Candidiasis

Key Features

Essentials of Diagnosis

• In normal or immunosuppressed individuals: superficial infections (oral thrush or ulcerations, vulvovaginitis, erythematous intertriginous rash with satellite lesions); fungemia related to intravascular devices

• In immunosuppressed individuals: systemic infections (candidemia with renal, hepatic, splenic, pulmonary, or cerebral abscesses); chorioretinitis; cutaneous nodules

• In either patient population: budding yeast and pseudohyphae are seen in biopsy specimens, body fluids, or scrapings of lesions; positive culture

General Considerations

• Infection caused by Candida albicans in > 50% of cases in children

• Severe systemic infection may also be caused by Candida tropicalis and Candida parapsilosis and a few other Candida species

• Speciation is important because of differences in pathogenicity and response to antifungal therapy

• C albicans is ubiquitous, usually in small numbers, on skin, mucous membranes, or in the intestinal tract

• Disseminated infection is almost always preceded by prolonged broad-spectrum antibiotic therapy, instrumentation (including intravascular catheters), and/or immunosuppression

• Patients with diabetes mellitus are prone to superficial Candida infection; thrush and vaginitis are most common

Clinical Findings

Symptoms and Signs

• Oral candidiasis (thrush)

  • Adherent creamy white plaques on the buccal, gingival, or lingual mucosa are seen.

  • These may be painful

  • Lesions may be few and asymptomatic, or they may be extensive, extending into the esophagus

• Vaginal infection

  • Thick, odorless, cheesy discharge with intense pruritus is typical

  • Vagina and labia are usually erythematous and swollen

  • Outbreaks are more frequent before menses

• Skin infection

  • Dermatitis

    • Pronounced erythema with a sharply defined margin and satellite lesions is typical

    • Pustules, vesicles, papules, or scales may be seen

    • Weeping, eroded lesions with a scalloped border are common

  • Scattered red papules or nodules in immunocompromised patients may represent cutaneous dissemination

  • Paronychia and onychomycosis occur in immunocompetent children but are also associated with immunosuppression, hypoparathyroidism, or adrenal insufficiency (Candida endocrinopathy syndrome)

  • Chronic draining otitis media may occur in patients who have received multiple courses of antibiotics and are superinfected with Candida

• Enteric infection

  • Esophageal involvement in immunocompromised patients, resulting in substernal pain, dysphagia, and painful swallowing

  • Nausea and vomiting are common in young children

  • Stomach or intestinal ulcers also occur

• Pulmonary infection

  • May cause abscesses, nodular infiltrates, and effusion

• Renal infection

  • Associated with instrumentation, an indwelling catheter, or anatomic abnormality of the urinary trac

  • Symptoms of cystitis may be present

• Other infections

  • Myocarditis, meningitis, and osteomyelitis usually occur only in immunocompromised patients or neonates, generally in those with high-grade candidemia

  • Endocarditis may occur on an artificial or abnormal heart valve, especially when an intravascular line is present

• Disseminated candidiasis

  • Skin and mucosal colonization precedes but does not predict dissemination

  • Infants often have unexplained feeding intolerance, cardiovascular instability, apnea, new or worsening respiratory failure, glucose intolerance, thrombocytopenia, or hyperbilirubinemia

  • A careful search in immunocompromised patients should be carried out for lesions suggestive of disseminated Candida (retinal cotton-wool spots or chorioretinitis; nodular dermal abscesses)

  • Hepatosplenic and renal candidiasis ...