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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 ...

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