Anda di halaman 1dari 3

187. CANDIDIASIS 7.

Secretions from the mouth, rectum or


vagina; drainage from surgical wounds
Etiologic agents: Candida albicans, new or tracheostomy sites – contaminate
species: C. dubliniensis, C. tropicalis, C. the hub or skin site of a catheter in an
parapsilosis, C. guilliermondii, C. glabrata umbilical or central vein.
(formerly Torulopsis glabrata), C. krusei
8. IV drug abuse or 3rd degree burns
th th
- 4 or 5 most common cause of nosocomial 9. compromised host defense in very low
bloodstream infections(through intravascular birthweight neonates, neutorpenia or
catheters) in the US. glucocorticoid therapy once candida
- causes lethal septic shock passed the integumentary barrier.
- are commensals of humans (mouth, stool and 10. hematogenous seeding in the retina,
vagina) kidney spleen and liver.
- grow rapidly at 25-37 ‘C on simple media as
oval, budding cells CLINICAL MANIFESTATIONS:
- in tissue, both yeasts and pseudohyphae are
present A. MUCOCUTANEOUS CANDIDIASIS

Pseudohyphae – elongated branching structures 1. Oral thrush


with constrictions at the septae. - discrete and confluent adherent white
Budding yeasts – separate structures or as plaques on the oral and pharyngeal mucosa,
projections from pseudohyphae. (mouth and tongue)
- painless lesions, but with painful fissuring
at the corners of the mouth.
Species: - raises possibility of acute HIV infection
1. C. glabrata – no true hyphae or especially when CD4+ cell count falls,
pseudohyphae in vitro or in infected esophageal thrush (CD4+ counts <50/uL)
tissue. - independent risk factor for vulvovaginal
2. C. albicans and C. dubliniensis – can thrush.
form germ tubes in serum, can form
2. Cutaneous candidiasis
chlamydospores (thick walled large
- red macerated intertriginous areas,
spores) in special culture medium.
paronychia, balanitis, or pruritus ani.
- candidiasis of the perineal and scrotal
PATHOGENESIS:
skin (discrete pustular lesions on inner
aspects of the thighs.)
1. Deeply invasive candidiasis is often
preceded by increased colonization of 3. Chronic Mucocutaneous Candidiasis
the mouth,vagina,stool with Candida (CMC) or Candidal granuloma
due to broad-spectrum antibiotic - circumscribed hyperkeratotic skin lesions,
therapy. Local and systemic factors crumbling dystrophic nails, partial alopecia
favors infection. in areas of scalp lesions, and both oral and
2. Oropahryngeal thrush- occur in vaginal thrush
neonates and in patients with DM, HIV - chronic ringworm, dental dysplasia, and
or dentures. hypofunction of the parathyroid, adrenal
3. Vulvovalginal candidiasis- 3rd trimester and thyroid gland.
- with permanent alopecia, severe
of pregnancy
disfigurement of face and hands
4. candida from the perineum can enter - major component of the immune
the urinary tract via an indwelling polyendocinopathy syndrome (mutation in
bladder catheter. the autoimmune regulator gene {AIRE} on
5. Cutaneous candidiasis – often involves chrom 21q22.3
macerated skin: diapered area of - childhood : autosomal dominant or
infants, under pendulous breasts, hands recessive d/o, or assoc with JOB’s
constantly in water or covered by Syndrome
occlusive gloves. - adult: assoc with thymoma
6. Deep tissue candidiasis – eg.
Perforation of the GIT through trauma, 4.Vulvovaginal thrush
surgery or peptic ulceration or by -causes pruritus, discharge and pain on
mucosal damage due to cytotoxic intercourse or urination
agents (cancer chemotherapy)
- speculum exam: inflamed mucosa, thin
exudate, often with white curds 5. Candida endocardidis – previously damaged
or prosthetic heart valves. Emboli to large
5. Esophageal Candidiasis arteries, such as iliac or femoral artery.
- often asymptomatic
- can cause substernal pain or a sense of 6. Candida endophthalmitis and purulent
obstruction on swallowing. (mistaken for folliculitis , with vertebral osteomyelitis
pain of cardiac origin) - caused by IV injection of impure brown heroin
- lesions: distal 3rd of esophagus
- endoscopy : areas of redness and edema, 7. Indolent Arthritis – knee in px who have
focal white patches or ulcers received Glucocorticoid injections into the joint
-biopsy and brushing – required for dx and of immunocompromised px, Low BW neonates.;
detection of concomitant infxns (HSV with also from infected prosthetic joints
hema malignancies and CMV infxn in AIDS
px) 8. Subacute peritonitis – from a perforated
- hema dissemination : neutropenic px viscus or from a peritoneal dialysis catheter.

B. DEEPLY INVASIVE CANDIDIASIS 9. Brain abcess or chronic meningitis –


hematogenous dissemination.
1.Obstructed Urinary tract – cystitis, pyelitis,
or renal papillary necrosis.
DIAGNOSIS
2.Candidemia – when a colonized Urinary tract
is operated or instrumented 1. Procedure of choice: demonstration of
- may clear when the catheter is removed pseudohyphae on wet smear with confirmation
- focal seeding of the retina can take place by culture.
even if candidemia clears and the px becomes
afebrile Scrapings for the smear : from skin, nails and
- unilateral or bilateral small white retinal oral or vaginal mucosa.
exudates (w/in 2 weeks of the onset of
candidemia) Culture of urine, sputum, existing abd. Drains,
endotracheal aspirates or the vagina – NOT
 vitreous humor becomes cloudy, and DIAGNOSTIC
the px notices blurring, ocular pain, or
scotoma Recovery of Candida species from multiple
 retinal detachment, vitreous abcess superficial sites – RISK FACTOR FOR DEEPLY
and extension to the anterior chamber INVASIVE CANDIDIASIS (px with prolonged
 retinal lesions (in 10% of neutropenic neutropenia or complicated abd surgery.)
px) – given systemic antifungal tx
2.Histologic section of biopsies or culture of CSF,
blood or joint fluid, CT guided aspirates or
3. Hepatosplenic Candidiasis or Chronic surgical specimens – dx of deeper lesions
Disseminated Candidiasis
- px with acute leukemia who are recovering 3. Blood cultures – dx of Candida endocarditis
from profound neutropenia. and IV catheter-induced sepsis
- originates from intestinal seeding of the portal
or venous circulation . serologic tests for antibody or antigen –NOT
- fever, elev. Alkaline phosphatase, multiple USEFUL
small abcesses on US, MRI and CT of the liver,
spleen, or kidney.
PROPHYLAXIS
Acute Candidemia in neutropenic px : small 1. Fluconazole 400 mg daily – preventing deeply
erythematous papules may appear in the skin, invasive candidiasis in some high risk post-op px.
(figure 187-1 page 1186 in Harrison’s), this can 2. Fluconazole 3-6mg/kg or Itraconazole
develop necrotic center. solution 5mg/kg – recommended daily oral dose
Punch biopsy – to distinguish it from Malassezia
folliculitis (similar- appearing but benign • Definition of groups at sufficient risk to
condition, involves the cape area of the chest or benefit from fluconazole depends on the ICU
but likely includes px undergoing repeat,
the extremities of a sweaty febrile px)
complicated abdominal surgery and patients
who are both heavily colonized with Candida
4.Candida pneumonia – tiny pulmonary nodules
and immunosuppressed at the time of
complicated surgery.
• The presence of IV Catheters, prolonged TREATMENT
stays in the ICU and renal failure increase Table 187-1 page 1187
the risk of candidemia.

Type of disease Preferred tx Alternatives


MUCOCUTA-NEOUS
Cutaneous Topical Azole Topical Nystatin
Vulvovaginal Azole cream or suppository or Nystatin suppository
oral fluconazole (150 mg)
Oropharyn-geal Clotrimazole troche or Nystatin susp; for azole unresponsive
fluconazole tablet (100mg/d ) or disease: Caspofungin (50mg/d) or
Itraconazole (200 mg/d) amphotericin B (0.3-0.5 mg/kg/d)
Esophageal Fluconazole tablet (100-200 For azole unresponsive disease:
mg/d) or Itraconazole solution Caspofungin (70mg once,then 50 mg/d) or
(200 mg/d) amphotericin B (0.3-0.5 mg/kg/d)
DEEPLY INVASIVE
Nonneutropenic Fluconazole (400 mg/d) or
Anphotericin Bb or Caspofungin
(70mg once,then 50 mg/d)
Neutropenic Anphotericin Bb

a Removal of foreign bodies is critical, including plastic catheters for IV fluids, peritoneal dialysis or CSF shunts,
prosthetic cardiac valves , and prosthetic joints

Bb The dosage of Amphotericin B for eeply invasive candidiasis is 0.5mg/kg daily, although initial doses of 0.7 – 1.0
mg/kg daily may be appropriate for severely immunocompromised patients. Amphotericin B lipid complex and
liposomal amphotericin B are given as 5 mg/kg daily.
__________________________________________________________________________________________________

Other tx: dose to 800 mg), use Amphotericin B


or Caspofungin
1. Bladder thrush – bladder irrigations
with Amphotericin B (50 ug/ml for 5 6. Candida endophthalmitis – IV
days). If no baldder catheter is in Amphotericin B with or w/o
place, Oral Fluconazole can be used to Flucytosine
control Candiduria. ( most px w/
candiduria – do not have unrelieved 7. Candida vitreous abcess – pars plana
uri. Tract obstruction and do not vitrectomy, injection of amphotericin
benefit from therapy.) B into vitreous humor

2. Candida endocarditis on prosthetic or 8. Candida osteolmyelitis – debridement,


native valves usually relapses unless fungal therapy
the valve is replaced. Long term
fluconazole- prevent recurrences after
valve replacement.

3. Candidemia from suppurative phlebitis


of a peripheral vein may not respond princez_alen
until the infected portion of the vein is
excised. Therapy for candidemia is
continued for 2 weeks after the px
becomes afebrile.

4. C. krusei and C. inconspicua – resistant


to Fluconazole in vitro

5. C. glabrata – exhibits intermediate


susceptibility to Fluconazole (increase