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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 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


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



  • 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 ...

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