Candidiasis

Key Features

Essentials of Diagnosis

• Common normal flora but opportunistic pathogen

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

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

• (1,3)-β-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

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

• Risk factors for invasive candidiasis include

  • Prolonged neutropenia

  • Abdominal surgery

  • Broad-spectrum antibiotic therapy

  • Corticosteroids

  • Kidney disease

  • Presence of intravascular catheters

• Although C albicans remains the most common cause of both mucocutaneous and systemic candidiasis, non-albicans strains are of considerable importance in certain contexts, and may impact therapy owing to antifungal resistance

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

• Candidal endocarditis

  • Rare

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

Diagnosis

Laboratory Tests

• Invasive candidiasis

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

  • 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

• 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 is established definitively by culturing Candida from emboli or from vegetations at the time of valve replacement

Imaging Studies

• Usually normal in invasive disease

• Hepatosplenic candidiasis: hepatosplenic abscesses may be seen on abdominal imaging

Treatment

Medications

• Esophageal candidiasis

  • Fluconazole, 200–400 mg daily for 10–14 days

  • For patients unable to tolerate oral therapy options include

    • Intravenous fluconazole, 400 mg daily

    • An echinocandin

  • For patients with fluconazole-refractory disease options include

    • Oral itraconazole solution, 200 mg ...