Candidiasis

Key Features

Essentials of Diagnosis

• Common normal flora but opportunistic pathogen

• Typically mucosal disease, particularly vaginitis, oral thrush, and esophagitis

• Persistent, unexplained oral or vaginal candidiasis: check for HIV or diabetes mellitus

• (1,3)-beta-D-glucan results may be positive in candidemia even when blood cultures are negative

General Considerations

• Candida albicans can be cultured from the mouth, vagina, and feces of most people

• Cellular immunodeficiency predisposes to mucocutaneous disease

• Risk factors for vulvovaginal candidiasis

  • Pregnancy, uncontrolled diabetes mellitus, broad-spectrum antimicrobial treatment, corticosteroid use, and HIV infection

  • Symptoms include

    • Acute vulvar pruritus

    • Burning vaginal discharge

    • Dyspareunia

• Risk factors for invasive candidiasis

  • Prolonged neutropenia

  • Recent abdominal surgery

  • Broad-spectrum antibiotics

  • Kidney disease

  • Intravascular catheters (especially for total parenteral nutrition)

Demographics

• Vulvovaginal candidiasis occurs in an estimated 75% of women during their lifetime

• Esophageal involvement is the most frequent type of significant mucosal disease

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 (ie, hepatosplenic candidiasis)

  • 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

• Candidal endocarditis

  • Rare

  • Affects patients with prosthetic heart valves or prolonged candidemia, such as with indwelling catheters

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

• Esophageal candidiasis: Best confirmed by endoscopy with biopsy and culture

• 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-beta-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 ...