Difference between revisions of "Candidiasis"

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==Background==
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==Background==  
* Candidiasis encompasses a wide array of local or invasive fungal infections caused by the ''Candida'' genus and infect more than 250,000 patients worldwide per year
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*Candidiasis encompasses a wide array of local or invasive fungal infections caused by the ''Candida'' genus and infect more than 250,000 patients worldwide per year <ref>Candidiasis. Centers for Disease Control and Prevention Web site. https://www.cdc.gov/fungal/diseases/candidiasis/. Published June 12, 2015. Accessed August 25, 2016.</ref>
* ''Candida'' yeasts (most commonly ''Candida albicans'') are normal flora that live on the skin and mucous membranes, but may cause infection with overgrowth and vary in clinical presentation depending on the infected area
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*''Candida'' yeasts (most commonly ''Candida albicans'') are normal flora that live on the skin and mucous membranes, but may cause infection with overgrowth and vary in clinical presentation depending on the infected area
* Local mucocutaneous candida infections: oropharyngeal candidiasis, esophagitis, vulvovaginitis, balanitis, chronic mucocutaneous candidiasis, and mastitis  
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*Local mucocutaneous candida infections: oropharyngeal candidiasis, esophagitis, vulvovaginitis, balanitis, chronic mucocutaneous candidiasis, and mastitis <ref name=candida>Kauffmann CA. Overview of Candida Infections. UptoDate. 2016.</ref>
* Invasive candida infections: Fungal UTI, Meningitis, Endocarditis, Empyema, Mediastinitis, Pericarditis  
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*Invasive candida infections: Fungal UTI, Meningitis, Endocarditis, Empyema, Mediastinitis, Pericarditis  
  
===Risk Factors===
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===Risk Factors===  
* Skin maceration
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*Skin maceration
* Immunosuppression: HIV/AIDS, Corticosteroid use, Chemotherapy, Immunomodulators
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*Immunosuppression: HIV/AIDS, Corticosteroid use, Chemotherapy, Immunomodulators <ref name=candida>Kauffmann CA. Overview of Candida Infections. UptoDate. 2016.</ref>
* Broad spectrum antibiotic use
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*Broad spectrum antibiotic use
* Diabetes Mellitus
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*[[Diabetes mellitus]]
* Oral Contraceptive use
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*Oral Contraceptive use
* Hematologic Malignancy
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*Hematologic Malignancy
* Central Venous Catheters use
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*Central Venous Catheters use
* Total Parenteral nutrition use
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*Total Parenteral nutrition use
* Neutropenia
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*[[Neutropenia]]
  
 
==Clinical Features==
 
==Clinical Features==
 
 
===Local Candida Infections===
 
===Local Candida Infections===
'''[[Oropharyngeal candidiasis]] (thrush)''' [[File:Oral candidiasis.jpg|thumb|Oral Candidiasis]]
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*Mouth: [[Oropharyngeal candidiasis]] (thrush)  
* Most commonly seen in infants, immunocompromised, older adults with dentures
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*Esophagus: [[Esophageal candidiasis]]  
* Clinical features
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*Vulva/vagina: [[Candida vulvovaginitis]]
** cotton sensation in mouth
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*Skin lesions: [[Candida dermatitis]]
** angular cheilitis
 
** loss of taste
 
*Diagnosis
 
** pseudomembrane white plaques adhered to oral mucosa, tongue, palate, or oropharynx
 
** KOH prep of skin scrapings using a tongue depressor 
 
  
'''[[Esophageal candidiasis]]''' [[File:Oral Candidiasis.jpg|thumb|Esophageal Candidiasis]]
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===Systemic===
* Most commonly seen in HIV patients (AIDS-defining illness) or chronic inhaled glucocorticoid use
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*hematogenous, central line cathether, intravenous catheter, [[Candiduria|indwelling foley catheter]]: [[Invasive candidiasis]]
* Clinical Features
 
** odynophagia
 
** dysphagia
 
** retrosternal pain
 
** nausea/vomiting
 
* Diagnosis
 
** thick, white, linear esophageal plaques on endoscopy
 
*Differential Diagnosis
 
** Cytomegalovirus Esophagitis
 
** Herpes Simplex Esophagitis
 
** Eosinophilic Esophagitis
 
** Medication-induced Esophagitis
 
  
'''[[Candida vulvovaginitis]]''' [[File:Candida vaginitis.JPG|thumb|Candida vaginitis]]
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<gallery mode="packed">
* Most commonly seen in females in high estrogen states: pregnancy, oral contraceptive use, obesity
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File:Oral candidiasis.jpg|[[Oral candidiasis]]
* Clinical Features
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File:Oral Candidiasis.jpg|[[Esophageal candidiasis]]
** intense vulvovaginal pruritis or burning
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File:Candida vaginitis.JPG|[[Candida vaginitis]]
** dyspareunia
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File:Diaper dermatitis.png|[[Diaper dermatitis]]
** dysuria
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</gallery>
* Diagnosis
 
** although other candida infections are clinically diagnosed, laboratory methods should be pursued to confirm diagnosis of candida vulvovaginitis
 
** cotton cheese curd-like non-odorous vaginal discharge on pelvic exam 
 
** vaginal pH < 4.5
 
** vaginal wet mount
 
* Differential Diagnosis
 
** Bacterial vagininosis
 
** Trichomoniasis
 
** Chlamydia/Gonorrheal infection
 
*Management
 
**Pregnant: Topical Imidazole
 
  
'''[[Candida dermatitis]]''' [[File:Diaper dermatitis.png|thumb|Diaper Dermatitis]]
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==Differential Diagnosis==
* Most commonly seen in infants (diaper dermatitis) or intertriginous areas
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===Esophageal candidiasis===
* Clinical Features
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*CMV esophagitis
** pruritus and erythematous changes in high risk locations: inguinal folds, axilla, scrotum, intergluteal/inframammary/abdominal folds
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*HSV esophagitis
* Diagnosis
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*Diptheria
** erythematous, macerated, intertriginous plaques with satellite pustules or papules
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*Pill esophagitis (bisphosphonates, NSAIDs, potassium chloride, iron supplements)
** KOH prep or culture of skin scrapings
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*Post-radiation esophagutis
* Differential Diagnosis
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*Mallory Weiss tear or Boerhaave syndrome
** Tinea cruris
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*Cardiac pain (ACS, pericarditis, myocarditis, dissection, etc.)
** Atopic Dermatitis
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*[[Zenker's diverticulum]]
** Contact Dermatitis
 
* Management
 
** Topical nystatin, ketoconazole, or clotrimazole applied twice per day until resolution
 
 
 
===[[Invasive candidiasis]]===
 
* Candida is an important nosocomial infection that requires evaluation to identify a source: central line cathether, intravenous catheter, indwelling foley catheter, recent abdominal surgery with anastamotic leak
 
* Associated with candidemia with further hematogenous spread to visceral organs (heart, kidney, liver, spleen, eye, brain, skin, joints etc)
 
* Clinical Features
 
** presence of biofilms on catheter
 
** fever and chills unresponsive to antibiotics
 
** chorioretinitis
 
** muscle abscesses
 
** skin lesions with satellite pustules
 
* Diagnosis
 
** positive blood culture
 
** positive culture of blood, tissue, urine from normally sterile sites
 
** biopsy of skin lesions for gram staining
 
** beta-D-glutan assay can be a diagnostic adjunct to blood cultures and identify systemic fungal infections weeks before positive blood cultures
 
* Management
 
** vascular catheter removal
 
** 1st line: IV Echinocandins (Caspofungin, Anidulafungin, Micafungin)
 
** Step down therapy: as early as 5 days, can step down to oral if blood stream is clear and patient can tolerate oral regime
 
** 2nd line: Fluconazole, Voriconazole
 
** Alternative: Amphotericin B is acceptable but carries a higher toxicity and side-effect profile
 
  
 
==Evaluation==
 
==Evaluation==
* Local candidiasis is primarily clinically diagnosed based on lesion characteristics and appearance
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*Local candidiasis is primarily clinically diagnosed based on lesion characteristics and appearance
* Confirmatory tests: KOH preparation of lesion scrapings, vaginal wet mount, culture, or endoscopic biopsy reveal budding yeast with pseudohyphae  
+
*Confirmatory tests: KOH preparation of lesion scrapings, vaginal wet mount, culture, or endoscopic biopsy reveal budding yeast with pseudohyphae  
  
 
==Management==
 
==Management==
* Local: Topical anti-fungal (Nystatin, azoles) or oral azole
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*Local: Topical anti-fungal (Nystatin, azoles) or oral azole
* Invasive: Intravenous Echinocandins (Caspofungin, Micafungin)
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*Invasive: Intravenous Echinocandins (Caspofungin, Micafungin)
  
 
==Disposition==
 
==Disposition==
* Local infections can be managed on an outpatient basis
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*Local infections can be managed on an outpatient basis
* Invasive infection will be managed with IV antibiotics and requires prolonged hospitalization  
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*Invasive infection will be managed with IV antibiotics and requires prolonged hospitalization  
  
 
==See Also==
 
==See Also==
*[[Candida vaginitis]]
 
 
*[[Candiduria]]
 
*[[Candiduria]]
*[[Oral thrush]]
 
  
 
==External Links==
 
==External Links==
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==References==
 
==References==
 
<references/>
 
<references/>
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[[Category:ID]]

Latest revision as of 18:04, 27 October 2016

Background

  • Candidiasis encompasses a wide array of local or invasive fungal infections caused by the Candida genus and infect more than 250,000 patients worldwide per year [1]
  • Candida yeasts (most commonly Candida albicans) are normal flora that live on the skin and mucous membranes, but may cause infection with overgrowth and vary in clinical presentation depending on the infected area
  • Local mucocutaneous candida infections: oropharyngeal candidiasis, esophagitis, vulvovaginitis, balanitis, chronic mucocutaneous candidiasis, and mastitis [2]
  • Invasive candida infections: Fungal UTI, Meningitis, Endocarditis, Empyema, Mediastinitis, Pericarditis

Risk Factors

  • Skin maceration
  • Immunosuppression: HIV/AIDS, Corticosteroid use, Chemotherapy, Immunomodulators [2]
  • Broad spectrum antibiotic use
  • Diabetes mellitus
  • Oral Contraceptive use
  • Hematologic Malignancy
  • Central Venous Catheters use
  • Total Parenteral nutrition use
  • Neutropenia

Clinical Features

Local Candida Infections

Systemic

Differential Diagnosis

Esophageal candidiasis

  • CMV esophagitis
  • HSV esophagitis
  • Diptheria
  • Pill esophagitis (bisphosphonates, NSAIDs, potassium chloride, iron supplements)
  • Post-radiation esophagutis
  • Mallory Weiss tear or Boerhaave syndrome
  • Cardiac pain (ACS, pericarditis, myocarditis, dissection, etc.)
  • Zenker's diverticulum

Evaluation

  • Local candidiasis is primarily clinically diagnosed based on lesion characteristics and appearance
  • Confirmatory tests: KOH preparation of lesion scrapings, vaginal wet mount, culture, or endoscopic biopsy reveal budding yeast with pseudohyphae

Management

  • Local: Topical anti-fungal (Nystatin, azoles) or oral azole
  • Invasive: Intravenous Echinocandins (Caspofungin, Micafungin)

Disposition

  • Local infections can be managed on an outpatient basis
  • Invasive infection will be managed with IV antibiotics and requires prolonged hospitalization

See Also

External Links

References

  1. Candidiasis. Centers for Disease Control and Prevention Web site. https://www.cdc.gov/fungal/diseases/candidiasis/. Published June 12, 2015. Accessed August 25, 2016.
  2. 2.0 2.1 Kauffmann CA. Overview of Candida Infections. UptoDate. 2016.