title: Fungal Opportunistic Pneumonias in HIV/AIDS Patients: An Indian Tertiary Care Experience.
abstract: BACKGROUND
  Opportunistic pneumonias are a major cause of mortality and morbidity in Human Immunodeficiency Virus (HIV) reactive patients. Despite the significant role that fungi play in causation of this opportunistic mycoses, very few Indian studies have attempted to investigate the burden and aetiological spectrum of HIV/AIDS-associated fungal pneumonias.
  
  
  OBJECTIVE
  To document the prevalence of fungal aetiology in HIV/AIDS-related opportunistic pneumonias in an Indian setting; and to elucidate the various fungal opportunists responsible for the same.
  
  
  METHODS
  The present study was a prospective, cross-sectional analysis conducted at Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi from October 2008 to September 2011. Expectorated sputa were collected from 71 HIV reactive patients with a clinical diagnosis of pneumonia and subjected to direct microscopic examination employing Gram stain, 10% KOH wet mount and India ink preparation. In addition, direct immunofluorescence of sputum samples was performed for detection of cysts and trophozoites ofPneumocystis carinii. Also, each sputum sample was inoculated in duplicate onto Sabouraud Dextrose Agar (SDA) for culture. A blood sample was drawn from each patient and a battery of serological tests was performed, including Cryptococcal Antigen Latex Agglutination System (CALASTM) for detection of cryptococcal capsular polysaccharide antigen; Platelia™AspergillusEIA for detection ofAspergillusgalactomannan antigen; SERION ELISAantigenCandidafor detection of Candidaantigen and Histoplasma DxSelect™ for detecting antibodies toHistoplasmaspecies. Descriptive statistics were employed to depict results as proportions and figures. Further, arithmetic mean and standard deviation were calculated for central tendencies and median for non-normal/skewed distributions.
  
  
  RESULTS
  A definite fungal aetiology was established in 25 (35.2%) of 71 HIV reactive patients with pneumonic involvement. Of these, sputa of 21 patients yielded single fungal isolates, while mixed fungal isolates were reported in four patients.Pneumocystis cariniiwas the predominant fungal pathogen isolated in our study and was reported in 14 (19.7%) patients. Pulmonary aspergillosis was reported in 7 (9.9%) patients, withAspergillus flavus(4),Aspergillus fumigatus(2) andAspergillus niger(1) being the commonly recoveredAspergillusspecies. Candida pneumonia was documented in 6 (8.5%) patients and theCandidaspecies isolated includedCandida albicansin four,Candida glabratain one andCandida tropicalisin one of these six patients respectively. Pulmonary cryptococcosis was diagnosed in 2 (2.8%) patients; a coexisting cryptococcal meningitis was documented in one of them. Furthermore, antibodies againstHistoplasmaspecies were detected in 21 (29.6%) cases suggesting its possible aetiological role.
  
  
  CONCLUSIONS
  Fungal opportunistic pneumonias are common in HIV reactive patients in Indian setting and warrant a prompt and accurate diagnostic evaluation in the form of a combination of microbiological, serological and histopathological techniques, for an effective prophylactic and therapeutic management.
authors.affiliation: Director Professor, Department of Microbiology, Lady Hardinge Medical College and Associated Kalawati Saran Children Hospital , New Delhi, India .
authors.forename: Ravinder
authors.initials: R
authors.lastname: Kaur
authors.affiliation: Senior Resident, Department of Microbiology, Maulana Azad Medical College and Lok Nayak Hospital , New Delhi, India .
authors.forename: Bhanu
authors.initials: B
authors.lastname: Mehra
authors.affiliation: Research Scholar, Department of Microbiology, Maulana Azad Medical College and Lok Nayak Hospital , New Delhi, India .
authors.forename: Megh Singh
authors.initials: MS
authors.lastname: Dhakad
authors.affiliation: Research Associate, Department of Microbiology, Maulana Azad Medical College and Lok Nayak Hospital , New Delhi, India .
authors.forename: Ritu
authors.initials: R
authors.lastname: Goyal
authors.affiliation: Director Professor, Department of Microbiology, Maulana Azad Medical College and Lok Nayak Hospital , New Delhi, India .
authors.forename: Preena
authors.initials: P
authors.lastname: Bhalla
authors.affiliation: Director Professor, Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital , New Delhi, India .
authors.forename: Richa
authors.initials: R
authors.lastname: Dewan
keywords: Aspergillus; Candida; Cryptococcus; Pneumocystis carinii