Diagnosis

Candidiasis

Etiology

Cause (>200 species exist) [s9k]

• Candida albicans (50-60%)

• Candida glabrata (15-20%) --> 15-25% are fluconazole-resistant

• Candida parapsilosis (10-20%)

• Candida tropicalis (6-12%)

• Candida krusei (1-3%)

• Candida kefyr (< 5%)

• Candida guilliermondi (< 5%)

• Candida lusitaniae (< 5%)

• Candida dubliniensis (HIV)

• Non-candida species: Aspergillus and Cryptococcus species

Pathophysiology [qaz][s9k]

1. Yeast fungi is a part of the normal flora in the GI tract and vagina (13% of the women)

2. Fungi causes disease in the immunocompromised and critical ill hospitalized patients

3. Invasive candidiasis is a leading cause of mycosis-associated mortality

4. Virulence factors:

   • Surface adherence molecules

   • Acid proteases and phospholipases that involve penetration and damage

   • Ability to convert to a hyphal form

Risk factors

• Intensive Care Unit (36% of candidaemia)

• Antibiotics (anti-anaerobic agents) [og4]

• Corticosteroids

• Chemotherapeutics

• Immunocompromised host (HIV, transplantation, Diabetes mellitus)

• Trauma/burns

• Cancer

• Catheters

• Surgery (abdominal surgery with bowel resection or anastomotic leak)

• Renal failure

• Mechanical ventilation

• Total parenteral nutrition [og4]

Clinical presentations - oral cavity, vagina, penis, GI, respiratory, systemic

1. Mucocutaneous: intertrigo, diaper dermatitis, erosio interdigitalis blastomycetica, perianal dermatitis, candidal balanitis, paronychia

2. Oropharyngeal: oral thrush

3. Esophageal: esophagitis

4. Nonesophageal gastrointestinal

5. Genitourinary tract: urinary tract infection, vulvovaginitis, balanitis

6. Respiratory tract: laryngitis, tracheobronchitis, pneumonia

7. Systemic: candidemia, endocarditis, myocarditis, pericarditis, endophthalmitis, renal candidiasis, CNS infections, arthritis

Epidemiology

Incidence per 100.000 [qaz][woq][fvp]

Approach

• Microscopy with KOH

• Biopsy

• Culture (respiratory, sputum, blood, urin)

• Endoscopy

• Bronchoscopy

• CT abdomen

• Echocardiography

Treatment

Guidelines by the Infectious Disease Society of America: [foc]

1. Candidemia and invasive candiasis

   --> Echinocandins (Caspofungin, Micafungin, Anidulafungin)

   --> transition to fluconazole/amphotericin B if clinically stable

2. Localized cutaneous candidiasis --> clotrimazole, econazole, ciclopirox, miconazole, ketoconazole, nystatin

3. Extensive cutaneous infection or immunocompromised patients --> systemic antifungal therapy

4. Candida onychomycosis --> oral itraconazole

5. Paronychia --> fluconazole or itraconazole

6. Oropharyngeal candidiasis --> topical antifungal agents (nystatin, clotrimazole, amphotericin B oral suspension) or systemic oral azoles (fluconazole, itraconazole, or posaconazole)

7. Candida esophagitis --> systemic therapy with fluconazole

8. Vulvovaginal candidiasis --> topical antifungal agents or oral fluconazole

9. Candida cystitis --> fluconazole

10. Renal candidiasis --> systemic fluconazole

11. Chronic mucocutaneous candidiasis --> oral fluconazole

12. Hepatosplenic candidiasis -->Induction with amphotericin B followed by fluconazole

13. Respiratory tract candidiasis --> treated as disseminated candidiasis

14. Surgery:

    • Abscess formation --> surgical drainage + antifungal therapy

    • Prosthetic infection --> removal of the prosthesis

    • Endocarditis --> Valve replacement surgery

    • Fungal endophthalmitis --> vitrectomy

Differential diagnoses

Abdominal abscess, Aspergillosis, Cryptococcosis, Eczema, Folliculitis, Impetigo, Intertrigo, Onychomycosis, Palmo+C790antar pustolosis, Psoriasis, Sepsis, Tinea