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ESSENTIALS OF DIAGNOSIS

  • Common normal flora but opportunistic pathogen.

  • Mucosal disease, particularly vaginitis and esophagitis.

  • Risk factors for fungemia: neutropenia, intravenous catheter, abdominal surgery, total parenteral nutrition, kidney disease, broad-spectrum antibiotics.

GENERAL CONSIDERATIONS

Candida albicans can be cultured from the mouth, vagina, and feces of most people. Cutaneous and oral lesions are discussed in Chapters 6-14 and 8-17, 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.

CLINICAL FINDINGS

A. Mucosal Candidiasis

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.

B. Candidal Funguria

Most cases of candidal funguria are asymptomatic and represent specimen contamination or bladder colonization. However, symptoms and signs of true Candida urinary tract infections are indistinguishable from bacterial urinary tract infections and can include urgency, hesitancy, fever, chills, or flank pain.

C. Invasive Candidiasis

Invasive candidiasis can be (1) candidemia (bloodstream infection) without deep-seated infection; (2) candidemia with deep-seated infection (typically eyes, kidney, or abdomen); and (3) deep-seated candidiasis in the absence of bloodstream infection. Varying ratios of these clinical entities depends on the predominating risk factors for affected patients (ie, neutropenia, dialysis, postsurgical). The clinical presentation of candidemia varies from minimal fever to septic shock that can resemble a severe bacterial infection. The diagnosis of invasive Candida infection is problematic because Candida species are often isolated from mucosal sites in the absence of invasive disease while blood cultures are positive only 50% of the time in invasive infection. Consecutively positive (1,3)-beta-D-glucan results may be used to guide empiric therapy in high-risk patients even in the absence of positive blood cultures.

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.

D. Candidal Endocarditis

Candidal endocarditis is a rare infection affecting patients with prosthetic heart valves or prolonged candidemia, such as with indwelling catheters. The diagnosis is established definitively by culturing Candida from emboli or ...

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