title: Invasive forms of Candida and Aspergillus in sputum samples of pulmonary tuberculosis patients attending the tuberculosis reference laboratory in Ghaemshahr, Northern Iran: An analysis of samples collected during the past 10years.
abstract: OBJECTIVE
  Tuberculosis (TB) continues to be a major public health problem worldwide. This is especially true in Northern Iran, which has high TB prevalence. The chronic nature of this disease is further exacerbated if it is accompanied by fungal infection, which usually remains undiagnosed and thus untreated. Thus, mycotic infections add fatal dimensions to pulmonary TB. Our objective was to determine the prevalence of invasive forms of fungal elements in sputum samples collected from patients with pulmonary TB at a reference laboratory in Ghaemshahr, Northern Iran, during the past 10years.
  
  
  METHODS
  In this retrospective study, sputum samples collected from 430 patients were examined. Pulmonary TB in patients was confirmed in our laboratory, and samples obtained during the period from March 2006 to February 2016 were analyzed. The sputum samples were subjected to biological (bacterial) staining (Ziehl-Neelsen and fluorochrome) and mycological investigation using KOH+Calcofluor White (Sigma-Aldrich, India) by fluorescent microscopy and fungal culture on Sabouraud dextrose agar (Sigma-Aldrich, India) and CHROMagar (Paris, France).
  
  
  RESULTS
  Invasive forms of fungal pathogens were observed as co-infection with Mycobacterium tuberculosis in 28/430 cases (6.51%). The frequency of Aspergillus, both branching and dichotomous infection, accounted for 3.72% (16/430): Aspergillus flavus, 1.63%; Aspergillus fumigatus, 1.16%; Aspergillus niger, 0.69%; and Aspergillus oryzae, 0.23%, respectively. Blastoconidia and pseudohyphae forms of yeast were observed as co-infection with M. tuberculosis in 2.79% (12/430) of the cases: Candida albicans, 1.86%; Candida krusei, 0.46%; and other Candida species, 0.46%, respectively.
  
  
  CONCLUSIONS
  Northern Iran is a critical region in the TB world and multidrug-resistant TB is a serious problem in this region. Although it is believed that there exists a commensal relationship between fungus and TB infections, the invasive forms of fungal pathogens and their co-infection can be caused by increasing disability and failure of treatment. Diagnosis of secondary or co-existing fungal infections in TB is most important for reducing the mortality and morbidity of these patients.
authors.affiliation: Invasive Fungi Research Center, Department of Medical Mycology and Parasitology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.
authors.forename: Mohammad Reza
authors.initials: MR
authors.lastname: Jabbari Amiri
authors.affiliation: Invasive Fungi Research Center, Department of Medical Mycology and Parasitology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran. Electronic address: aghili70@yahoo.com.
authors.forename: Seyed Reza
authors.initials: SR
authors.lastname: Aghili
authors.affiliation: Invasive Fungi Research Center, Department of Medical Mycology and Parasitology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.
authors.forename: Tahereh
authors.initials: T
authors.lastname: Shokohi
authors.affiliation: Invasive Fungi Research Center, Department of Medical Mycology and Parasitology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.
authors.forename: Mohammad Taghi
authors.initials: MT
authors.lastname: Hedayati
authors.affiliation: Invasive Fungi Research Center, Department of Medical Mycology and Parasitology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.
authors.forename: Mahdi
authors.initials: M
authors.lastname: Abastabar
authors.affiliation: Department of Internal Medicine, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.
authors.forename: Masoud
authors.initials: M
authors.lastname: Aliyali
authors.affiliation: Central Laboratory of Health Center, Ghaemshahr City, Iran.
authors.forename: Masoumeh
authors.initials: M
authors.lastname: Jabbari Amiri
authors.affiliation: Central Laboratory of Health Center, Ghaemshahr City, Iran.
authors.forename: Hamid
authors.initials: H
authors.lastname: Hasanpour
keywords: Aspergillosis; Candidiasis; Co-infection; Fungal infection; Tuberculosis