Candidiasis in Emergency Medicine Workup

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

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-albicansCandida species.
  • CHROMagear is a specialized media for Candida isolation, which distinguishes C albicans, C tropicalis, and C krusei based on the species’ distinctive pigments.
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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.
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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.

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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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