Overview Candida species are considered to be part of the normal microbiota in the gastrointestinal and genitourinary tracts of humans, they have the propensity to invade and cause disease when an imbalance is created in the ecologic niche in which these organisms usually exist
Mucocutaneous candida Infection
Oropharyngeal candidiasis (thrush)
- Risk factors: immunosuppressed, antibiotics, dentures
- Symptoms: cottony feeling in the mouth, loss of taste, and sometimes pain on eating and swallowing.
- Diagnosis: Lesion scarping with a tongue depressor → Gram stain or potassium hydroxide (KOH) → budding yeasts with or without pseudohyphae are seen
- Risk factors: immunosuppressed specifically HIV infected person (AIDs defining illness) and haematologic malignancies
- Symptoms: dynophagia, or pain on swallowing.
- Diagnosis: Endoscopy showing white mucosal plaque-like lesions + biopsy confirming presence of yeast and pseudohyphae invading mucosal cells.
Vulvovaginal candidiasis (most common cause of mucosal candida infection)
- Risk factors: increased estrogen levels, such as oral contraceptive use and pregnancy. Antibiotics, glucocorticoids, diabetes mellitus, HIV infection, intrauterine devices, and diaphragm
- Symptoms: itching and discharge. Dyspareunia, dysuria, and vaginal irritation also may be present.
- Physical examination: vulvar erythema and swelling and vaginal erythema and discharge, which is classically white and curd-like but may be watery
- Diagnosis: Usually clinical but confirmed by wet mount of KOH preperation of vaginal secretions showing budding yeast, with or without pseudohyphae.
Balanitis can present as white patches on the penis in association with severe burning and itching (picture 5). The infection can also spread to the thighs, gluteal folds, buttocks, and scrotum. (See “Balanitis in adults”.)
Chronic mucocutaneous candidiasis — Chronic mucocutaneous candidiasis is a rare syndrome that usually has its onset in childhood. Some patients have autosomal recessive polyglandular autoimmune syndrome type I, which is also referred to as the autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) syndrome. (See “Causes of primary adrenal insufficiency (Addison’s disease)”, section on ‘Polyglandular autoimmune syndrome type 1’.)
The clinical manifestations of candidiasis in these patients include severe, recurrent thrush, onychomycosis, vaginitis, and chronic skin lesions. The skin lesions may assume a hyperkeratotic, crusted appearance on the face, scalp, and hands (picture 6). Visceral invasion is rare. (See “Chronic mucocutaneous candidiasis”.)
Mastitis — Lactating women with injured nipples are at increased risk for developing skin or breast infections, including candidal infections. The management of such infections is discussed in detail separately
Candidaemia refers to the presence of Candida species in the blood. Immunocompromised hosts and patients in intensive care units are at the highest risk of candidemia
Risk factors – Immunosuppressed
- Haematologic malignancy
- Solid organ or hematopoietic cell transplants
- Chemotherapeutic agents
Risk factors – Intensive Care Unit (critically unwell patients)
- Central venous catheters
- Total parenteral nutrition
- Broad-spectrum antibiotics
- Acute renal failure (requiring hemodialysis)
- Prior surgery, particularly abdominal surgery
- Gastrointestinal tract perforations and anastomotic leaks
Hepatosplenic candidiasis (chronic disseminated candidiasis)
Associated with haematologic malignancies who have just recovered from an episode of neutropenia
- Persistent fevers following recent neutropenic episode
- Nausea, vomiting, anorexia
- Right upper quadrant pain
- Elevated alkaline phosphatase
- Imaging showing evidence of microabscess in the liver and kidney