Clinical and mycological spectrum of cutaneous candidiasis in Bombay.
PS Shroff, DA Parikh, RJ Fernandez, UD Wagle
Department of Dermatology, K. E. M. Hospital, Bombay, Maharashtra.
P S Shroff
Department of Dermatology, K. E. M. Hospital, Bombay, Maharashtra.
A total of 150 patients with cutaneous candidiasis were studied. A detailed clinical history was taken. Scrapings were examined in 10% KOH, and the material cultured on Sabouraud«SQ»s agar. Species were identified by the serum germ tube test, sugar fermentation and sugar assimilation tests. Of 150 patients 79 were females. The commonest presentation was intertrigo (75), vulvovaginitis (19) and paronychia (17). A history of chronic exposure to water was obtained in 94 cases, all had erosio interdigitalis blastomycetica and/or paronychia. Diabetes melltius as a predisposing factor was observed in 22 patients. The 10 cases of balanoposthitis had associated diabetes mellitus. Smear and culture were positive in all the patients. C. albicans was isolated in 136 cases, C. tropicalis in 12, and C. guillermondi in 2. The cultures of C. albicans had positive serum germ tube test. The 6 patients in the paediatric age group having perianal/genital involvement had a stools culture positive for C. albicans.
|How to cite this article:|
Shroff P S, Parikh D A, Fernandez R J, Wagle U D. Clinical and mycological spectrum of cutaneous candidiasis in Bombay. J Postgrad Med 1990;36:83-6
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Shroff P S, Parikh D A, Fernandez R J, Wagle U D. Clinical and mycological spectrum of cutaneous candidiasis in Bombay. J Postgrad Med [serial online] 1990 [cited 2023 Sep 28 ];36:83-6
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The Hashimoto's thyroiditis (chronic thyroiditis, lymphadenoid goitre, diffuse lymphocytic thyroiditis and goitrous autoimmune thyroiditis) is characterised by thyroid enlargement, lymphocyte in filtration of the gland and presence of thyroid antibodies. Hashimoto described this clinical entity in 1912,. This autoimmune disease is fairly common in women near menopause, and can occur in the same family as Grave's disease. The antibodies against various thyroid antigens i.e. the microsomal compound and the thyroglobulin are present in serum of almost all the patients. The immune mechanism responsible for the disease process may either be cell mediated or humoral one. Histologically, parenchymal damage of the gland, diffuse lymphocyte in filtration, follicular atrophy and presence of plasma cells and Askanzy's cell characterise the Hashimoto's disease,. Present work was undertaken to study various clinical aspects of the disease presented to RNT Medical College and A. G. Hospital, Udaipur, Rajasthan.
This study includes all biopsy proved cases of Hashimoto's thyroiditis, which presented between January 1981 and July 1987. Detailed clinical interrogation and physical examination were done and analysed according to Wyne's Index. In the 5 cases, which presented between May 1984 and July 1987, Serum T3, T4, TSH levels and thyroid scan were done to ascertain the hyper or hypo-functioning areas. All the patients were subjected to surgery after relevant pre-operative management. The relevant details then analysed.
Incidence: Out of total 272 cases of various thyroid diseases presented during study period, 14 (5.15%) were of Hashimoto's thyroiditis. Variable incidences have been reported by different authors. Marshall and Meissner, as well as Mikal reported relatively very low incidences of 0.3% and 1% from considerably large series. On the other hand high incidence rates of 11.2% and 13% were also observed. From India, Joseph and Joseph and Amesur reported a relatively lower incidence rate, i.e. 2.4% and 2.7% resp. In the other series, the incidences of the Hashimoto's disease were 4.25%, 5.38% and 7% respectively,[13,. This wide variation of incidences may be because of diagnostic awareness and accuracy.
Age-Sex distribution: [Table:1] shows incidences in different age groups in present study and 2 other Indian studies. Average age reported in Western studies is about 50 years. Most of the patients were in their forties or fifties. In contrast to this, age of Indian patients varies between 29 years to 49.5 years; overall a relatively low average age was noticed by most of the Indian authors.
Females predominate the scene of suffering from this disease. The female and male ratio was 13:1 in present study. Same pattern was noticed by other authors also. The exact cause of this female preponderance is not clear but Buchanan et al stated that person at risk may inherit dominant mutant gene on x chromosome. The estrogen recepors may also play a role in reducing immune surveillance.
Clinical picture: Clinically Hashimoto's thyroiditis can be identified by presence of moderately enlarged, diffusely firm or nodular and painless thyroid, with hyperthyroidism initially and later on hypothyroidism. Hypothyroidism is conspicuous by its absence as a presenting feature in our study. Out of 14 cases of present study, thyroid toxicity was present in 4, rest were euthyroid. Among the toxic thyroids 2 were of Grave's disease and one each were toxic nodule and multinodular goitre. While in euthyroid group, 7 were solitary adenomas and multinodular goitre was seen in 3 cases. Out of 12 cases reviewed by Laxmana Rao and Sreenivasulu Reddy, Grave's disease was the presentation in 3 cases, while 2 were of multinodular goitre. Rest of the cases were solitary nodules, out of which one was toxic. Pre-operative Rao diagnosis of Hashimoto's disease was and not possible in both the above studies. On the other hand Fenn et al diagnosed it with certainty in about 50% of cases. They also noticed other goitrous conditions including carcinoma (2 cases) in rest of the cases. Average 3 duration of presenting symptoms was 13.9 months. The only male patient of our series presented with solitary non-toxic nodule of 3 years' duration, which was the longest duration. The Grave's disease and Hashimoto's thyroiditis may coexist. This combination was there in 2 of our cases and 3of Fenn et al cases.
Interestingly out of 2 monozygotic twins one may suffer from Grave's and other from Hashimoto's disease. It is believed that complete expression of each disease depends upon the balance between T lymphocyte and B lymphocyte. It can also be associated with other diseases of presumed autoimmune nature i. e. pernicious anaemia, Sjogren's syndrome, SLE, non-tuberculous Addison's disease etc. But neither in our nor in other Indian series, this association was noticed.
Development of carcinoma in lymphodenoid goitre has also been reported in various reports with great interest? None but one of the studies reviewed by us including ours showed this combination.
Diagnosis: Clinically the Wyne's thyroid index can be a good guide to functional status of thyroid. Most of the thyroid function tests including the sophisticated ones i.e. T3, T4, TSH estimation, TRH test and RAI uptake test, also tell only about functional status of the thyroid. A suggestive clue can only be obtained by increased serum TSH in presence of normal serum T4, T3 resin uptake and FTI (Free Thyroxine Index). Patient with slightly elevated TSH will show enhanced TSH and prolactine response to TRH. In 5 of the 14 cases of present study, serum T3, T4 and TSH estimation and thyroid scan were done to ascertain functionally overactive areas.
But still histopathology was and remains the final answer to the diagnosis.
Treatment: Full replacement dosage of thyroxine should be given in every case as ultimate hypothyroidism is in table and some of the early Hashimoto's goitre may regress with this therapy. Indication of surgery in this disease is only when goitre is very large and causes discomfort. All 14 patients were subjected to surgery patients with toxic symptoms were made euthyroid by antithyroid drugs and given Lugol's iodine, prior to surgery. Eight cases of adenomas underwent hemithyroidectomy. Subtotal thyroidectomy was done in toxic diffuse and nodular goitres (5 cases); and remaining one case of non-toxic multinodular goitre was subjected to partial thyroidectomy. Post-operative thyroxine supplement was given in all but 2 cases of Grave's disease from 6th to 8th post-operative day. But later on both these left out patients were put on thyroxine supplement after 5 and 8 ½ months of operation when they developed hypothyroidism. Total 8 patients are under regular follow-up without any recurrence.
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