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For further information, see CMDT Part 36-02: 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 ...

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