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For further information, see CMDT Part 38-02: 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 antibiotics

    • 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

  • Vulvovaginal candidiasis

    • Acute vulvar pruritus

    • Burning vaginal discharge

    • Dyspareunia

  • Esophageal candidiasis

    • Substernal odynophagia, gastroesophageal reflux, or nausea without substernal pain

    • Oral candidiasis may not be present

  • 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

  • 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

  • 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 while Candida species are often isolated from mucosal sites in the absence of invasive disease

    • Consecutively positive 1,3-β-D-glucan results can guide empiric therapy in high-risk patients even in the absence of positive blood cultures

    • Hepatosplenic candidiasis: 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

  • Esophageal candidiasis best confirmed by endoscopy with biopsy and culture

Imaging Studies

  • Usually normal in invasive disease

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

TREATMENT

Medications

  • Vulvovaginal candidiasis

    • Fluconazole

      • 150 mg orally once has equivalent efficacy to topical treatments with better patient acceptance

      • 150 mg orally once weekly helps prevent disease recurrence

    • Clotrimazole 100 mg vaginally once daily for 7 days, or miconazole 200 mg vaginally once daily for 3 days

    • In azole-resistant disease, alternative therapies (such as intravaginal boric acid) may be ...

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