Fungal infections have assumed an increasingly important role as use of broad-spectrum antimicrobial agents has increased and the number of immunodeficient patients has grown. Some pathogens (eg, Cryptococcus, Candida, Pneumocystis, Fusarium) rarely cause serious disease in normal hosts. Other endemic fungi (eg, Histoplasma, Coccidioides, Paracoccidioides) commonly cause disease in normal hosts but tend to be more aggressive in immunocompromised ones. Superficial mycoses are discussed in Chapter 6.
Successful management of most systemic fungal infections requires knowledge of the natural history of these diseases as well as familiarity with the unique pharmacokinetics, adverse effects, and drug interactions of the various therapeutic agents. Furthermore, most affected individuals usually have significant underlying illnesses. Consequently, clinicians with extensive experience in the management of these disorders should be routinely consulted.
ESSENTIALS OF DIAGNOSIS
Common normal flora but opportunistic pathogen.
Gastrointestinal mucosal disease, particularly esophagitis, most common.
Fungemia, arising from an intravenous catheter or the gastrointestinal tract occurs in patients who have sustained cutaneous or mucosal injury, undergone instrumentation, are receiving total parenteral nutrition, have kidney disease, or have received broad-spectrum antibiotics.
Candida albicans can be cultured from the mouth, vagina, and feces of most people. Cutaneous and oral lesions are discussed in Chapters 6 and 8, respectively. The risk factors for invasive candidiasis include prolonged neutropenia, recent abdominal surgery, broad-spectrum antibiotic therapy, kidney disease, and the presence of intravascular catheters (especially when providing total parenteral nutrition). Cellular immunodeficiency predisposes to mucocutaneous disease. When no other underlying cause is found, persistent oral or vaginal candidiasis should arouse a suspicion of HIV infection.
Esophageal involvement is the most frequent type of significant mucosal disease. Presenting symptoms include substernal odynophagia, gastroesophageal reflux, or nausea without substernal pain. Oral candidiasis, though often associated, is not invariably present. Diagnosis is best confirmed by endoscopy with biopsy and culture.
Vulvovaginal candidiasis occurs in an estimated 75% of women during their lifetime. Risk factors include pregnancy, uncontrolled diabetes mellitus, broad-spectrum antimicrobial treatment, corticosteroid use, and HIV infection. Symptoms include acute vulvar pruritus, burning vaginal discharge, and dyspareunia.
Most cases of candidal funguria are asymptomatic and represent specimen contamination or bladder colonization. However, signs and symptoms of true Candida urinary tract infections are indistinguishable from bacterial urinary tract infections and can include urgency, hesitancy, fever, chills, or flank pain.
C. Disseminated Candidiasis
The clinical presentation of disseminated candidiasis varies from minimal fever to septic shock that can resemble a severe bacterial infection. Occasionally, patients with candidiasis will have skin lesions ranging from pustules to large nodules. Organs that may be involved in disseminated candidiasis include the liver, spleen, kidney, eyes, and heart. The diagnosis of ...