History
Thrush
Infants with thrush may experience pain, poor feeding, or fussiness.
Cutaneous candidiasis
Patients with cutaneous candidiasis experience itching, burning, and soreness.
Most commonly affected areas are the diaper area in infants and toddlers and abdominal fat folds and groin in older individuals.
Paronychia and onychomycosis
Candidal paronychia and nail disease has a predilection for the fingernails.
Paronychia is usually painful.
Vulvovaginitis
Most women with vulvovaginitis complain of a creamy vaginal discharge with soreness and burning.
Dyspareunia is often present.
Otitis externa
Otitis externa is found most commonly in tropical and subtropical climates.
Malnutrition and immunosuppression are risk factors.
Candidiasis is clinically difficult to distinguish from other causes of otitis externa.
GI candidiasis
GI candidiasis is primarily observed in individuals who are immunocompromised, especially in persons with human immunodeficiency virus (HIV) infection and/or primary immunodeficiency.
This may be a cause of chronic diarrhea.
Common in infants, glossitis may occur in older children following use of broad-spectrum antibiotics or may signal immunodeficiency.
Esophagitis should be suspected in individuals who are immunocompromised when oral candidiasis is present. Symptoms include dysphagia and odynophagia. Risk of esophagitis is elevated in children taking H2 blockers.
Pneumonia
This is extremely rare and usually results from disseminated disease.
Cystitis
Risk factors for cystitis include indwelling urinary catheters, immunosuppression, diabetes mellitus, and use of broad-spectrum antibiotics.
Endophthalmitis
Endophthalmitis is the most common intraocular infection in newborns.
Risk factors include low birth weight and prolonged hospitalization.
CNS infections
CNS infections usually present as subacute meningitis.
Risk factors include premature neonates with candidemia, AIDS, indwelling catheters (especially shunts), malnutrition, immunodeficiency, and organ transplantation.
Endocarditis
Risk factors for endocarditis include immunosuppression, HIV infection, intravenous catheters, corticosteroid use, prolonged hospitalization, and use of broad-spectrum antibiotics.
Hepatic (hepatosplenic) candidiasis
Risk factors include neutropenia.
Hepatic candidiasis may present with fever of unknown origin. It is usually a manifestation of disseminated candidiasis.
Hepatic candidiasis commonly occurs in oncology patients after a prolonged course of neutropenia. Symptoms develop with return of neutrophils.
Physical
Thrush
White plaques are observed in the mouth and may affect the lips, tongue, gums, and palate (see the image below).
Typical appearance of thrush. Note multiple white plaques on lips, gingivae, tongue, and palate.
Scraping of the lesions may reveal erythema and bleeding at the base (see following image). The plaques do not scrape off easily.
Cutaneous candidiasis
Lesions consist of beefy-red plaques, often with scalloped borders.
Satellite papules and pustules may be observed surrounding the plaques.
Maceration is often present; especially in intertriginous areas (see following image).
Candidal diaper dermatitis (see the image below) is generally confluent in intertriginous areas, whereas generic diaper dermatitis may demonstrate sparing in the folds.
Candidal diaper dermatitis. Note satellite papules and involvement of intertriginous folds.
Paronychia and onychomycosis
Paronychia typically involves the cuticular fold of fingernails, causing redness, swelling, and pain.
Pus may be present.
Nail involvement usually stems from long-standing paronychia and causes a yellow discoloration of the nail, often with separation of the nail from the nail bed.
Genital candidiasis
With vulvovaginitis, a creamy white discharge is usually present. White plaques may be observed on an erythematous base of the vaginal mucosa or vulvar skin. Papules and pustules may be present.
With balanitis, lesions are usually observed on the glans penis and consist of erythematous plaques, pustules, or erosions.
GI disease
Glossitis is characterized by creamy or curdlike white plaques, which may be painful and bleed beneath when scraped.
With esophagitis, oral candidiasis may or may not be present. Weight loss is common.
Otitis externa
Tenderness of the pinna, aural discharge, and erythema characterize otitis externa.
Lymphadenopathy of postauricular or preauricular nodes may be present.
A grayish membrane may be present in the canal.
Hepatic candidiasis
This infection usually presents as abscesses in the liver and/or spleen.
Endocarditis
Endocarditis is characterized by fever and a new or changing heart murmur.
Symptoms relating to embolization to other organs (eg, CNS, kidneys, lungs, retina and choroid, skin) may be present.
Endophthalmitis
White well-circumscribed lesions of the retina and choroid in the posterior pole characterize endophthalmitis.
Isolation of candida from blood, urine, or other sources supports the diagnosis of endophthalmitis.
CNS infections
Signs consistent with meningitis are often present with CNS infections.
Evidence of candidal infection of other organ systems may be present.
Causes
Candidal infections have differing presentations in patients who are immunocompetent versus persons who are immunocompromised.
Patient who is immunocompetent
Although candidal diaper rash is common in healthy infants, predisposing factors causing candidal infections in older individuals are often present.
The most common factor is the disruption of normal flora following a course of antibiotic therapy, which is most commonly observed as cutaneous candidiasis or vulvovaginitis.
Other risk factors for candidal infection relate to impaired immune function, including individuals with diabetes mellitus, premature infants, hosts who are immunocompromised, and persons using systemic or topical corticosteroids.
Other risk factors include obesity, heat, and excessive sweating.
Patient who is immunocompromised
Individuals who are immunocompromised, including AIDS, are more susceptible to oral and cutaneous candidiasis and often have a more severe course.
Oral candidiasis may appear as acute or chronic atrophic candidiasis, which causes painful red erosions of the tongue and mucous membranes.
Candida species are frequent causes of central venous catheter infections.
Immunosuppression may also cause systemic candidiasis, which may present as fungemia or funguria. Candida species may cause fungal bezoars in the kidney or bladder, or candidiasis may cause abscesses in the liver or spleen. Candidal meningitis, arthritis, and endophthalmitis all have been reported.
Neonates
Neonates with very low birth weight are at a higher risk of developing candidemia.
Risk factors include low birth weight, broad spectrum antibiotic use, total parental nutrition, previous bloodstream infections, or necrotizing enterocolitis.
Chronic mucocutaneous candidiasis (CMCC)
CMCC is a cluster of disorders of cell-mediated immunity that presents as chronic severe candidal infections of the skin and mucous membranes.
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Typical appearance of thrush. Note multiple white plaques on lips, gingivae, tongue, and palate.
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Candidal diaper dermatitis. Note satellite papules and involvement of intertriginous folds.
