The spectrum of cutaneous deep fungal infections in HIV positive patients at Chris Hani Baragwanath academic hospital (August 2013-July 2016)gu

Abstract

Background Cutaneous deep fungal infections may be classified as subcutaneous or systemic. Populations that are particularly at risk are patients with human immunodeficiency virus (HIV) or haematological malignancies, recipients of solid organ or hematopoietic stem cell transplants, and patients on immunosuppressants. Early diagnosis and prompt treatment are imperative in these potentially life-threatening infections where mortality rates for localised disease range from 4-10% and can be as high as 94% in patients with systemic infections. Unfortunately few studies have been published on this subject especially against the background of HIV infection. South Africa is at the epicentre of the HIV epidemic and the true spectrum of cutaneous deep fungal infections in HIV-infected patients in South Africa should ideally be demonstrated. Objectives To describe the prevalence and aetiological spectrum of cutaneous deep fungal infections in HIV positive adults at Chris Hani Baragwanath Academic Hospital. Methods This was a retrospective descriptive study of patients seen at Chris Hani Baragwanath Academic Hospital (CHBAH) from 1st August 2013 - 31st July 2016, who were HIV infected and had a skin biopsy done which proved a cutaneous deep fungal infection histologically. A list of subjects was obtained from the Department of Anatomical Pathology at CHBAH using the National Health Laboratory Services(NHLS) computer system. Participants’ demographic information and HIV status were obtained from the histopathology report. Fungal culture results as well as other relevant results not found in the report were obtained using the NHLS Trakcare system. Results A total of 53 patients were diagnosed with a deep fungal infection on histopathology amongst 2576 adults who had skin biopsies giving a 2% prevalence rate. Only 20/53 (37%) cases had a definite diagnosis. The commonest infection was cryptococcosis with 9 cases, followed by emergomycosis (formerly known as emmonsiosis) with 7 cases and sporotrichosis and candidiasis with 2 cases each. Microbiology culture was positive in only 5 (17%) of 30 cases who had tissue cultures done and in only 9 (29%) of 31 who had blood culture performed. The other 33 cases did not have a definitive diagnosis. . However 22/53 cases were classified as having a possible diagnosis as suggested on histopathology and of these, 19/53 were classified as possible histoplasmosis/emergomycosis and 3/53 were possible sporotrichosis/cryptococcosis. The average CD4 count was 43 cell/mm3 and 57% of patients were on antiretroviral treatment. Conclusion The prevalence of cutaneous deep fungal infections in adults with advanced HIV infection in South Africa who have skin biopsies performed is significant. There has been a striking emergence of emergomycosis, which was only recently recognised as a cause of disease in the HIV infected. Improved methods for definitive aetiological diagnosis are needed. We need to have a high index of suspicion in diagnosing and treating these potentially life threatening infections.