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Key Features

Essentials of Diagnosis

  • Common normal flora and opportunistic pathogen

  • Oral, vaginal or gastrointestinal mucosal disease, manifesting as oral thrush, vaginitis or esophagitis

  • Fungemia arising from intravenous catheter or 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

General Considerations

  • Cutaneous and oral lesions

  • Persistent oral or vaginal candidiasis should arouse suspicion of HIV infection

  • Fungemia in immunocompromised patients receiving fluconazole prophylaxis is increasingly due to imidazole-resistant Candida albicans or non-albicans species

Demographics

  • Mucocutaneous disease occurs with cellular immunodeficiency

  • Vulvovaginal candidiasis occurs with

    • Pregnancy

    • Uncontrolled diabetes mellitus

    • Broad-spectrum antibiotics

    • Corticosteroids

    • HIV

  • Invasive candidiasis occurs with

    • Prolonged neutropenia

    • Recent abdominal surgery

    • Broad-spectrum antibiotics

    • Intravascular catheters (especially for total parenteral nutrition)

    • Kidney disease

  • Candidal endocarditis occurs with repeated inoculation with injection drug use and direct inoculation during valvular heart surgery causing infection of prosthetic valves in first few months following surgery

Clinical Findings

Symptoms and Signs

  • Esophageal candidiasis

    • Substernal odynophagia, gastroesophageal reflux, or nausea without substernal pain

    • Oral candidiasis may not be present

  • Vulvovaginal candidiasis

    • Acute vulvar pruritus

    • Burning vaginal discharge

    • Dyspareunia

  • Invasive candidiasis

    • Candidemia without deep seated infection

    • Candidemia with deep seated infection (typically eyes, kidney, or abdomen)

    • Deep-seated candidiasis in the absence of bloodstream infection

    • Clinical presentation of candidemia ranges from minimal fever to septic shock

  • Candidal funguria

    • Asymptomatic and typically represents specimen contamination or bladder colonization

    • However, signs and symptoms of true Candida urinary tract infections (UTIs) are indistinguishable from bacterial UTIs and can include urgency, hesitancy, fever, chills or flank pain

  • Hepatosplenic candidiasis: fever and variable abdominal pain weeks after chemotherapy for hematologic cancers, when neutrophil counts have recovered

Differential Diagnosis

  • Esophageal candidiasis

    • Herpes simplex virus (HSV) esophagitis

    • Cytomegalovirus (CMV) esophagitis

    • Varicella-zoster virus esophagitis

    • Pill esophagitis, eg, nonsteroidal anti-inflammatory drugs, bisphosphonates, KCl

    • Gastroesophageal reflux disease

  • Vulvovaginal candidiasis

    • Bacterial vaginosis

    • Trichomonas vaginitis

    • Normal vaginal discharge

  • Candidemia

    • Histoplasmosis

    • Coccidioidomycosis

    • Tuberculosis

    • Bacterial endocarditis

    • Aspergillosis

Diagnosis

Laboratory Tests

  • Invasive candidiasis

    • Blood cultures are positive in only about 50% of cases

    • While candidemia can be benign (transient, eg, catheter-related), positive blood cultures are sufficient to initiate treatment for disseminated disease

    • Consecutively positive 1,3-β-D-glucan results may be used to guide empiric therapy in high-risk patients even in the absence of positive blood cultures

    • Positive mucosal cultures (urine, sputum) may be a clue to underlying disseminated candidiasis

  • Hepatosplenic candidiasis

    • Can occur following prolonged neutropenia in patients with underlying hematologic cancers but this entity is less common in the era of widespread antifungal prophylaxis

    • Typically, fever and variable abdominal pain present weeks after chemotherapy, when neutrophil counts have recovered

    • Blood cultures are generally negative

  • Candidal endocarditis: diagnosis requires either positive culture from ...

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