Medical mycology has gained a lot of importance over recent years due to the emergence of new pathogenic fungi, including yeast and moulds [1]. The entire scenario regarding the epidemiology of fungal infections has undergone a paradigm shift. Earlier, the fungal isolates, which were mainly considered as non-pathogenic and laboratory contaminants, have now proved to be true pathogens and etiological agents of various emerging and opportunistic fungal infections. The overall increase in fungal infections is mainly due to the steep rise in population at risk, including cancer patients, transplant recipients, long term use of immunosuppressive agents, and prolonged hospitalization with overuse of broad-spectrum antibiotics and indwelling devices.

These organisms can also affect immunocompetent individuals [2-4]. Advances in medical science have helped clinicians treat fatal diseases, leading to prolonged life of immunocompromised individuals who in the further course get prone to opportunistic infections. Moreover, these infections are severe, rapidly progressing, and challenging to diagnose and treat as their clinical manifestations often mimic other common diseases. Rapid diagnosis is limited and culture is often delayed due to slow growth rates of many fungi. This study was undertaken to find the magnitude and incidence of fungal infections in our centre. This study is of particular relevance keeping in mind that our institute is a tertiary care health centre for people coming from hilly regions of the state where good quality health services are not approachable.

This retrospective observational study has conducted by the Department of Microbiology at a tertiary level hospital situated in the Uttarakhand state of India from February 2019 to January 2020. All the samples collected from clinically suspected cases of fungal infections were sent to the Microbiology department (Mycology section). How the samples were collected and transported to the laboratory depending on the specimen type.

Samples received in leaky containers or sent in formalin were not accepted. The common specimens were respiratory samples like sputum, broncho-alveolar lavage (BAL) and scrapings from skin, cornea and nail.

Of all the samples received, skin, hair and nail samples accounted for the maximum percentage i.e., 25% (225), followed by sputum samples 21% (189), Cerebrospinal fluid (CSF) 16% (144), bronchoalveolar lavage (BAL)15% (135), corneal scrapings 12% (110), pus sample 7% (63) and tissue 4% (34). [Figure 3]. Most of the culture positives were obtained from tissue samples (73.50%, 25/34), followed by corneal scrapings (31%, 34/110), BAL (19.20%, 26/135), pus (14.30%, 9/63), sputum (13.20%, 25/189), skin, nail & appendages (10.60%, 24/225) and CSF (0.69%, 1/144).

[Table 1, Figure 3]. Among the 144 culture-positive samples, the predominant fungus isolated was Candida albicans (40.3%, 58/144), followed by filamentous fungi like Aspergillus spp. (16%, 23/144), Fusarium spp (13.2%, 19/144), and Zygomycetes (10.4%, 15/144). Rare fungi like Trichosporon dohaense, Scedosporium apiospermum and Cladophialophora bantiana were also isolated. [Table 1]

Although fungal infections are not as common as bacterial, viral, and parasitic infections as causes of human suffering, they still are the most challenging diseases to be managed. In recent times, mycotic infections are noticeably on the rise in health care facilities. Still, the data on the burden of these infections in our country is under-reported, though the country's climate is suitable for rising fungal infections.

There are very few established reference mycology laboratories in the country and the clinicians are still not aware of the change in mycotic infections spectra. [10]. Consequently, there is a scarcity of studies mentioning the spectrum and aetiology of fungal infections.

A total of 900 samples were received from various suspected cases from all the Out-patient Departments (OPDs) and wards, in the Mycology laboratory. Of these, 144 (16%) were culture positive. A study from Western India documented a culture positivity rate of 48%, while a study from the Northern part reported it to be 14%. [11, 12]. Candida was the commonest isolate followed by filamentous fungi like Aspergillus spp., Fusarium spp, and Zygomycetes. [13]. Few cases of Cryptococcus spp. were also isolated. [14-16]. The lesser percentage of culture positivity is attributed to the fact that technical staff was posted on a rotation basis in different sections of the Microbiology Department owing to an acute shortage of workforce in the institute.

There was a high rate of attrition concerning those handling specimens sent for fungal culture. A wide variation was observed during other months concerning fungal growth obtained in cultures. In due course of time, an increasing rate of culture positivity was observed indicating streamlining of laboratory procedures and workflow. Clinical Microbiology has a well-earned reputation for unpredictability & the Mycology section advocates this dictum. [17,18]. Most of the culture positives were obtained from tissue samples and corneal scrapings followed by respiratory samples, skin & appendages, pus and CSF. The ocular mycology section was developed as 'Eye bank' and cornea transplant facilities started at the institute in the year 2019. Fungal growth was obtained in 31% (34/110) corneal scrapings sent to the ocular mycology section. [19,20]. Rare fungi like Trichosporon (blood culture), Cladophialophora bantiana (C. bantiana) (brain abscess), and Scedosporium apiospermum (corneal scraping), Wickerhamomyces anomalous (blood) were also isolated.

This is a preliminary hospital-based study to know the magnitude of the repertoire of fungal infections in the hospital and to identify the varied etiological agents. More detailed multicentric prospective studies considering the demographic data, risk factors, occupation, and socioeconomic condition of the Patient can be conducted.

To summarize, similar studies backed up by more comprehensive laboratory investigations, including serological tests, exoantigen tests and molecular methods, are needed to estimate the actual burden of fungal infections in tertiary care health facilities. Improved diagnostic and therapeutic strategies, evaluation of risk factors, and the development of new methods for rapid diagnosis and monitoring should help decrease the morbidity and mortality associated with mycotic infections.

Dr. Aroop Mohanty -first draft and data analysis, Dr. Ranjana Rohilla - concept, Dr. Suneeta Meena- data analysis, Mamta Bora-images, Anshu Singh- revision of the manuscript, Dr. Neelam Kaistha-data analysis, literature search and Dr. Pratima Gupta- literature search.