified using needle mount, Gram stain and sugar fermentation/assimilation tests.  A total of 120 diabetic patients were analyzed and 63(52.5%) had systemic fungal isolates.  The females had higher isolates than the males, 36(30%) and 27(22.5%) respectively.  The age range above 61years old had yields of fungal isolates, 27(33.5%) followed by those of 51-60years old with 21(17.5%).  The subjects with primary education had 24(20%) of fungal isolates while those that were traders, 22(18.3%) fungal isolates were obtained. The duration of diabetes was statistically significant as those with less than 5 years of diabetes had higher fungal infections of 40(33.3%).  The diabetic patients with FBS levels >5.8mmol/l had higher isolates, 51(42.5%), (P=0.001) while the subjects on insulin therapy and with persistent elevated FBS level had 40(45.5%) systemic fungal isolates.  The frequency of opportunistic fungal infections in this study showed that Aspergillusflavus 21(17.5%), Aspergillusniger 1(0.8%), Aspergillusfumigatus 2(1.7%), Candida albicans 17(14.2%), Candida tropicalis 7(5.8%) and Candida kefyr 5(4.2%) and dimorphic fungus – Blastomycete dermatitidis 10(8.3%) were isolated.  The findings in this study showed that opportunistic fungal infection is prevalent among diabetic patients. Of interest were the dimorphic fungi that are not common in this environment.  Thus incorporation of antifungal agents in routine diabetic drugs will help in controlling these infections.

TABLE OF CONTENTS

Title page        –           –           –           –           –           –           –           –           –           –           i

Dedication       –           –           –           –           –           –           –           –           –           –           ii

Acknowledgement                  –           –           –           –           –           –           –           –           iii

Table of Contents       –           –           –           –           –           –           –           –           –           iv

List of Tables             –           –           –           –           –           –           –           –           –           vi

Abstract          –           –           –           –           –           –           –           –           –           –           vii

CHAPTER ONE: INTRODUCTION

1.1       Justification                 –           –           –           –           –           –           –           –           2

1.2       Aims   –           –           –           –           –           –           –           –           –           –           2

1.3       Specific Objectives                 –           –           –           –           –           –           –           2

CHAPTER TWO: LITERATURE REVIEW

2.1       Classification of systemic and opportunistic fungi    –           –           –           –           3

2.2       Systemic mycoses due to opportunistic pathogen      –           –           –           –           6

2.3       Mechanism of system infection          –           –           –           –           –           –           10

2.4       Risk factors for systemic infection     –           –           –           –           –           –           17

2.5       Epidemiology for systemic fungal infection  –           –           –           –           –           19

2.6       Symptoms and pathogens of systemic fungi  –           –           –           –           –           20

2.7       Association between systemic fungal infection and diabetes –           –           –           22

2.8       Major infections associated with diabetes mellitus    –          –           –           –           23

2.9       Diagnosis        –           –           –           –           –           –           –           –           –           27

2.10     Prevention and control            –           –           –           –           –           –           –           28

CHAPTER THREE: MATERIALS AND METHODS

3.1       Study Area      –           –           –           –           –           –           –           –           –           30

3.2       Study Design              –           –           –           –           –           –           –           –           30

3.3       Study Population        –           –           –           –           –           –           –           –           30

3.4       Inclusion Criteria        –           –           –           –           –           –           –           –           30

3.5       Exclusive Criteria                   –           –           –           –           –           –           –           30

3.6       Questionnaire              –           –           –           –           –           –           –           –           31

3.7       Ethical Consideration –           –           –           –           –           –           –           –           31

3.8       Sample Collection and Processing      –           –           –           –           –           –           31

3.9       Laboratory Procedures            –           –           –           –           –           –           –           31

3.10     Estimation of blood sugar using glucose oxidase test            –           –           –           35

3.11     Data Analysis  –           –           –           –           –           –           –           –           –           36

CHAPTER FOUR: RESULTS

4.1       Demographic characteristic of the diabetic patients   –           –           –           –           37

4.2       Risk factors for fungal infections       –           –           –           –           –           –           38

4.3       Influence of fasting blood sugar (FBS)          –           –           –           –           –           38

4.4       Logistic regression analysis    –           –           –           –           –           –           –           39

CHAPTER FIVE: DISCUSSION AND CONCLUSION

5.1       Discussion       –           –           –           –           –           –           –           –           –           45

5.2       Conclusion      –           –           –           –           –           –           –           –           –           49

5.3       Recommendation        –           –           –           –           –           –           –           –           50

REFERENCES        –           –           –           –           –           –           –           –           –           51

CHAPTER ONE

INTRODUCTION

Opportunistic invasive fungal infections are emerging health challenges worldwide (Singh, 2001). This occurs mostly among immunocompromised patients such as diabetes, cancer patients with chemotherapy induced neutropenia, transplant recipients receiving immunosuppressive therapy and human immunodeficiency (HIV)-infected patients (Upxon and Marr, 2006; Groll et al., 1996; Fridkin and Jarvis, 1996).

It has been reported that patients with systemic fungal infections are at high risk of disseminated fungemia and prolonged stay in hospital (Richardson, 2005). This scenario may be worsened if the patient has a metabolic disorder due to diabetes mellitus. This is because the diabetic patients are prone to high sugar concentration which weakens the immune system and causes several health complications (Kotran, 2007).

In general, infectious diseases are more frequent and serious in patients with diabetes mellitus which potentially increases morbidity and mortality (Fluvbjerg, 2010). Diabetes mellitus is a clinical syndrome associated with deficiency of insulin secretion or action. It is considered one of the largest threats to health in the 21^st century. It is estimated that there will be 380 million people with diabetes in 2025, besides the classical complications of the diseases; diabetes has been associated with reduced response of T cell, neutrophil function and disorder of humoral immunity (Peleg et al., 2007). Diabetes increases susceptibility to various types of infection. The most common sites are the skin and urinary tract.

• JUSTIFICATION

The diabetic patients due to their condition lack adequate immunity to defend the body system against invading pathogenic fungal organisms thus they can be exposed to these agents either by inhalation of the spores of these fungal agents from the environment or by close contacts.

This study will identify the cause and types/species of systemic fungal infections that complicate diabetic conditions; this will help in control and management of the illness.

1.2  AIM OF THE STUDY

Assessment of Systemic Fungal Infection in Diabetic Patients Attending Enugu State University Teaching Hospital Parklane Enugu, Nigeria.

1.3 SPECIFIC OBJECTIVES

1. To determine the occurrence of systemic fungal infections in diabetic patients
2. To assess the risk factors associated with systemic fungal infections
3. To assess the relationship between fasting blood sugar and fungal isolates.

ASSESSMENT OF SYSTEMIC FUNGAL INFECTION IN DIABETIC PATIENTS ATTENDING ENUGU STATE UNIVERSITY TEACHING HOSPITAL PARKLANE ENUGU, NIGERIA.