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1 Korean Journal of Oral and Maxillofacial Pathology 2017;41(2): ISSN: (Print); (Online) Available online at 구강질환을가진환자들의캔디다균종의분포와채취방법에따른배양결과비교 김윤규 1)#, 강재국 1)#, 임영관 2), 김병국 2), 김혜은 1), 조혜중 1), SUN QIAOCHU 1), 안규현 1), SHI SHUHAN 1), 김옥준 1)* 1) 전남대학교치의학전문대학원구강병리학교실 2) 전남대학교치의학전문대학원구강내과학교실 <Abstract> Candida Species Distribution in Patients with Oral Disease and Investigation of Candida Isolation Technique Yoon Kyu Kim 1)#, Jae Kook Kang 1)#, Yeong Gwan Im 2), Byung Gook Kim 2), Hye Eun Kim 1), Hye Joung Cho 1), SUN QIAOCHU 1), Kyu Hyeon Ahn 1), SHI SHUHAN 1), Ok Joon Kim 1)* 1) Dental Research Institute, Department of Oral Pathology, 2) Department of Oral medicine School of Dentistry, Chonnam National University. The purpose of this study is to analyze the distribution of Candida species in patients with oral disease and clarify the distinction of Candida culture test according to its isolation technique. 75 samples was isolated from 42 patients who visited Chonnam National University Dental Hospital due to oral disease from December 2015 to August For isolating the candida sampling, saliva sampling and oral swabbing were used. Acquired sampling was cultured in CHROMagar Candida Culture Medium, which indicates the candida species as color. Of the 42 patients, C. albicans was the most frequently isolated species in 39 patients. For 17 patients out of 21 who underwent saliva sampling and oral swabbing simultaneously, oral swabbing was quantitatively underestimated comparing to saliva sampling. 12 samples in 21 samples having particular Candida species were not isolated by oral swabbing. Considering the possibility of fungal infection in various oral disease, it is recommended to perform not only oral swabbing but saliva sampling when isolating Candida. Key words: Candida species, Oral disease, Candida isolation Ⅰ. INTRODUCTION 면역약화환자수의증가로기회감염병원체중하나인캔디다균에관한문제가전세계적으로대두되고있다 1). 구강 캔디다증은인간에게가장흔한진균감염이다. 인체면역결 # These authors contributed equally to this work. * Correspondence: Ok-Joon Kim, D.D.S, Ph.D, Department of Oral Pathology, College of Dentistry, Chonnam National University, Bug-Gu, Gwangju, , Korea Tel: , Fax: js3894@chonnam.ac.kr ORCID : Received: Mar ; Revised: Apr ; Accepted: Apr 핍바이러스 (HIV), 다양한면역억제제, 광범위스펙트럼을 가진항생제의사용, 보철물을장착한노년인구의증가, 그리 고비만과당뇨병과같은생활습관병의증가로구강캔디다증

2 이더욱증가하는추세이다 2). 유럽과북미에서는 20~40% 의사람들이캔디다균을가지고있다고알려져있으며, 이중 C. albicans 가가장우세하다고알려져있다 3,4). 아프리카와같은개발도상국에서는캔디다보균자의비율은선진국과비슷하거나높은수준이지만캔디다균종의다양성은선진국보다높고 C. albicans 의비율은더낮은것으로나타났다 5). 국가별로캔디다균종분포의차이가있기때문에한국인의캔디다균종분포를파악하여그에맞게진균감염의예방과치료계획을세우는것이필요하다. 캔디다균종의분포는시간의흐름에따라변화하는것으로보인다. Kamikawa 등에따르면캔디다균종의분포는 년에 C. albicans (86.2%), C. glabrata (12.3%), C. tropicalis (1.5%) 였던반면에, 년에는 C. albicans (73.4%), C. glabrata (22.8%), C. tropicalis (1.9%), C. parapsilosis (1.3%), C. krusei (0.6%) 으로나타났다 6). Arendrup 등은덴마크에서 2005년과 2011년두해의캔디다균종분포를비교하였는데, 2005 년에는 C. albicans (63.0%), C. glabrata (20.0%), C. parapsilosis (4.0%), C. tropicalis (4.0%), C. krusei (3.0%), 그외 (6.0%) 였고 2011년에는 C. albicans (57.1%), C. glabrata (21.1%), C. parapsilosis (3.7%), C. tropicalis (4.8%), C. krusei (4.1%), 그외 (9.2%) 였다 7,8). 2005년, 2013년에스페인에서이루어진연구에서는 2005년에는 C. albicans (51.0%), C. glabrata (8.0%), C. parapsilosis (23.0%), C. tropicalis (10.0%), C. krusei (4.0%), 그외 (3.0%) 의분포를나타내었고 2013 년에는 C. albicans (45.4%), C. glabrata (13.4%), C. parapsilosis (24.9%), C. tropicalis (7.7%), C. krusei (2.0%), 그외 (6.5%) 를나타내었다 9,10). 이렇듯캔디다균종은변화하고있음을알수있으며, 특히, C. albicans 이차지하는비율은작아지고있으며, 상대적으로다른종들의분포가변화하고있다. 캔디다균종에따라독성과항진균제에대한감수성이다르기때문에 Candida 균종의분포를이해하는것은진균감염의치료와예방에있어서큰의미를갖는다 1). 이러한캔디다균종의분포는여러요인에의한결과이며, 특히술자의검체도말에따라다를수있다. 따라서본연구는술자의검체체취법중에가장많이이용하는면봉채취법과타액샘플링을비교하여이들의분포를살피고자한다. Ⅱ. MATERIALS and METHODS 2015년 12월부터 2016년 8월사이에전남대학교치과병원구강내과에서캔디다균검체도말을시행한환자 42명으로부터 75개의검체를획득하였다. 환자의평균나이는 65.1세이고남자가 12명, 여자가 30명이었다. 검체의획득에는면봉채취법과타액샘플링방법이사용되었다. 면봉채취법은생리식염수를적신멸균된면봉으로환자의구강내병소부위를닦아내는방법이고타액샘플링은멸균된컵에환자의타액을그대로받아내는방법이다. 채취된면봉과타액을 CHROMagar Candida Culture Medium Fig 1. Sample number according to site 74

에도말한뒤 36 에서 48 시간동안배양하였다. CHROMagar Candida 배지의비색물질들이캔디다균종들의효소에의해색이변하기때문에군락의색을통해캔디다균종의분포를확인할수있었다. 청록색은 C. albicans 를분홍색은 C.tropicalis, C.lusitaniae, C.

0% : 0, 0<t 25% : 1, 25 < t 50% : 2, 50 < t 75% : 3, 75 < t 100% : 4 그림1은 75개검체의채취부위를나타낸다. 면봉채취법을사용하여혀에서 31개의검체를획득하였고이부위는모든채취부위중에서가장많이채취된부위이다.

3 에도말한뒤 36 에서 48 시간동안배양하였다. CHROMagar Candida 배지의비색물질들이캔디다균종들의효소에의해색이변하기때문에군락의색을통해캔디다균종의분포를확인할수있었다. 청록색은 C. albicans 를분홍색은 C.tropicalis, C.lusitaniae, C.kefyr 를백색은 C.glabrata 를비롯한그외종을나타낸다. 색상별로집락형성단위의숫자를세어집락수를바탕으로환자의캔디다균종의분포비율을결정하였다. 그리고난뒤그비율을다음과같은기준으로점수화하였다. 0% : 0, 0<t 25% : 1, 25 < t 50% : 2, 50 < t 75% : 3, 75 < t 100% : 4 그림1은 75개검체의채취부위를나타낸다. 면봉채취법을사용하여혀에서 31개의검체를획득하였고이부위는모든채취부위중에서가장많이채취된부위이다. 이어서타액샘플링이 22회로가장많았고구개, 협점막, 치은, 구강저, 의치, 비강, 구순, 침착물에서의면봉채취법이뒤를이었다. 그림2는 75개검체의캔디다균종분포를보여준다. 1-타는 타 : 타액샘플링법, 면 : 면봉채위법 Fig 2. Candida distribution of specimen Fig 3. Scoring of Candida distribution 75

4 1번환자에서타액샘플링결과를 1-면은 1번환자에서면봉채취법의결과를나타낸다. 42명중에서 3명 (6, 9, 17번 ) 은캔디다균이검출되지않았고나머지환자들에서는캔디다균이발견되었다. 그림3은캔디다균종의분포를앞에서언급한방법으로점수화하여나타낸도표이다. 청록색군락의경우 75개검체중에서 4점, 즉 C. albicans 가 75% 이상차지하는검체는 56 개 (75.6%) 였다. 0점, 즉 C. albicans 가존재하지않은검체는 8개였다. 검체중에서분홍색군락이한개도발견되지않은검체는 67개였고흰색군락은 51개의검체에서발견되지않았다. 표 1은타액샘플링과면봉채취법을모두시행한 21명의환자 (1-4, 5, 10, 12, 15, 16, 18-23, 25, 28-30, 32, 38번 ) 들의군락수를나타낸다. 21명중 17명의환자 (1, 3, 4, 10, 12, 15, 16, 19-23, 25, 29, 30, 32, 38) 에서면봉채취법이타액샘플링에비해정량적으로과소평가되었다. 그리고 12명의환자 (3, 4, 15, 19-23, 25, 28, 29, 32) 에서는면봉채취법에서특정균주가분리되지않았다. Ⅲ. DISCUSSION 구강질환을갖고있는환자의대부분 (42 명중 39명 ) 이캔디다균보균자이므로다양한구강질환을평가할때진균감염의가능성을항상고려해야한다. 면봉채취법은타액샘플링에비해캔디다균종의집락형성단위가적게나타날뿐만아니라특정캔디다균종의전체가누락되는경우가잦으므로환자의구강내에서캔디다균분리방법을고려할때면봉채취법을단독으로시행하는것보다타액샘플링을병행하면더정확한결과를얻을수있다. 이전의연구들에따르면건강한유아에서는 45~65%, 건강한성인에서는 30~55% 에서캔디다균을가지고있다고알려져있다 2). 하지만본연구에서는다양한구강질환을주소로우리병원에내원한환자의 42명중 39명 (92.8%) 이캔디다균을가지고있음이확인되었다. 구강질환을가진환자의대부분이캔디다균보균자이므로구강질환을가진환자를치료할때진균감염으로인한발병가능성을항상염두에두고진균감염여부를확인해야한다. 본연구에서도캔디다균종중에서가장많은빈도를나타 Table 1. Comparision of colony number in saliva sampling and cotton swab 76

5 낸균종은 C. albicans 였다. 이것은이전의연구들과도일치하는결과이다 1-4,6-10). KH Neppelenbroek 의연구에서는면봉채취법이집락형성단위의정량적인분석 (quantitative analysis) 에는불리하지만정성적인분석 (qualitative analysis) 에는문제가되지않는다고하였다 11). 하지만본연구에서는면봉채취법으로균을분리했을시군락수의큰감소를보였을뿐만아니라정성적인분석에도문제점을보였다. 캔디다균종에따라독성과항진균제의감수성이다르므로특정균주의미분리는진균치료를더욱어렵게한다. 정확한균종의분포를이해하고그에맞는항진균제를처리하는것은진균치료에서매우중요하기때문에구강내의캔디다균종의분포환경과일치하도록균을분리시켜야한다. 이과정에서균종의분포가실제와다르게분리되었다면적절한항진균제치료가불가하고이로인해진균감염의치료가장기화될수있다. 타액샘플링시에면봉채취법보다유리한결과가나오는이유에는다음과같은몇가지요인이있을것으로생각된다. 첫번째로타액은캔디다균이생존하는데에필요한양분을제공하기때문에타액에서의서식이유리하다는점 12), 두번째는점막표면의방어체계가건전하면캔디다균이이곳에서생존하지못하거나부착할수없는가능성, 마지막으로방법상의문제로면봉에캔디다균이충분히분리되지않았을가능성등이있다. 타액샘플링과면봉채취법을모두시행하였던 21명의환자중에서 8명 (3, 4, 10, 20-23, 25) 은구강건조증을호소하고있었다. 구강건조증을지닌 8명의경우, 병소에서면봉채취법을시행하였을때타액샘플링에비해군락수가매우낮게평가되었고그중에서 7명은균주가분리되지않았다. 이환자들의경우만약타액샘플링을하지않고면봉채취법만시행하였다면정확한캔디다균종의분포의몰이해로인해적합하지못한약물치료가이루어졌을가능성이있다. 따라서정확한진단을위해서임상가들은캔디다균종의분리시에면봉채취법에만의존하지않고타액샘플링, 오랄린스와같은방법을병행해야한다. 또한캔디다균이주로증식하는곳은혀의후방부, 입천장, 협점막이므로면봉사용시이부위를이용하는것이추천된다. Ⅳ. ACKNOWLEDGMENTS This work was supported by a National Research Foundation of Korea(NRF) grant funded by the Korea government(mest) (NRF-2016R1D1A1B ) REFERENCES 1. Arjuna N.B. Ellepola, Leeba Philip: Prevalence of Candida dubliniensis among oral Candida isolates in patients attending the Kuwait University dental clinic. Med Princ Pract 2011;20: Lakshman PS, Lim KC, Yuthika HS: Candidiasis and other fungal diseases of the mouth. Dermatologic Therapy 2002;15: Hazen KC: New and emerging yeast pathogens. Clin Microbiol Rev 1995;8: Kleinegger CL, Lockhart SR, Soll DR: Frequency, intensity, species, and strains of oral Candida vary as a function of host age. J Clin Microbiol 1996;34: Okungbowa FI, Isikhuemhen OS, Dede AP: The ditribution frequency of Candida species in the genitourinary tract among symptomatic individuals in Nigerian cities. Rev Iberoam Micol 2003;20: Yoshiaki Kamikawa, Youichirou Mori, Kazumasa Sugihara: Frequency of clinically isolated strains of oral Candida species at Kagoshima University Hospital, Japan, and their susceptibility to antifungal drugs in and BMC Oral Health 2014;14: Arendrup MC, Fuursted K, Gahrn-Hansen B: Seminational surveillance of fungemia in Denmark: notably high rates of fungemia and numbers of isolates with reduced azole susceptibility. J Clin Microbial 2005;43: Arendrup MC, Bruun B, Christensen KK: National surveillance of fungemia in Denmark (2004 to 2009). J Clin Microbiol 2011;49: Almirante B, Rodriguez D, Park BJ: Epidemiology and 77

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( )Kju225.hwp 비임균성비뇨생식기감염에서 의진단적효용성 Usefulness of the Mycofast Test (MYCOFAST Evolution 2) for the Diagnosis of Nongonococcal Genitourinary Infections Hang Ro Park, Yang Hyun Kim, Ho Jae Lee, Jea Sang Oh, Hyoung Jin