Candidiasis

Candida is an almost ubiquitous commensal found on skin, orally and genital tract. Invasive disease and dissemination can be subtle in someone with many other problems e.g. On an ITU, multiple and broad spectrum antibiotics, Central lines, ventilated or Immunosuppressed. Be vigilant especially if candida is found in a sterile site e.g. blood culture. Take expert advice about the early use of systemic antifungals.

About

• Opportunistic infection due to Candida albicans
• Other Candidal species can produce all of the clinical syndromes,
• Drug users who inject are at risk
• Endophthalmitis is an early signs of disseminated infection

Aetiology

• Candida species are ubiquitous fungi
• Commonest fungi causing human disease

Clinical

• Localised mucosal infections involving oropharyngeal or vaginal colonisation and infection. Redraw patches. "Thrush". Seen with new dentures, diabetics, malignancy, xerostomia, HIV, broad-spectrum antibiotics. Immunosuppressed may also have odynophagia due to oesophageal disease (AIDS-defining). Any infection should always warrant testing for diabetes.
• Acute Disseminated: Due to instrumentation and Immunocompromised hosts e.g. on an ITU/ Risks include Central line catheter, recent abdominal surgery, broad-spectrum antibiotics, parenteral nutrition. Affects eyes with retinal cotton wool spots, endophthalmitis
• Chronic Disseminated (Hepatosplenic): Neutropenic patient with a fever despite wide spectrum antibiotics often with a central line. Symptoms persist even when neutrophils normalise. Parenchymal involvement of other organs such as spleen, liver, kidneys seen on abdominal imaging.
• Chronic mucocutaneous candidiasis (some have polyglandular autoimmune syndrome type I) - severe thrush, nail infection and vaginitis
• Spread can cause can lead to pyelonephritis, endocarditis ( fever, changing or new heart murmurs), meningitis, osteomyelitis

Investigations

• Mucocutaneous disease - scrapings or smears obtained from skin, nails, or oral or vaginal mucosa are examined under the microscope for hyphae, pseudohyphae, or budding yeast cells
• Urine cultures may show candidal growth
• Positive blood cultures for Candida spp should never be ignored
• ↑ alkaline phosphatase levels with hepatosplenic disease
• CXR - may show bronchopneumonia which may be due to candida
• OGD - may show oesophageal candida
• CT/Abdo USS - may show solid organ abscesses
• Echo - may show fungal endocarditis

Management

• Exclude/manage diabetes. Removal of indwelling catheters or other sources
• Mucocutaneous disease - Topical clotrimazole (Canesten) cream 1% applied topically usually for 14 days. Nystatin. Vaginal pessaries are available for vaginal infection. For ongoing infection consider Fluconazole (Diflucan) may also be used orally for candidal infection both vaginal, cutaneous and in those who are neutropenic. An alternative is itraconazole, terbinafine and griseofulvin.
• Systemic candidiasis - remove catheters, Amphotericin B or Lipid amphotericin IV may be used or Fluconazole IV for 14 days. Expert microbiological or Infectious diseases help.