187. CANDIDIASIS
Secretions from the mouth, rectum or
Etiologic agents: Candida albicans, new
species: C. dubliniensis, C. tropicalis, C.
parapsilosis, C. guilliermondii, C. glabrata
(formerly Torulopsis glabrata), C. krusei
th th
- 4 or 5 most common cause of nosocomial
bloodstream infections(through intravascular
catheters) in the US.
- causes lethal septic shock
- are commensals of humans (mouth, stool and
vagina)
- grow rapidly at 25-37 ‘C on simple media as
oval, budding cells
- in tissue, both yeasts and pseudohyphae are
present
Pseudohyphae – elongated branching structures
with constrictions at the septae.
Budding yeasts – separate structures or as
projections from pseudohyphae.
Species:
1. C. glabrata – no true hyphae or
pseudohyphae in vitro or in infected
tissue.
2. C. albicans and C. dubliniensis – can
form germ tubes in serum, can form
chlamydospores (thick walled large
spores) in special culture medium.
PATHOGENESIS:
1. Deeply invasive candidiasis is often
preceded by increased colonization of
the mouth,vagina,stool with Candida
due to broad-spectrum antibiotic
therapy. Local and systemic factors
favors infection.
2. Oropahryngeal thrush- occur in
neonates and in patients with DM, HIV
or dentures.
3. Vulvovalginal candidiasis- 3rd trimester
of pregnancy
4. candida from the perineum can enter
the urinary tract via an indwelling
bladder catheter.
5. Cutaneous candidiasis – often involves
macerated skin: diapered area of
infants, under pendulous breasts, hands
constantly in water or covered by
occlusive gloves.
6. Deep tissue candidiasis – eg.
Perforation of the GIT through trauma,
surgery or peptic ulceration or by
mucosal damage due to cytotoxic
agents (cancer chemotherapy)
7.
vagina; drainage from surgical wounds
or tracheostomy sites – contaminate
the hub or skin site of a catheter in an
umbilical or central vein.
8. IV drug abuse or 3rd degree burns
9. compromised host defense in very low
birthweight neonates, neutorpenia or
glucocorticoid therapy once candida
passed the integumentary barrier.
10. hematogenous seeding in the retina,
kidney spleen and liver.
CLINICAL MANIFESTATIONS:
A. MUCOCUTANEOUS CANDIDIASIS
1. Oral thrush
- discrete and confluent adherent white
plaques on the oral and pharyngeal mucosa,
(mouth and tongue)
- painless lesions, but with painful fissuring
at the corners of the mouth.
- raises possibility of acute HIV infection
especially when CD4+ cell count falls,
esophageal thrush (CD4+ counts <50/uL)
- independent risk factor for vulvovaginal
thrush.
2. Cutaneous candidiasis
- red macerated intertriginous areas,
paronychia, balanitis, or pruritus ani.
- candidiasis of the perineal and scrotal
skin (discrete pustular lesions on inner
aspects of the thighs.)
3. Chronic Mucocutaneous Candidiasis
(CMC) or Candidal granuloma
- circumscribed hyperkeratotic skin lesions,
crumbling dystrophic nails, partial alopecia
in areas of scalp lesions, and both oral and
vaginal thrush
- chronic ringworm, dental dysplasia, and
hypofunction of the parathyroid, adrenal
and thyroid gland.
- with permanent alopecia, severe
disfigurement of face and hands
- major component of the immune
polyendocinopathy syndrome (mutation in
the autoimmune regulator gene {AIRE} on
chrom 21q22.3
- childhood : autosomal dominant or
recessive d/o, or assoc with JOB’s
Syndrome
- adult: assoc with thymoma
4.Vulvovaginal thrush
-causes pruritus, discharge and pain on
intercourse or urination
 - speculum exam: inflamed mucosa, thin
exudate, often with white curds
5. Esophageal Candidiasis
- often asymptomatic
- can cause substernal pain or a sense of
obstruction on swallowing. (mistaken for
pain of cardiac origin)
- lesions: distal 3rd of esophagus
- endoscopy : areas of redness and edema,
focal white patches or ulcers
-biopsy and brushing – required for dx and
detection of concomitant infxns (HSV with
hema malignancies and CMV infxn in AIDS
px)
- hema dissemination : neutropenic px
B. DEEPLY INVASIVE CANDIDIASIS
1.Obstructed Urinary tract – cystitis, pyelitis,
or renal papillary necrosis.
2.Candidemia – when a colonized Urinary tract
is operated or instrumented
- may clear when the catheter is removed
- focal seeding of the retina can take place
even if candidemia clears and the px becomes
afebrile
- unilateral or bilateral small white retinal
exudates (w/in 2 weeks of the onset of
candidemia)
 vitreous humor becomes cloudy, and
the px notices blurring, ocular pain, or
scotoma
 retinal detachment, vitreous abcess
and extension to the anterior chamber
 retinal lesions (in 10% of neutropenic
px) – given systemic antifungal tx
3. Hepatosplenic Candidiasis or Chronic
Disseminated Candidiasis
- px with acute leukemia who are recovering
from profound neutropenia.
- originates from intestinal seeding of the portal
or venous circulation .
- fever, elev. Alkaline phosphatase, multiple
small abcesses on US, MRI and CT of the liver,
spleen, or kidney.
Acute Candidemia in neutropenic px : small
erythematous papules may appear in the skin,
(figure 187-1 page 1186 in Harrison’s), this can
develop necrotic center.
Punch biopsy – to distinguish it from Malassezia
folliculitis (similar- appearing but benign
condition, involves the cape area of the chest or
the extremities of a sweaty febrile px)
4.Candida pneumonia – tiny pulmonary nodules
5. Candida endocardidis – previously damaged
or prosthetic heart valves. Emboli to large
arteries, such as iliac or femoral artery.
6. Candida endophthalmitis and purulent
folliculitis , with vertebral osteomyelitis
- caused by IV injection of impure brown heroin
7. Indolent Arthritis – knee in px who have
received Glucocorticoid injections into the joint
of immunocompromised px, Low BW neonates.;
also from infected prosthetic joints
8. Subacute peritonitis – from a perforated
viscus or from a peritoneal dialysis catheter.
9. Brain abcess or chronic meningitis –
hematogenous dissemination.
DIAGNOSIS
1. Procedure of choice: demonstration of
pseudohyphae on wet smear with confirmation
by culture.
Scrapings for the smear : from skin, nails and
oral or vaginal mucosa.
Culture of urine, sputum, existing abd. Drains,
endotracheal aspirates or the vagina – NOT
DIAGNOSTIC
Recovery of Candida species from multiple
superficial sites – RISK FACTOR FOR DEEPLY
INVASIVE CANDIDIASIS (px with prolonged
neutropenia or complicated abd surgery.)
2.Histologic section of biopsies or culture of CSF,
blood or joint fluid, CT guided aspirates or
surgical specimens – dx of deeper lesions
3. Blood cultures – dx of Candida endocarditis
and IV catheter-induced sepsis
serologic tests for antibody or antigen –NOT
USEFUL
PROPHYLAXIS
1. Fluconazole 400 mg daily – preventing deeply
invasive candidiasis in some high risk post-op px.
2. Fluconazole 3-6mg/kg or Itraconazole
solution 5mg/kg – recommended daily oral dose
• Definition of groups at sufficient risk to
benefit from fluconazole depends on the ICU
but likely includes px undergoing repeat,
complicated abdominal surgery and patients
who are both heavily colonized with Candida
 and immunosuppressed at the time of
complicated surgery.
• The presence of IV Catheters, prolonged TREATMENT
stays in the ICU and renal failure increase Table 187-1 page 1187
the risk of candidemia.

Type of disease Preferred tx Alternatives

MUCOCUTA-NEOUS
Cutaneous Topical Azole Topical Nystatin
Vulvovaginal Azole cream or suppository or Nystatin suppository
oral fluconazole (150 mg)
Oropharyn-geal Clotrimazole troche or Nystatin susp; for azole unresponsive
fluconazole tablet (100mg/d ) or disease: Caspofungin (50mg/d) or
Itraconazole (200 mg/d) amphotericin B (0.3-0.5 mg/kg/d)
Esophageal Fluconazole tablet (100-200 For azole unresponsive disease:
mg/d) or Itraconazole solution Caspofungin (70mg once,then 50 mg/d) or
(200 mg/d) amphotericin B (0.3-0.5 mg/kg/d)
DEEPLY INVASIVE
Nonneutropenic Fluconazole (400 mg/d) or
Anphotericin Bb or Caspofungin
(70mg once,then 50 mg/d)
Neutropenic Anphotericin Bb

a Removal of foreign bodies is critical, including plastic catheters for IV fluids, peritoneal dialysis or CSF shunts,
prosthetic cardiac valves , and prosthetic joints

Bb The dosage of Amphotericin B for eeply invasive candidiasis is 0.5mg/kg daily, although initial doses of 0.7 – 1.0
mg/kg daily may be appropriate for severely immunocompromised patients. Amphotericin B lipid complex and
liposomal amphotericin B are given as 5 mg/kg daily.
__________________________________________________________________________________________________

Other tx: dose to 800 mg), use Amphotericin B

or Caspofungin
1. Bladder thrush – bladder irrigations
with Amphotericin B (50 ug/ml for 5 6. Candida endophthalmitis – IV
days). If no baldder catheter is in Amphotericin B with or w/o
place, Oral Fluconazole can be used to Flucytosine
control Candiduria. ( most px w/
candiduria – do not have unrelieved 7. Candida vitreous abcess – pars plana
uri. Tract obstruction and do not vitrectomy, injection of amphotericin
benefit from therapy.) B into vitreous humor

2. Candida endocarditis on prosthetic or 8. Candida osteolmyelitis – debridement,

native valves usually relapses unless fungal therapy
the valve is replaced. Long term
fluconazole- prevent recurrences after
valve replacement.

3. Candidemia from suppurative phlebitis

of a peripheral vein may not respond princez_alen
until the infected portion of the vein is
excised. Therapy for candidemia is
continued for 2 weeks after the px
becomes afebrile.

4. C. krusei and C. inconspicua – resistant

to Fluconazole in vitro

5. C. glabrata – exhibits intermediate

susceptibility to Fluconazole (increase