Candidiasis in Emergency Medicine Workup

Updated: Oct 12, 2017
  • Author: Sukhveer (Sukhi) Bains, MD, MA; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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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 has developed a rapid yeast detection kit for diagnosis of vulvovaginal candidiasis at home or at the physician’s office. 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, of the 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%.

In September 2014, the US Food and Drug Administration (FDA) approved the marketing of a direct blood test used to detect the five most common Candida species that cause bloodstream infections: C albicans, C tropicalis, C parapsilosis, Cglabrata, and Ckrusei. The test, T2Candida, utilizes amplified DNA technology with magnetic resonance to allow for rapid identification of potentially fatal candidemia to facilitate timely parenteral treatment. [24]

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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 diagnosing 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 an option to aid in diagnosis of esophagitis caused by Candida species; however, this should not prevent empirical treatment, as it is a clinical and visual diagnosis (ie, with esophagogastroduodenoscopy (EGD) or pathology). 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 CMV or 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 due to multiple microabscesses may be present. Deformity of renal outline may also be present. In addition, 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 in immunocompromised patients, especially those who present with altered mental status.

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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 if clinically indicated. Positive candidal cultures in a normally sterile site should not be disregarded as a contaminant.

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