candidiasis%20(pediatric)
CANDIDIASIS (PEDIATRIC)
Candida sp are the most common cause of fungal infections.
It can manifests from benign mucocutaneous illnesses to invasive process that may affect any organ.
It is considered as normal flora in the gastrointestinal & genitourinary tracts, but when there is an imbalance in the ecological niche they can invade & cause disease.
The immune response of the patient is the important determinant of the type of infection caused by Candida.
Most common risk factors include: prematurity, very low birth weight, use of broad-spectrum antibiotics use, use of central venous catheters, receipt of parenteral nutrition, receipt of renal placement therapy by patients in intensive care unit (ICU), neutropenia, use of implantable prosthetic devices and receipt of immunosuppressive agents.

Diagnosis

Mucocutaneous Candidiasis

  • Candidal infection of the skin &/or mucous membranes

Oropharyngeal or Thrush

  • Common in young infants
    • Risk factors are maternal vaginal candidal colonization & birth asphyxia
  • May also be seen in older children
    •  Risk factors include use of antibiotics & inhaled glucocorticoids & undergone chemotherapy or radiation therapy & cellular immune deficiency
  •  Pseudomembranous is the most common form & appears as white plaques on the buccal mucosa, palate, tongue, or the oropharynx
    •  Infants may be asymptomatic or may refuse to eat due to discomfort
    •  Children have cottony feeling in the mouth, loss of taste, & sometimes pain on eating & swallowing
  •  Angular cheilitis is painful fissuring at the corners of the mouth
    •  Occur in individuals who habitually lick the corners of the mouth, creating an environment in w/c Candida can establish an infection
  •  Acute atrophic candidiasis or glossitis is the erosion of the papillae on the dorsum of the tongue that is the result of alteration of the bacterial microbiota of the oral mucosa secondary to broad spectrum antibiotics
    •  The tongue appears smooth, erythematous & often feels painful

Esophagitis

  • Occurs predominantly in individuals w/ hematologic malignancies & human immunodeficiency virus (HIV)
  • Odynophagia or pain w/ swallowing is the hallmark clinical manifestation
    • Discrete retrosternal pain & concomitant thrush may be present

Diaper Dermatitis

  • Common in young infants
    • Peak incidence in 7-10 months of age in term infants
  • Rash usually occurs in the inguinal region & has areas of confluent erythema w/ discrete erythematous papules & plaques, superficial scale & satellite lesions
  •  Persistent Candida diaper rash in young children may be a sign of type 1 diabetes mellitus, chronic mucocutaneous candidiasis, or an underlying immunodeficiency

Candida Balanitis

  • May occur as a component of diaper dermatitis in infants
  • May also be acquired sexually in adolescents
  • White patches on the penis in association w/ severe burning & itching are the clinical manifestations
  • The infection can spread to the thighs, gluteal folds, buttocks & scrotum

Chronic Mucocutaneous Candidiasis

  • Rare syndrome that usually has its onset in childhood
  • An underlying T cell defect is thought to be responsible for the inability of these patients to eradicate Candida from mucous membranes & cutaneous structures
  • Severe, recurrent thrush, vaginitis, onychomycosis & chronic skin lesions are the clinical manifestations

Intertrigo

  • Candida infection of closely opposed skin surfaces (eg neckfolds in infants, axillae, intergluteal folds)
  • Erythematous, macerated plaques & erosions w/ peripheral scale & satellite papulopustules

Vulvovaginitis

  • Predisposing factors in infants include diaper use, broad-spectrum antibiotics & immunosuppression
  • Additional risk factors in adolescents include certain contraceptive devices, estrogen therapy & pregnancy
  • Itching & discharge are the initial clinical manifestations
  • Dysuria & vaginal irritation may also be present
  • Examination shows vulvar erythema & swelling & vaginal erythema & discharge, which is classically curd-like, but may be watery

Congenital Candidiasis

  • Candidal infection acquired in utero or during delivery
    • It is a rare disorder
  • A generalized eruption 2-4 mm erythematous macules &/or papules that rest upon a 5-10 mm erythematous base can be seen in the affected infant on the first day of life
  •  At birth, oral thrush may be present
  •  Yellow-white papules may be observed on the umbilical cord
  •  In term infants, the skin lesions generally resolve w/ desquamation by the first week of life
  •  In pre-term infants, the rash may be a variable presentation including widespread pustular & vesicular lesions, or diffuse erythematous macular patches resembling a burn

Invasive Fungal Dermatitis

  • Unique condition that usually occurs in extremely low birth weight premature infants during the first
  • 2 weeks of life
  • The lesions vary from macular, papular, vesicular or pustular that are typically in dependent or intertriginous areas of the skin
    • Erosions can be extensive & sometimes involve the whole area of the abdomen or back
  • Risk factors include: postnatal steroids & hyperglycemia

Invasive Candidiasis

  • Common syndrome in neonates & children that causes significant morbidity & mortality
  • Risk factors include: prematurity, central vascular catheterization, abdominal surgery, necrotising enterocolitis, exposure to broad-spectrum antibiotics, parenteral nutrition, antacids & endotracheal intubation
    • Infants w/ smaller gestational age & birthweight have a higher incidence of invasive candidiasis
  • Candida albicans is the most frequent Candida species causing invasive candidiasis in neonates

Candidemia & Acute Disseminated Candidiasis

  • It is the presence of Candida sp in the blood
  • Most at risk are neonates, immunocompromised hosts & children in the intensive care unit (ICU)
  • Clinical manifestations may vary from minimal fever to a fulminant sepsis syndrome indistinguishable from severe bacterial infection
  • Neonatal candidemia symptoms include: lethargy, feeding intolerance, hyperbilirubinemia, apnea, cardiovascular instability, &/or respiratory distress
  • Signs of multiorgan system failure may be present

Urinary Tract Infection (UTI)

  • Candiduria is common in hospitalized patients especially in infants in the neonatal ICU (NICU)
  • Risk factors include: indwelling bladder catheter, antibiotics, diabetes, & recent surgery
  • Fungus balls that consist of masses of hyphae can develop in patients w/ candiduria
    • These balls may grow to a large size & lead to obstruction of the collecting system
  • Clinical manifestations of candiduria ranges from Candida cystitis in infants w/ indwelling urinary catheters to parenchymal renal disease from candidemia

Peritonitis

  • It an occur as a result of postoperative wound infection, gastrointestinal perforation, or chronic peritoneal dialysis
  • Clinical manifestations include: fever, chills & abdominal pain

Endophthalmitis

  • May result from trauma or eye surgery or through hematogenous seeding of the retina & choroid as a complication of candidemia
  • Indirect ophthalmoscopy examination must be performed to make the diagnosis of candidal chorioretinitis in all infants w/ suspected or proven candidemia, because affected neonates may not present w/ any clinical signs or symptoms
  • The classic ophthalmologic findings are focal, glistening, white, infiltrative, often mound-like lesions on the retina w/ indistinct borders
  • If untreated, may cause limitation of vision

Hepatosplenic or Chronic Disseminated Candidiasis

  • Occur in patients w/ hematologic malignancies who have just recovered from an episode of neutropenia
  • Clinical manifestations include: persistent fever, w/c is frequently high & spiking, in a patient who was recently neutropenic & whose neutrophil count has returned to normal
    • The fever is often accompanied by right upper quadrant discomfort or pain, nausea, vomiting, & anorexia

Meningitis/Central Nervous System (CNS) Infection

  • Candida can cause acute meningitis during the course of widespread dissemination
  • Most often occurs in neonates w/ candidemia
  • Initial presentation ranges from subacute, indolent illness, which is only identified because of a high index of suspicion, to severe illness w/ cardiorespiratory instability & multiorgan failure
  • Clinical manifestations may be the same as in acute bacterial meningitis that include: temperature instability, irritability, poor feeding or vomiting, respiratory distress & apnea

Endocarditis

  • Risk factors include: indwelling central venous catheters, underlying congenital heart disease, a history of cardiac surgery, & prolonged candidemia
  • Clinical manifestations include: fever, changing or new heart murmurs, peripheral embolization & signs & symptoms of heart failure

Osteoarticular Infections

  • Candidal infection of the bones & joints may occur as a result of hematogenous seeding or exogenous inoculation during trauma, intraarticular injection, a surgical procedure, or injection drug use
  • Arthritis or osteomyelitis due to Candida most often develops as a sequel of candidemia
  • During an episode of fungemia, bone or joint involvement may become evident or after the fungemia has resolved it may have a more subtle presentation
  • Clinical manifestations that are usually mild include: swelling & decreased range of motion

Laboratory Tests

  • Lab exams are used to help identify the different Candida species & susceptibility to antifungals

Mucocutaneous Candidiasis

Skin

  • Gram stain or potassium hydroxide (KOH) preparation/mount showing budding yeasts w/ or w/o hyphae confirms the diagnosis

Oropharyngeal

  • Gram stain or KOH preparation/mount showing budding yeasts w/ or w/o hyphae confirms the diagnosis
  • Culture is rarely indicated as it is not reliable but can be used if oral candidiasis is recurrent or recalcitrant

Esophageal

  • Definitive diagnosis is through biopsy during endoscopy or by brushing
  • Endoscopic appearance of white patches that show masses of hyphae & pseudohyphae on scraping is enough evidence to initiate therapy

Invasive Fungal Dermatitis

  • A skin biopsy w/ isolation or histologic identification of Candida sp confirms the diagnosis

Congenital Candidiasis

  • Identification of Candida sp by gram stain of the vesicular contents or by potassium hydroxide preparations of skin scrapings can be a presumptive diagnosis
  • Isolation of Candida sp from a culture of the discrete lesions or swabs of the affected skin areas confirms the diagnosis

Chronic Mucocutaneous Candidiasis

  • Culture & biopsy of involved areas/organs

Invasive Candidiasis

  • Lumbar puncture & dilated retinal examination confirms the presence of Candida sp in blood & urine

Candidemia

  • Gold standard is a positive blood culture
  • A presumptive clinical diagnosis based on the presence of typical signs & symptoms in a high-risk patient is often the basis for initiating antifungal therapy

Peritonitis

  • Diagnosis is best made by aspiration of fluid under computed tomographic (CT) or ultrasound guidance or at the time of surgery
  • Culture of Candida species from an indwelling drain is not adequate for the diagnosis of infection since it often reflects only colonization or contamination of the drain

Endocarditis

  • Persistent candidemia is seen in blood cultures
  • Echocardiographic studies usually reveal large valvular vegetations
  • In some cases, the early manifestation is embolization of the large vegetation to major vessel
  • Histopathology of the embolus shows yeasts & by culture yields Candida species

Hepatosplenic

  • An elevated serum alkaline phosphatase concentration is typically revealed in laboratory testing
  • Discrete persistent microabsecesses occur in the liver, spleen & sometimes kidneys
  • Multiple characteristic lucencies in the liver & spleen on ultrasonography, magnetic resonance imaging, or CT scan are observed
  • Biopsy reveals multiple granulomas & yeasts & hyphae that can be seen using special stains
  • Blood cultures are negative, & even culture of liver obtained at biopsy frequently is also negative

Urinary Tract Infection (UTI)

  • Candidal UTI is present if there are >1000 colony forming units (CFU)/mL in a specimen collected by suprapubic aspiration or >10,000 CFU/mL in a specimen collected by catheterization
  • Ultrasonography is useful to detect any renal parenchymal infiltration, calyceal mycetoma, or fungal masses (ie, fungal balls) in the urinary tract
  • Renal ultrasonography is used to screen for congenital anomalies of the kidney & urinary tract
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