candidiasis
CANDIDIASIS
Candida sp are the most common cause of fungal infections.
 It can cause infections that range from benign mucocutaneous illnesses to invasive process that may affect any organ.
 It is considered as normal flora in the gastrointestinal and genitourinary tracts, but when there is an imbalance in the ecological niche, they can invade and cause disease.
Most common risk factors include broad-spectrum antibiotic use, central venous catheter use, receipt of parenteral nutrition, receipt of renal placement therapy by patients in ICUs, neutropenia, implantable prosthetic device use and receipt of immunosuppressive agents.

Introduction

  • Infections caused by Candida sp are major causes of morbidity and mortality causing diverse spectrum of clinical disease that ranges from superficial and mucosal infections to invasive disease associated with candidemia and metastatic organ involvement
  • Most common pathogens of invasive candidiasis are Candida albicans, Candida glabrata, Candida tropicalis, Candida parapsilosis, Candida krusei
    • Please see Invasive Candidiasis disease management chart for further information

Signs and Symptoms

Cutaneous Candidiasis
Skin
  • Signs and symptoms: Erythematous papules or macules that may be confluent, very pruritic, frequently pustular with distinct border and sometimes accompanied by creamy white exudate or scaling
  • Usually occurs in warm moist places (eg inguinal, axillary and intergluteal regions)
Paronychia and Onychomycosis
  • Signs and symptoms of paronychia: Well-localized area of inflammation that becomes warm and bright red accompanied by pain due to swelling of proximal and lateral nailfolds and may extend extensively under the nail that usually occurs in persons who frequently immerse hands in the water
    • Purulent material under the cuticle may be seen
    • In chronic cases, cuticle separates from the nail plate which leaves a space between proximal nailfold and nail plate exposed to infection
  • Signs and symptoms of onychomycosis: Nail appears discolored and thickened with splitting and roughening with occasional nail loss
Mucosal Candidiasis
Oropharyngeal
  • Signs and symptoms: Creamy white, curd-like patches on the tongue and other oral mucosal surfaces

Esophageal

  • Symptoms: Painful swallowing, a feeling of obstruction on swallowing, substernal chest pain, nausea and vomiting
Intra-abdominal
  • Occur in patients that have had recent abdominal surgery or intra-abdominal events referring to a heterogenous group of infections that includes peritonitis, abdominal abscess and purulent or necrotic infection at sites of gastrointestinal perforation or anatomic leak
  • Symptoms: Abdominal pain (symptoms of gastritis)
Vulvovaginal
  • Common in diabetic and immunocompromised patients, patients on hormone replacement therapy, postpubertal females, females in childbearing age and postmenopausal women
  • Symptoms: Vaginal discomfort, vulvar pruritus, burning sensation in vaginal area, curdlike discharge, erythematous and swollen labia, erythematous with white plaques vaginal walls, occasional dysuria and dyspareunia
  • Please see Vaginitis: Trichomoniasis, Candidiasis, Bacterial Vaginosis disease management chart for further information
Chronic Mucocutaneous Candidiasis
  • A group of disorders that includes Candida infections of the skin, mucous membranes, hair and nails characterized by a protracted and persistent course despite what is usually adequate therapy
  • Signs: Alopecia, esophageal stenosis, disfiguring lesions of the face, scalp, hands and nail

Invasive Candidiasis

Candidemia

  • It is the isolation of Candida sp from ≥1 blood culture specimen with hematogenous spread of the yeast to ≥1 organs
  • Positive for Candida in a single central-line or peripheral blood culture (BC)
  • The following factors predispose to the condition:
    • Abdominal surgery
    • Neutropenia
    • Broad-spectrum antibiotics
    • Indwelling intravenous catheters
    • Peripheral alimentation
    • Cancer chemotherapy
    • Immunosuppressive therapy in transplant patients
    • Colonization with Candida sp
    • Renal failure
  • Clinical features include:
    • Fever of unclear etiology
    • Sepsis syndrome
    • Signs of multiple organ involvement including the kidney, brain, myocardium and eye
  • Macronodular skin lesions
  • Endophthalmitis
  • Suppurative manifestations ie micro- and macro-abscesses
Chronic Disseminated (Hepatosplenic)
  • Most infections occur in severely immunocompromised patients and manifest during their recovery from neutropenia
  • Signs and symptoms: Persistent fever, abdominal pain, hepatosplenomegaly, increased alkaline phosphatase levels, leukocytosis
Endocarditis
  • Candidal endocarditis is associated with the following factors:
    • Underlying valvular heart disease
    • Heroin addiction
    • Cancer chemotherapy
    • Implantation of prosthetic valves
    • Prolonged use of intravenous catheters
    • Preexisting bacterial endocarditis
  • Signs and symptoms are similar to bacterial endocarditis with the exception of the occurrence of large emboli to major vessels and include the following:
    • Hepatosplenomegaly
    • Hematuria, proteinuria, pyuria
    • Splinter hemorrhages
    • Osler’s nodes
    • Janeway lesions
Endophthalmitis
  • Infections within the eye can be:
    • Exogenous affecting the anterior chamber of the eye that occur following trauma or surgical procedure
    • Endogenous is when Candida infection reaches the posterior chamber of he eye via hematogenous spread; it can be manifested as chorioretinitis with or without extension into the vitreous leading to vitritis
  • Signs and symptoms: Retina has visible white lesions that may progress to vitritis with high risk of vision loss
Genitourinary Tract (GUT)
  • Risk factors:
    • Diabetes
    • History of previous antibiotic use
    • Indwelling urinary catheters
    • Immunosuppressive therapy
  • Male patients: Urethral candidiasis usually results from sexual contact with women with Candida vaginitis
  • Female patients: Urethral candidiasis infection may be acquired from the extension of Candida vaginitis
  • Signs and symptoms: Lower tract infection (cystitis) is usually asymptomatic but may present with dysuria, hematuria, frequency
Central Nervous System (CNS)
  • Most cases occur in the setting of trauma, neurosurgery, immunosuppression or AIDS
  • Signs and symptoms:
    • Meningeal irritation (eg headache, stiff neck, irritability)
    • In the comatose or non-communicative patient, observation of abnormalities is difficult
Pulmonary
  • Signs and symptoms: Fever and cough
Peritonitis
  • Often a complication of peritoneal dialysis, gastrointestinal tract surgery and perforation of an abdominal viscus
  • Prior antibiotic administration is a predisposing factor
Musculoskeletal
  • Signs and symptoms: Arthritis and osteomyelitis (eg similar to disease of bacterial etiology, includes suppurative synovitis)
Infection of the Vasculature
  • Often occur in association with intravenous catheters
  • Signs and symptoms:
    • In patients with peripheral septic thrombophlebitis, symptoms may be minimal with the extent of the disease being greater than is apparent on initial clinical assessment
    • Patient may have fever, signs of sepsis and persistent candidemia
    • Suppuration and thrombosis may be present
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