Candidiasis

Revision as of 23:28, 25 August 2016 by Rossdonaldson1 (talk | contribs) (Clinical Features)

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
  • 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
  • Invasive candida infections: Fungal UTI, Meningitis, Endocarditis, Empyema, Mediastinitis, Pericarditis

Risk Factors

  • Skin maceration
  • Immunosuppression: HIV/AIDS, Corticosteroid use, Chemotherapy, Immunomodulators
  • 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
    • 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
    • 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
    • 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
    • Pregnant: Topical Imidazole

Candida dermatitis

Diaper Dermatitis
  • Most commonly seen in infants (diaper dermatitis) or intertriginous areas
  • Clinical Features
    • 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
    • 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

  • 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