Candidiasis: Difference between revisions
(Updated references)
Line 1: Line 1:
==Background==
==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
* 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
* ''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  
* 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  
* Invasive candida infections: Fungal UTI, Meningitis, Endocarditis, Empyema, Mediastinitis, Pericarditis  


===Risk Factors===
===Risk Factors===  
* Skin maceration
* Skin maceration
* Immunosuppression: HIV/AIDS, Corticosteroid use, Chemotherapy, Immunomodulators
* Immunosuppression: HIV/AIDS, Corticosteroid use, Chemotherapy, Immunomodulators <ref name=candida>Kauffmann CA. Overview of Candida Infections. UptoDate. 2016.</ref>
* Broad spectrum antibiotic use
* Broad spectrum antibiotic use
* Diabetes Mellitus
* Diabetes Mellitus
Line 25: Line 25:
** angular cheilitis
** angular cheilitis
** loss of taste
** loss of taste
*Diagnosis
*Diagnosis<ref name=management>Pappas PG, Kauffman CA, Andes DR, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 62:e1.</ref>
** pseudomembrane white plaques adhered to oral mucosa, tongue, palate, or oropharynx
** pseudomembrane white plaques adhered to oral mucosa, tongue, palate, or oropharynx
** KOH prep of skin scrapings using a tongue depressor   
** KOH prep of skin scrapings using a tongue depressor   
Line 31: Line 31:
'''[[Esophageal candidiasis]]''' [[File:Oral Candidiasis.jpg|thumb|Esophageal Candidiasis]]
'''[[Esophageal candidiasis]]''' [[File:Oral Candidiasis.jpg|thumb|Esophageal Candidiasis]]
* Most commonly seen in HIV patients (AIDS-defining illness) or chronic inhaled glucocorticoid use
* Most commonly seen in HIV patients (AIDS-defining illness) or chronic inhaled glucocorticoid use
* Clinical Features
* Clinical Features <ref name=candida>Kauffmann CA. Overview of Candida Infections. UptoDate. 2016.</ref>
** odynophagia
** odynophagia
** dysphagia
** dysphagia
Line 46: Line 46:
'''[[Candida vulvovaginitis]]''' [[File:Candida vaginitis.JPG|thumb|Candida vaginitis]]
'''[[Candida vulvovaginitis]]''' [[File:Candida vaginitis.JPG|thumb|Candida vaginitis]]
* Most commonly seen in females in high estrogen states: pregnancy, oral contraceptive use, obesity
* Most commonly seen in females in high estrogen states: pregnancy, oral contraceptive use, obesity
* Clinical Features  
* Clinical Features <ref name=candida>Kauffmann CA. Overview of Candida Infections. UptoDate. 2016.</ref>
** intense vulvovaginal pruritis or burning
** intense vulvovaginal pruritis or burning
** dyspareunia
** dyspareunia
Line 59: Line 59:
** Trichomoniasis
** Trichomoniasis
** Chlamydia/Gonorrheal infection  
** Chlamydia/Gonorrheal infection  
*Management
*Management<ref name=management>Pappas PG, Kauffman CA, Andes DR, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 62:e1.</ref>
**Pregnant: Topical Imidazole
**1st line: Oral Fluconazole
**Pregnant: Topical imidazole (clotrimazole, miconazole)


'''[[Candida dermatitis]]''' [[File:Diaper dermatitis.png|thumb|Diaper Dermatitis]]
'''[[Candida dermatitis]]''' [[File:Diaper dermatitis.png|thumb|Diaper Dermatitis]]
* Most commonly seen in infants (diaper dermatitis) or intertriginous areas
* Most commonly seen in infants (diaper dermatitis) or intertriginous areas
* Clinical Features
* Clinical Features <ref name=candida>Kauffmann CA. Overview of Candida Infections. UptoDate. 2016.</ref>
** pruritus and erythematous changes in high risk locations: inguinal folds, axilla, scrotum, intergluteal/inframammary/abdominal folds
** pruritus and erythematous changes in high risk locations: inguinal folds, axilla, scrotum, intergluteal/inframammary/abdominal folds
* Diagnosis
* Diagnosis
Line 73: Line 74:
** Atopic Dermatitis
** Atopic Dermatitis
** Contact Dermatitis
** Contact Dermatitis
* Management
* Management <ref name=management>Pappas PG, Kauffman CA, Andes DR, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 62:e1.</ref>
 
** Topical nystatin, ketoconazole, or clotrimazole applied twice per day until resolution
** Topical nystatin, ketoconazole, or clotrimazole applied twice per day until resolution


Line 90: Line 92:
** biopsy of skin lesions for gram staining  
** 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  
** beta-D-glutan assay can be a diagnostic adjunct to blood cultures and identify systemic fungal infections weeks before positive blood cultures  
* Management
* Management <ref name=invasive>Kullberg BJ, Arendrup MC Maiken, Invasive Candidiasis. N Engl J Med 2015; 373:1445-1456.</ref>
** vascular catheter removal
** vascular catheter removal
** 1st line: IV Echinocandins (Caspofungin, Anidulafungin, Micafungin)
** 1st line: IV Echinocandins (Caspofungin, Anidulafungin, Micafungin)

Revision as of 19:16, 26 August 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

Oropharyngeal candidiasis (thrush)

Oral Candidiasis
  • Most commonly seen in infants, immunocompromised, older adults with dentures
  • Clinical features
    • cotton sensation in mouth
    • angular cheilitis
    • loss of taste
  • Diagnosis[3]
    • pseudomembrane white plaques adhered to oral mucosa, tongue, palate, or oropharynx
    • KOH prep of skin scrapings using a tongue depressor

Esophageal candidiasis

Esophageal Candidiasis
  • Most commonly seen in HIV patients (AIDS-defining illness) or chronic inhaled glucocorticoid use
  • Clinical Features [2]
    • 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

Candida vaginitis
  • Most commonly seen in females in high estrogen states: pregnancy, oral contraceptive use, obesity
  • Clinical Features [2]
    • intense vulvovaginal pruritis or burning
    • dyspareunia
    • dysuria
  • 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[3]
    • 1st line: Oral Fluconazole
    • Pregnant: Topical imidazole (clotrimazole, miconazole)

Candida dermatitis

Diaper Dermatitis
  • Most commonly seen in infants (diaper dermatitis) or intertriginous areas
  • Clinical Features [2]
    • pruritus and erythematous changes in high risk locations: inguinal folds, axilla, scrotum, intergluteal/inframammary/abdominal folds
  • Diagnosis
    • erythematous, macerated, intertriginous plaques with satellite pustules or papules
    • KOH prep or culture of skin scrapings
  • Differential Diagnosis
    • Tinea cruris
    • Atopic Dermatitis
    • Contact Dermatitis
  • Management [3]
    • 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 [4]
    • 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

  • 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 2.2 2.3 2.4 Kauffmann CA. Overview of Candida Infections. UptoDate. 2016.
  3. ↑ 3.0 3.1 3.2 Pappas PG, Kauffman CA, Andes DR, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 62:e1.
  4. ↑ Kullberg BJ, Arendrup MC Maiken, Invasive Candidiasis. N Engl J Med 2015; 373:1445-1456.
Retrieved from "https://www.wikem.org/w/index.php?title=Candidiasis&oldid=96875"