Vulvovaginal candidiasis: Retrospective study (2019- 2021) at the Centre Hospitalier National de Pikine, Suburban Dakar, Senegal

Abbreviations

SC: Sabouraud Plus Chloramphenicol; SCA: Sabouraud Plus Chloramphenicol and Actidione; Cis: Confidence Intervals.

Introduction

Yeast-like fungi of the genus Candida cause vulvovaginal candidiasis. It affects approximately three out of four women during their lifetime and is a common reason for consultation in gynaecology [1, 2]. Furthermore, around 5% of these women experience a primary sporadic episode, which can then progress to a recurrent form characterized by at least 4 episodes per year [3]. In sub-Saharan Africa, about one-third of women have vulvovaginal candidiasis, mainly caused by Candida albicans [4]. In most of these countries, especially in rural and peri-urban areas, genital infections are diagnosed using a syndromic approach, which considers the epidemiological and clinical aspects of the disease along with the microbiological knowledge of the clinician. The symptoms most suggestive of candidiasis include abundant, whitish, curdled leucorrhea, which may or may not be associated with severe vulvar pruritus [5]. This approach could lead to diagnostic errors, resulting in recurrences and the emergence of resistant pathogens. Therefore, biological identification of the pathogen is ideal. Usually, several steps of the diagnosis include direct examination of samples, culture on specific media, and species identification to help tailor treatment [5]. It can also be used to determine the extent of vaginal candidiasis. Research indicates that the prevalence of vaginal candidiasis in Senegal ranges from 27.22% to 34.8% [2]. However, most of these studies have been conducted in hospitals in urban areas, with less focus on suburban regions. In this context, the present study was carried out to gather epidemiological data on vaginal candidiasis in the suburbs of Dakar. The general objective was to describe the epidemiological, clinical, and paraclinical aspects of vulvovaginal candidiasis and its associated factors in the Pikine National Hospital laboratory.

Discussion

This study was carried out to update the data on vulvovaginal candidiasis in Senegal. The aim was to describe the epidemiological, clinical and paraclinical aspects of this disease in the laboratory of the National Hospital of Pikine, in the suburbs of Dakar. As many of retrospective study, data such as age and sometimes clinical indications were missing for some patients during the study.

The majority of women in our study were aged between 16 and 49 years. The mean age was 30.98 (± 9.76) years. Other hospital studies in Senegal have made the same observation. At Fann University Hospital and in studies on vaginal candidiasis, Diouf et al in 2012 worked on women with a mean age of 31.2±10 years [8], and Sylla K in 2017 on women with a mean age of 31±9 years [2]. This large number of women of childbearing age referred for biological diagnosis of a gynecological infection, including Candida, could be explained by the fact that this is the age of peak sexual activity, with a frequent risk of genital infections, as shown by the clinical indications that led to the request for biological examination of vaginal swabs (VS). In our study, leucorrhea (18.13%) was one of the main reasons for requesting the test. This observation of an infectious indication as a reason for biological examination of vaginal swabs has also been reported in numerous studies, including one in a hospital setting in Senegal in 2014 [8]. A study conducted among women in Benin showed that clinical symptoms were dominated by vaginal discharge (74.8%), vulvar pruritus (51.9%) and dyspareunia (36.6%) [9]. Other authors found pruritus to be the most common symptom, with prevalence ranging from 37% to 92.2% [10, 11, 12, 13]. This was also the case in a European study where pruritus predominated with a frequency of 85.9% [14].

In our study, Candida spp. was found in 635 samples from our cohort, representing a hospital frequency of 24.8%. This was lower than in studies conducted in other healthcare facilities in the country. In 2015, research to determine the prevalence of Candida in women admitted to the parasitology laboratory of the Ouakam military hospital in Dakar, Senegal, showed a frequency of 27.22% [15]. In a 2017 assessment of vulvovaginal candidiasis at the parasitology and mycology laboratory of Fann University Hospital, the frequency of this disease was 32.6% [2]. Vulvovaginal candidiasis is not only a health problem in Senegal. In fact, it is a problem in Africa and everywhere else. In some African countries, such as Morocco, Benin and Côte d’Ivoire, prevalence rates of 19%, 38.9% and 43% respectively have been reported. In Europe, prevalence rates vary between 40% and 42% [16, 17].

The highest number of Candida cases was found in women of childbearing age (91.02%). The fact that this is the period of peak sexual activity and the increase in estrogenic hormone activity at this time in women’s lives may explain the higher incidence of Candida vulvovaginitis in the young population [15]. Similar results were described by Sylla K [2], who found that the most affected category was women aged 20-35, with a prevalence of 37.8%. Similar results have been reported by other authors, such as Anane et al in Tunisia and Benchellal et al in Morocco. Their studies showed that the most affected age groups were 20-39 and 25-35 years, respectively [18, 19]. These results show that vulvovaginal candidiasis is very common in the young population.

Vaginal flora of patients with Candida positive specimens was mostly type IV. This was not the case in the studies by Seck MC [15] and Sylla K [2], where the fungus was most commonly present in a type III vaginal flora.

Candida was sometimes associated with other organisms. The most common co-infection in our study was Gardnerella vaginalis (13.07%). The same observation has also been made, even in higher proportions than in our study. This was the case in a study carried out in 2014 at the CHNU de Fann

and Thies regional hospital, in which the combination of Gardnerella vaginalis and Candida spp accounted for 26.6% of cases [8]. The predominance of this co-infection was also noted in Togo in a hospital-based assessment of vaginal infections in pregnant women [20]. The same finding was reported in a study in Burkina Faso in 2001 [21]. This could be explained by the imbalance in the vaginal flora caused by Gardenella vaginalis infection [8, 20, 21].

Conclusion

Candida fungi were more frequently found in vaginal swabs taken from women of childbearing age and those with type IV flora in the suburbs of Dakar. Infectious symptoms were the main clinical signs. The identification of Candida strains was mainly based on the filamentation test. However, this test has certain limitations due to the existence of other species like Candida dubliniensis that also possess this ability. The identification of pathogenic species with a view to appropriate and certainly effective treatment would be better served by the use of other techniques such as auxanogram or zymogram. References

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