SPUTUM COLONIZATION BY Candida IN PATIENTS OF THE PNEUMOLOGY UNIT OF GENERAL HOSPITAL IN RECIFE ( BRASIL ) . 11

Se pesquisaron 322 pacientes internados en '/a Unidad de neuJJlologia del Hospital Geral Otovio de Freitas, Recife, PE, Brasil ,para determinar la colonización por Candida en el esputo. De estos, 225 correspondian al sexo masculino y 97 al feminino. La colonización fue diagnosticada en 25 pacientes (7, 7%) del sexo masculino y 9 (2,8%) del feminino. De los 25 casos detectados, 15 estaban asociados solamente a tuberculosis pulmonar, 5 a tuberculosis pulmonar y otra neumopatia, 2 a bronquiectasia, 1 a cancel' pulmonar, 1 a fistula arteriovenosa y 1 a infección respiratoria. Fueron aisladas 13 cepas de C. albicans, 6 C. parapsilosis, 4 C. membranaefaciens y 2 C. tropicalis.

The objective ofthis study was to detect, isolated and identiry fungi of the upper respiratory tract(sputum) in patients hospitalized in the Pneumology Unit ofthe Otavio de Freitas (SANCHO) General Hospital.Recife, Brasil.

MATERIAL AND METBODS
Sputum samples were collected from patients, hospitalized, with respiratory systems problems.Three hundred and twenty two patients were surveyed being 225 were male and 97 female .
The sputum samples were collected from each patient 3 times in sterilized Petri plates at intervals of 3 to 4 days.After collection, the samples were transported to the Department ofMycology where they were duly processed for direct examination and culture.The time between collection and manipulation of those did not exceed 2 hours.
The direct examination ofthe sputum was carried out on their native state (without colouring and without clarifier) and clarified with aqueous solution at 20% of potassium hydroxide.
The sputum samples were seeded in duplicate, by spreading Sabouraud agar + 0.5% of yeast extract (YE) on their surface, to which 50mg ofChloramphenicol /1 contained in a Petri plate was added.A plate was left at room temperature (28°C± 1°C) and the other incubatedat 37°C.The development ofthe cultures were lasted for up to 20 days.The colonies which emerged after being purified were maintained in the aboye mentioned culture medium without antibiotic and held in a test tube.
The data about the patients were collected from their clinical records.

RESULTS
Candida colonization was diagnosed through the direct examination ofthe sputum of25 (7 .7%)patients, being 16 (4 .98)male and 9 (2.8%) female.Direct examination revealed the presence of isolated yeast cells and pseudomycelium, both of which adhered to the epithelial cells present in the sputum (Figures 1 and 2).
C. albicans occurred in 7 male and 6 female patients; C. parapsilosis in 4 male and 2 female patients; C. membranaefaciens in 3 male and 1 female; C. tropicalis only in 2 male patients (Table 1; Figure 3).
The minimum age ofthe male patients was 29 and the maximum 85 years old.AH ofthem had different occupations and all were born in the State ofPernambuco (Table 1).
The age ofthe female patients ranged from a minimum of 19 to a maximum of78 years old, being aH ofthem domestic servants.These patients were born in the State ofPernambuco; (Table 1).
Ofthe 16 male patients with colonization, C. albicans was isolated mainly i n 5 patients with pulmonary tuberculosis and other species in another infections (

DISCUSSION
Primary pulmonary candidiasis is rare, being more frequent the secondary attack of the lungs, because of various primary conditions such as tuberculosis and other bacterial and viral pneumopathies; neoplasias; suppurations; bronchiectasis and others (Wanke, 1984;Lacaz et al. , 1991).
Due to the presence of Candida in such processes, its role is discussed in the quoted pneumopathies.Even as a secondary agent, this fungus can cause serious dangers (Lacaz et al., 1991).
In this study, the presence of Candida in the sputum, found in the direct examination and culture, was considered as "colonization" and not as candidiasis, based on considerations made by various authors.According to them, the presence ofyeasts like Candida, Trichosporonand other opportunist fungi in the sputum, bronchial secretion or eXlldate, associated with other primary pathologies, is referred to by the terms colonization, secondary mycosis, opportunist pathogen and infection (Vidotto etal., 1986;Jain etal., 1991;Shigera etal., 1991;Kumar etal., 1992;Bandele etal., 1993).
The difficulties of diagnosingfo rpulmonary candidiasis are related to the clinical sample.What is considered of diagnostic value for primary pulmonary candidiasis is the demonstration of blastopores and/or pseudomycelium in samples obtained by pulmonary biopsy (Conant et al. , 1971 ;Rippon, 1982;Browne et al ., 1990; Pizzo & Walsh, 1990; Lacaz et al., 1991).
It is worth emphasizing that the importance of the direct examination is unanswerable to give evidence of Candida in the sputum.This has also been emphasized by Negroni & Daglio (1948); Schwarting & Skinner (1948); Conant et al. , (1971); Osoagbaka (1981); as well as Meunier (1990) and Remington (1990), when they refer to the presence of Candida in clinical samples of the buccal cavity.
The results of this study with sputum samples demonstrate Candida colonization in patients with different pneumopathies Taking into account men as weH as women, the greatest number of cases occurred in patients in the age I ranges of 32-49 and 72-78 years old (Table 1).Osoagbaka (1981) isolated the greatest number of Candida specimens from the sputum of patients with an age range of 41-80 years old without reference to sexo Of 20 patients with pulmonary tuberculosis, there were 15 with BAAR positive, 1 with BAAR not undertaken and 4 with BAAR negative .Amongst them, 15 were carries of pulmonary tuberculosis only.The others presented different types of associations Of patients who were not bearers of pulmonary  .J .. Cases of association between bronchiectasis and Candida are reported by Wanke (1984), Lacaz et al.(1991) and Kumar et al. (1992).
Patients with neoplasias under treatment present serious risks of infections, these are fungals which are difficuIt to diagnose and treat (Vidotto et al., 1986 The presence of Candida and Trichosporon in patients with cancer has been found through c1inical samples obtained by brush, bronchial washing, exudation , biopsy and blood culture (Stokes et al., 1989;Browne et al., 1990;Shigehara et al., 1991;Elias et al., 1992).These last authors report a fatal case of septicemia by Candida in a patient with cancer.
The presence of Candida species in the sputum of patients with diabetes mellitus was reported by Bandele et al. (1993), as well as being reported in this study, however the patient had pulmonary tuberculosis too (Table 1).
Candida parapsilosis was isolated in an arteriovenous fistula and respiratory infection.Was not found reference on the isolation of this species with backgrounds such as these.
AIl the authors referred to in this study, mention pulmonary tuberculosis as the most frequent pneumopathy; this information is analagous to the resuIts contained in Table 1; since the same pathology was reported in 20 patients.
The process of colonization by Candida, verified in this study, is corroborated by Nwobu et al. (1989), who isolated Candida strains from the sputum of patients with primary pneumopathy.
Bandele et al. (1993) did not consider the high percentage of pulmonary "infections" caused by species of Candida in patients with pulmonary tuberculosis due to the nutritional, depressive and immunological state of these patients.
An interest in infections by Candida has increased in recent years, due to the ageing population, those with cancer under treatment, with transplants, AIDS patients and with prolonged use of antibiotics and intensive ca re units.Colonization by species ofCandida can evolve toa disseminated iIIness, mainly in immuno-compromised patients (Gibbs, 1990, Meunier, 1990).
Sorne gastroenterologists argue that unless these organisms are seen in biopsy, there is no reason why they have to be treated as candidiasis.This is incorrect, because esophagitis by Candida can be ulcerative, being it possible to have lesions al so with a negative biopsy.On the other hand there can occur cases in which Candida invades lhe submucosa from where it enters the blood stream and is fully disseminated; consequentIy, the serious problem of oral and esophagal candidiasis is then evident (Remington, 1990).
Almost 50% of the patients with cancer die of infections from Candida, being the patients with altered immunological systems who demonstrate vulnerability to the infections.Diagnosing pneumonia by Candida without a pulmonary biopsy, but in autopsy, 61% of the patients with profound candidiasis presented pulmonarycompromise. " This highlights the sad fact that nowadays we are not capable of making a diagnosis premortem in the majority of patients with deep candidiasis" (Remington, 1990).
Thus we can concIude that in all the cases of colonization by Candida, they were associated with pneumopathies and that mainly one species ofyeast was isolated; C. albicans prevailed amongst the other species of the cases of colonization; it is worth emphasizing that direct examination is indispensable for the diagnosis of colonisation by.Camlida.

Table 1
) Ofthe 9 cases offemale patients with colonisation, C. albicans was isolated in 6 patients, mainly with pulmonary tuberculosis(3cases). (Table1).The strains of yeasts were stored in the Mycotheca-URM of the Biological Sciences Centre of the Federal

Table 1 .
-Aspects related to the cases of Candida colonization detected in patients hospitalized.