Candidiasis in Emergency Medicine 

  • Author: Tarlan Hedayati, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Apr 15, 2010
 

Background

The Candida fungus is both normal flora and an invasive pathogen. The range of infection with Candida species varies from a benign local mucosal membrane infection to disseminated disease. Severe disease is typically associated with an immunocompromised state including those vulnerable to iatrogenic pathogens in the intensive care unit or those with predisposing immunologic conditions such as malignancy, organ dysfunction, or immunosuppressive therapy.

Rash due to candidiasis is shown in the images below.

Candidiasis. Image courtesy of Hon Pak, MD. Candidiasis. Image courtesy of Hon Pak, MD. Candidiasis. Erythema, maceration, and satellite pCandidiasis. Erythema, maceration, and satellite pustules in the axilla, accompanied by soreness and pruritus, result in a form of intertrigo. Image courtesy of Matthew C Lambiase, DO.
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Pathophysiology

Candida is a unicellular yeast whose cells reproduce by budding. This organism can flourish in most environments. It frequently colonizes the oropharynx, skin, mucous membranes, lower respiratory, and gastrointestinal and genitourinary tracts. Pathogenesis occurs with increased fungal burden and colonization, such as in the setting of broad-spectrum antimicrobial agents; breakdown of normal mucosal and skin barriers, which can occur with indwelling intravascular devices, recent surgery/trauma or tissue damage secondary to chemotherapy or radiation; or immune dysfunction secondary to disease states or iatrogenic conditions.

Candidiasis is the most common opportunistic fungal infection. Disease manifestation of candidal infection can vary with type of host immunodeficiency. Lymphocytes and cell-mediated immunity are important in the prevention of mucosal candidiasis. Therefore, patients with T-cell deficiency, such as human immunodeficiency virus (HIV), have a propensity to develop recurrent and/or persistent mucocutaneous candidiasis. Patients with neutropenia are at risk for invasive candidiasis and candidemia as functioning monocytes and polymorphonuclear cells are responsible for killing pseudohyphae and blastospores. Complement and immunoglobulins are necessary for intracellular killing of the organisms and patients with deficiencies can have a more prolonged and complicated course of candidal infection.

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Epidemiology

Frequency

United States

  • Candida is the fourth most common cause of nosocomial bloodstream infection in the United States.[1]
  • Three quarters of women experience vaginitis in their lifetime, and 30% of vaginitis is caused by Candida. Vaginitis accounts for 10 million office visits per year.
  • Invasive candidiasis is the most common invasive fungal infection in the United States. There is an increasing shift toward infections caused by non-albicans Candida species with 40-60% of the species currently being reported as non-albicans species.

International

  • Internationally , Candida epidemiology is similar to that of the United States.
  • Non-albicans Candida accounted for 70% of candidemia in a Northern Indian pediatric intensive care unit. Candida species isolated were Candida tropicalis (48.4%), C albicans (29.7%), C guilliermondii (14.1%), C krusei (6.3%), and C glabrata (1.6%).
  • Other Candida species that have emerged are C parapsilosis and C dubliniensis.[2]
  • C glabrata and C krusei have been identified as the leading causes of candidemia in patients with malignancy of hematologic origin;[3] C parapsilosis has been identified as the leading cause of candidemia secondary to medical instrumentation such as central venous catheters, prosthetic devices, and nosocomial spread.[4]
  • C dubliniensis has been identified in an immunocompromised patient with multifocal osteomyelitis in Germany[5] and in a patient with meningitis in Australia[6] .
  • Fungal keratitis is more prevalent in the tropics; therefore, Candida accounts for proportionately more fungal corneal isolates at temperate latitudes.

Mortality/Morbidity

  • Invasive candidiasis has a mortality rate of 40-50%, with an estimated cost of $40,000 per episode.
  • Neonates and children have better outcomes with approximately 20% mortality rate for candidemia.
  • Risk factors for death or poor prognosis are age, failure to remove central lines, malnutrition, and non-albicans fungemia.

Race

  • No racial predilection exists for infection with Candida.

Sex

  • Three quarters of all women experience at least one episode of vulvovaginal candidiasis in their lifetime, and about one half of these women experience a recurrence.

Age

  • Elderly persons with high Acute Physiology and Chronic Health Evaluation (APACHE) II scores as well as neonates with low gestational age, low APGAR scores, and congenital malformations are at high risk for candidal infection.
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Contributor Information and Disclosures
Author

Tarlan Hedayati, MD  Assistant Professor of Emergency Medicine, Rush Medical College, John H Stroger Hospital of Cook County

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)

Ghazal Shafiei, MD  Resident Physician, Department of Emergency Medicine, John H Stroger Jr Hospital

Ghazal Shafiei, MD is a member of the following medical societies: American Medical Association and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

David FM Brown, MD  Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, 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: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Barry J Sheridan, DO  Chief Warrior in Transition 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.

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  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

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

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Emily Anne Carpenter Rose, MD, to the development and writing of this article.

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Candidiasis. Image courtesy of Hon Pak, MD.
Candidiasis. A moist, erosive, pruritic patch of the perianal skin and perineum (with satellite pustule formation) is demonstrated in this woman with extensive candidosis. Image courtesy of Matthew C Lambiase, DO.
Candidiasis. Discrete superficial pustules developed within hours of birth on the hand of an otherwise healthy newborn. A potassium hydroxide preparation revealed spores and pseudomycelium, and culture demonstrated the presence of Candida albicans. Image courtesy of Matthew C Lambiase, DO.
Candidiasis. Dry, red, superficially scaly, pruritic macules and patches on the penis represent candidal balanitis. Image courtesy of Matthew C Lambiase, DO.
Candidiasis. White plaques are present on the buccal mucosa and the undersurface of the tongue and represent thrush. When wiped off, the plaques leave red erosive areas. Image courtesy of Matthew C Lambiase, DO.
Candidiasis. Erythema, maceration, and satellite pustules in the axilla, accompanied by soreness and pruritus, result in a form of intertrigo. Image courtesy of Matthew C Lambiase, DO.
Candidiasis. A nailfold with candidal infection becomes erythematous, swollen, and tender with an occasional discharge. Image courtesy of Matthew C Lambiase, DO.
Candidiasis. Soreness and cracks at the lateral angles of the mouth (angular cheilitis) is a frequent expression of candidosis in elderly individuals. Image courtesy of Matthew C Lambiase, DO.
Candidiasis. Fine superficial pustules on an erythematous patchy base are suggestive of candidosis. Image courtesy of Matthew C Lambiase, DO.
Candidiasis. Candida infection should be in the differential diagnosis when one or more nails become discolored, has subungual discoloration, nailplate separation from the nailbed, and lack evidence of a dermatophyte. Image courtesy of Matthew C Lambiase, DO.
 
 
 
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