eMedicine Specialties > Emergency Medicine > Infectious Diseases

Candidiasis: Differential Diagnoses & Workup

Author: Tarlan Hedayati, MD, Instructor of Clinical Emergency Medicine, Director of Observation Unit, Director of Chest Pain Unit, Department of Emergency Medicine, Los Angeles County/University of Southern California Medical Center
Coauthor(s): Joseph Choi, MD, Resident Physician, Department of Emergency Medicine, LAC+USC Medical Center, Keck School of Medicine, University of Southern California
Contributor Information and Disclosures

Updated: Apr 28, 2009

Differential Diagnoses

Dermatitis, Contact
Pneumonia, Immunocompromised
Dermatitis, Exfoliative
Pneumonia, Mycoplasma
Encephalitis
Pneumonia, Viral
Endocarditis
Urinary Tract Infection, Female
Esophagitis
Urinary Tract Infection, Male
Herpes Simplex
Vaginitis
Herpes Simplex Encephalitis
Vulvovaginitis
Pityriasis Rosea
Wernicke Encephalopathy
Pneumonia, Aspiration
Pneumonia, Bacterial

Other Problems to Be Considered

Mucocutaneous candidiasis - Contact or allergic dermatitis, folliculitis, Stevens-Johnson syndrome
GI tract candidiasis - Viral infection or gastroesophageal reflux disease (GERD)
Respiratory candidiasis - Bacterial or other fungal infection, acute respiratory distress syndrome (ARDS)
Genitourinary candidiasis - Bacterial infection, pyelonephritis
Candidemia - Bacteria sepsis or endocarditis
Disseminated candidiasis - Bacterial sepsis, meningitis, tuberculosis
Hepatosplenic candidiasis - Abscess, cholecystitis, ascending cholangitis, malignancy recurrence
Ophthalmic candidiasis -Endophthalmitis, herpes zoster ophthalmicus, iritis/uveitis, corneal ulcer

Workup

Laboratory Studies

  • The criterion standard diagnostic tool for mucocutaneous candidiasis is culture. Cutaneous or mucosal scrapings can be used for a potassium hydroxide smear or Gram stain, which show hyphae, pseudohyphae, and budding yeast forms. The sensitivity of wet mount is as low as 39.6%.
  • Savyon Diagnostics currently is developing a rapid yeast detection kit for home diagnosis of vulvovaginal candidiasis. Preliminary data indicate better sensitivity than wet mount, and it costs less than culture.
  • Invasive Candida infections are typically difficult to diagnose because the clinical presentation is frequently similar to other disease states or bacterial infections (eg, blood, urine, CSF), and cultures are unreliable. In one report, blood cultures were positive in only 50-70% of disseminated candidiasis cases when the disease was proven by autopsy. Thus, nonculture diagnostic techniques are frequently used to aid in diagnosis. The 1,3 beta-glucan assay, which measures the fungal cell was component, has a sensitivity of 70% and specificity of 87%.
  • Non–Food Drug Administration (FDA)–approved diagnostic tools include the Platellia Aspergillus ELISA (PA-ELISA) and polymerase chain reaction–based assay.
  • The peptide nucleic acid fluorescent in situ hybridization (PNA-FISH) is used to distinguish C albicans from non-albicans Candida species.
  • CHROMagear is a specialized media for Candida isolation, which distinguishes C albicans, C tropicalis, and C krusei based on the species’ distinctive pigments.

Imaging Studies

  • Imaging studies are not necessary for routine mucocutaneous candidiasis.
  • Radiographic evaluations for systemic candidiasis are often nonspecific; thus, differentiation of candidiasis from other disease processes may be difficult.
  • Chest radiography may be helpful in making the diagnosis of pulmonary candidiasis.
    • Disease spreads via the airway system. Chest radiographic findings are characterized by bilateral, diffuse, and poorly marginated areas; pulmonary parenchymal densities are common.
    • Other nonspecific findings include air bronchogram and obscure cardiac and hemidiaphragm borders.
    • Hematogenous infection may produce a miliary nodular pattern.
  • Esophagography with contrast is indicated for diagnosis of esophagitis caused by Candida species.
    • Peristaltic abnormalities caused by small plaques appear as superficial filling defects. A nodular or cobblestone pattern may be seen.
    • Findings may be similar to those seen with esophagitis caused by cytomegalovirus (CMV) or herpes simplex virus (HSV).
    • Stricture may occur in severe esophageal candidiasis.
  • Ultrasonography is useful for diagnosis of microabscesses in the liver, spleen, or kidneys.
    • "Wheel-within-a-wheel" hypoechoic zones surrounded by hyperechoic zones are early findings.
    • Typical "bull's-eye" lesion may evolve from the initial lesion.
    • A uniformly hyperechoic lesion may be observed.
    • Echogenic foci with variable degrees of acoustic shadowing are late findings.
  • CT scan allows diagnosis of microabscesses, represented by low-attenuation foci, in the liver, spleen, or kidneys.
  • Intravenous pyelography (IVP) may be helpful in the diagnosis of urinary tract candidiasis.
    • Renal edema may be present from multiple microabscesses, deformity of renal outline, diminished renal excretion, papillary necrosis, and candidal fungal balls in the bladder or collecting system may be seen.
    • Hydronephrosis is a common late finding.
  • CT scan/MRI is indicated for evaluation of CNS lesions and prior to lumbar puncture.

Procedures

Endoscopy, tissue biopsy, and percutaneous needle aspiration of a body site suspected of Candida infection are recommended to aid in diagnosis. Positive candidal cultures in a normally sterile site should not be disregarded as a contaminant.

More on Candidiasis

Overview: Candidiasis
Differential Diagnoses & Workup: Candidiasis
Treatment & Medication: Candidiasis
Follow-up: Candidiasis
Multimedia: Candidiasis
References
Further Reading
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References

  1. Pappas PG, Kauffman CA, Andes D, Benjamin DK Jr, Calandra TF, Edwards JE Jr, et al. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis. Mar 1 2009;48(5):503-35. [Medline].

  2. Sullivan DJ, Westerneng TJ, Haynes KA, Bennett DE, Coleman DC. Candida dubliniensis sp. nov.: phenotypic and molecular characterization of a novel species associated with oral candidosis in HIV-infected individuals. Microbiology. Jul 1995;141 ( Pt 7):1507-21. [Medline].

  3. Hachem R, Hanna H, Kontoyiannis D, Jiang Y, Raad I. The changing epidemiology of invasive candidiasis: Candida glabrata and Candida krusei as the leading causes of candidemia in hematologic malignancy. Cancer. Jun 2008;112(11):2493-9. [Medline].

  4. Trofa D, Gacser A, Nosanchuk JD. Candida parapsilosis, an emerging fungal pathogen. Clin Microbiol Rev. Oct 2008;21(4):606-25. [Medline].

  5. Wellinghausen N, Moericke A, Bundschuh S, Friedrich W, Schulz AS, Gatz SA. Multifocal osteomyelitis caused by Candida dubliniensis. J Med Microbiol. Mar 2009;58:386-90. [Medline].

  6. van Hal SJ, Stark D, Harkness J, Marriott D. Candida dubliniensis Meningitis as delayed sequela of treated C. dubliniensis Fungemia. CDC. Available at http://www2a.cdc.gov/ncidod/ts/print.asp. Accessed January 29, 2008.

  7. Hirshoren N, Eliashar R, Weinberger JM. Candida epiglottitis: a rare emergent condition--appearance, treatment and pitfalls. Eur J Intern Med. Dec 2008;19(8):e84-5. [Medline].

  8. Yildirim M, Ozaydin I, Sahin I, Yasar M. Acute calculous cholecystitis caused by Candida lusitaniae: an unusual causative organism in a patient without underlying malignancy. Jpn J Infect Dis. Mar 2008;61(2):138-9. [Medline].

  9. Chassot F, Negri MF, Svidzinski AE, Donatti L, Peralta RM, Svidzinski TI, et al. Can intrauterine contraceptive devices be a Candida albicans reservoir?. Contraception. May 2008;77(5):355-9. [Medline].

  10. Loulergue P, Mahe V, Bougnoux ME, Poiree S, Hot A, Lortholary O. Fournier's gangrene due to Candida glabrata. Med Mycol. Mar 2008;46(2):171-3. [Medline].

  11. Stamatakos M, Kontzoglou K, Sargedi C, Tsaknaki S, Safioleas M. Mammary candidiasis. A breast infection difficult to handle. Chirurgia (Bucur). Sep-Oct 2008;103(5):583-6. [Medline].

  12. Mendes V, Castro S, Linhares P, Ribeiro-Silva ML. Tumoriform presentation of cerebral candidiasis in an HIV-infected patient. J Clin Neurosci. Apr 2009;16(4):587-8. [Medline].

  13. Baradkar VP, Mathur M, Kulkarni SD, Kumar S. Thoracic empyema due to Candida albicans. Indian J Pathol Microbiol. Apr-Jun 2008;51(2):286-8. [Medline].

  14. McGee SM, Thompson CA, Granberg CF, Hutcheson JC, Vandersteen DR, Reinberg Y, et al. Acute renal infarction due to fungal vascular invasion in disseminated candidiasis. Urology. Mar 2009;73(3):535-7. [Medline].

  15. Cha JG, Hong HS, Koh YW, Kim HK, Park JM. Candida albicans osteomyelitis of the cervical spine. Skeletal Radiol. Apr 2008;37(4):347-50. [Medline].

  16. Ozdemir N, Celik L, Oguzoglu S, Yildirim L, Bezircioglu H. Cervical vertebral osteomyelitis and epidural abscess caused by Candida albicans in a patient with chronic renal failure. Turk Neurosurg. Apr 2008;18(2):207-10. [Medline].

  17. Guillen Fiel G, Gonzalez-Granado LI, Mosqueda R, Negreira S, Giangaspro E. [Arthritis caused by Candida in an immunocompetent infant with a history of systemic candidiasis in the neonatal period.]. An Pediatr (Barc). Apr 2009;70(4):383-5. [Medline].

  18. Tiraboschi IN, Niveyro C, Mandarano AM, Messer SA, Bogdanowicz E, Kurlat I, et al. Congenital candidiasis: confirmation of mother-neonate transmission using molecular analysis techniques. Med Mycol. Mar 20 2009;1-5. [Medline].

  19. Thompson GR 3rd, Wiederhold NP, Vallor AC, Villareal NC, Lewis JS 2nd, Patterson TF. Development of caspofungin resistance following prolonged therapy for invasive candidiasis secondary to Candida glabrata infection. Antimicrob Agents Chemother. Oct 2008;52(10):3783-5. [Medline].

  20. De Rosa FG, Garazzino S, Pasero D, Di Perri G, Ranieri VM. Invasive candidiasis and candidemia: new guidelines. Minerva Anestesiol. Dec 17 2008;[Medline].

  21. Martinez RC, Franceschini SA, Patta MC, Quintana SM, Candido RC, Ferreira JC, et al. Improved treatment of vulvovaginal candidiasis with fluconazole plus probiotic Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14. Lett Appl Microbiol. Mar 2009;48(3):269-74. [Medline].

  22. Liu CY, Huang LJ, Wang WS, Chen TL, Yen CC, Yang MH, et al. Candidemia in cancer patients: impact of early removal of non-tunneled central venous catheters on outcome. J Infect. Feb 2009;58(2):154-60. [Medline].

  23. Magill SS, Swoboda SM, Shields CE, Colantuoni EA, Fothergill AW, Merz WG, et al. The epidemiology of Candida colonization and invasive candidiasis in a surgical intensive care unit where fluconazole prophylaxis is utilized: follow-up to a randomized clinical trial. Ann Surg. Apr 2009;249(4):657-65. [Medline].

  24. Buergers R, Rosentritt M, Schneider-Brachert W, Behr M, Handel G, Hahnel S. Efficacy of denture disinfection methods in controlling Candida albicans colonization in vitro. Acta Odontol Scand. Jun 2008;66(3):174-80. [Medline].

  25. Sanita PV, Vergani CE, Giampaolo ET, Pavarina AC, Machado AL. Growth of Candida species on complete dentures: effect of microwave disinfection. Mycoses. Mar 2009;52(2):154-60. [Medline].

  26. Anttila VJ, Salonen J, Ylipalosaari P, Koivula I, Riikonen P, Nikoskelainen J. A retrospective nationwide case study on the use of a new antifungal agent: patients treated with caspofungin during 2001-2004 in Finland. Clin Microbiol Infect. Jun 2007;13(6):606-12. [Medline].

  27. Borman AM, Petch R, Linton CJ, Palmer MD, Bridge PD, Johnson EM. Candida nivariensis, an emerging pathogenic fungus with multidrug resistance to antifungal agents. J Clin Microbiol. Mar 2008;46(3):933-8. [Medline].

  28. Brion LP, Uko SE, Goldman DL. Risk of resistance associated with fluconazole prophylaxis: systematic review. J Infect. Jun 2007;54(6):521-9. [Medline].

  29. Charles PE. Multifocal Candida species colonization as a trigger for early antifungal therapy in critically ill patients: what about other risk factors for fungal infection?. Crit Care Med. Mar 2006;34(3):913-4. [Medline].

  30. Cohen and Powderly's: Infectious Diseases. 2nd ed. 2004.

  31. Healy CM, Baker CJ, Zaccaria E, Campbell JR. Impact of fluconazole prophylaxis on incidence and outcome of invasive candidiasis in a neonatal intensive care unit. J Pediatr. Aug 2005;147(2):166-71. [Medline].

  32. Kauffman CA. Candidemia in adults. 2007;Available at uptodate.com.

  33. Kauffman CA. Hepatosplenic candidiasis. 2007;Available at uptodate.com.

  34. Kauffman CA. Overview of Candida infections. 2007;Available at uptodate.com.

  35. Kaufman D, Boyle R, Hazen KC, Patrie JT, Robinson M, Grossman LB. Twice weekly fluconazole prophylaxis for prevention of invasive Candida infection in high-risk infants of <100 grams birth weight. J Pediatr. 2005;147(2):172-9. [Medline].

  36. Kiss H, Petricevic L, Husslein P. Prospective randomised controlled trial of an infection screening programme to reduce the rate of preterm delivery. BMJ. Aug 14 2004;329(7462):371. [Medline].

  37. Kuse ER, Chetchotisakd P, da Cunha CA, Ruhnke M, Barrios C, Raghunadharao D, et al. Micafungin versus liposomal amphotericin B for candidaemia and invasive candidosis: a phase III randomised double-blind trial. Lancet. May 5 2007;369(9572):1519-27. [Medline].

  38. Li L, Redding S, Dongari-Bagtzoglou A. Candida glabrata: an emerging oral opportunistic pathogen. J Dent Res. Mar 2007;86(3):204-15. [Medline].

  39. Long SS, Stevenson DK. Reducing Candida infections during neonatal intensive care: management choices, infection control, and fluconazole prophylaxis. J Pediatr. Aug 2005;147(2):135-41. [Medline].

  40. Lum LC. Candidal bloodstream infection: will prevention work?. Pediatr Crit Care Med. Mar 2006;7(2):184-5. [Medline].

  41. Makhoul IR, Bental Y, Weisbrod M, Sujov P, Lusky A, Reichman B, et al. Candidal versus bacterial late-onset sepsis in very low birthweight infants in Israel: a national survey. J Hosp Infect. Mar 2007;65(3):237-43. [Medline].

  42. [Best Evidence] Manzoni P, Stolfi I, Pugni L, Decembrino L, Magnani C, Vetrano G, et al. A multicenter, randomized trial of prophylactic fluconazole in preterm neonates. N Engl J Med. Jun 14 2007;356(24):2483-95. [Medline].

  43. Ostrosky-Zeichner L. Prophylaxis for invasive candidiasis in the intensive care unit: is it time?. Crit Care Med. Sep 2005;33(9):2121-2. [Medline].

  44. Ostrosky-Zeichner L, Pappas PG. Invasive candidiasis in the intensive care unit. Crit Care Med. Mar 2006;34(3):857-63. [Medline].

  45. Pappas PG. Invasive candidiasis. Infect Dis Clin North Am. Sep 2006;20(3):485-506. [Medline].

  46. Parker ER, Guitart J. Candidal Intertrigo. 2007;Available at uptodate.com.

  47. Patel DA, Gillespie B, Sobel JD, Leaman D, Nyirjesy P, Weitz MV, et al. Risk factors for recurrent vulvovaginal candidiasis in women receiving maintenance antifungal therapy: results of a prospective cohort study. Am J Obstet Gynecol. Mar 2004;190(3):644-53. [Medline].

  48. Phillips AJ. Treatment of non-albicans Candida vaginitis with amphotericin B vaginal suppositories. Am J Obstet Gynecol. Jun 2005;192(6):2009-12; discussion 2012-3. [Medline].

  49. Piarroux R, Grenouillet F, Balvay P, Tran V, Blasco G, Millon L, et al. Assessment of preemptive treatment to prevent severe candidiasis in critically ill surgical patients. Crit Care Med. Dec 2004;32(12):2443-9. [Medline].

  50. Mandell, Bennet and Dolin. Principles and Practice of Infectious Diseases. 6th ed. 2005.

  51. [Best Evidence] Reboli AC, Rotstein C, Pappas PG, Chapman SW, Kett DH, Kumar D, et al. Anidulafungin versus fluconazole for invasive candidiasis. N Engl J Med. Jun 14 2007;356(24):2472-82. [Medline].

  52. Singhi SC, Reddy TC, Chakrabarti A. Candidemia in a pediatric intensive care unit. Pediatr Crit Care Med. Jul 2004;5(4):369-74. [Medline].

  53. Smith PB, Steinbach WJ, Benjamin DK Jr. Neonatal candidiasis. Infect Dis Clin North Am. Sep 2005;19(3):603-15. [Medline].

  54. Sobel JD, Wiesenfeld HC, Martens M, Danna P, Hooton TM, Rompalo A, et al. Maintenance fluconazole therapy for recurrent vulvovaginal candidiasis. N Engl J Med. Aug 26 2004;351(9):876-83. [Medline].

  55. Spinillo A, Zara F, Gardella B, Preti E, Mainini R, Maserati R. The effect of vaginal candidiasis on the shedding of human immunodeficiency virus in cervicovaginal secretions. Am J Obstet Gynecol. Mar 2005;192(3):774-9. [Medline].

  56. Sun RL, Jones DB, Wilhelmus KR. Clinical characteristics and outcome of Candida keratitis. Am J Ophthalmol. Jun 2007;143(6):1043-1045. [Medline].

  57. Wells CL, Johnson MA, Henry-Stanley MJ, Bendel CM. Candida glabrata colonizes but does not often disseminate from the mouse caecum. J Med Microbiol. May 2007;56(Pt 5):688-93. [Medline].

  58. Wertz KK, Pretzlaff RK. Caspofungin in a pediatric patient with persistent candidemia. Pediatr Crit Care Med. Mar 2004;5(2):181-3. [Medline].

  59. Zaas AK, Dodds Ashley ES, Alexander BD, Johnson MD, Perfect JR. Caspofungin for invasive candidiasis at a tertiary care medical center. Am J Med. Nov 2006;119(11):993.e1-6. [Medline].

  60. Zhang AY, Camp WL, Elewski BE. Advances in topical and systemic antifungals. Dermatol Clin. Apr 2007;25(2):165-83, vi. [Medline].

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Further Reading

Clinical guidelines
Guidelines for treatment of candidiasis. Pappas PG, Kauffman CA, Andes D, Benjamin DK Jr, Calandra TF, Edwards JE Jr, et al. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis. Mar 1 2009;48(5):503-35.

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Keywords

candidiasis, Candida albicans, C albicans, Candida tropicalis, C tropicalis, Candida parapsilosis, C parapsilosis, Candida guilliermondi, C guilliermondi, Candida lusitaniae, C lusitaniae, Candida krusei, C krusei, Torulopsis glabrata, Tglabrata, mycotic infection, vaginitis, vulvar rash, oral thrush, conjunctivitis, endophthalmitis, diaper rash, infections of nail, infections of rectum, infections of skin folds, systemic candidiasis, oral candidiasis, gastrointestinal candidiasis, red macerated intertriginous areas, vulvovaginitis, candidal infection, nosocomial bloodstream infection, candidemia, fungemia, vulvovaginal candidiasis, candidal esophagitis

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Contributor Information and Disclosures

Author

Tarlan Hedayati, MD, Instructor of Clinical Emergency Medicine, Director of Observation Unit, Director of Chest Pain Unit, Department of Emergency Medicine, Los Angeles County/University of Southern California Medical Center
Tarlan Hedayati, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Joseph Choi, MD, Resident Physician, Department of Emergency Medicine, LAC+USC Medical Center, Keck School of Medicine, University of Southern California
Joseph Choi, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

David FM Brown, MD, Assistant Professor, Department of Medicine, Division of Emergency Medicine, Harvard Medical School; Associate-Chief, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital
David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Schering  Honoraria Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Barry J Sheridan, DO, Chief, Department of Emergency Medical Services, Brooke Army Medical Center
Barry J Sheridan, DO is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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