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Acute
Mucocutaneous Candidosis |
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Acute
Mucocutaneous Candidosis Pathophysiology:
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| The
Organism: The
predominant pathogen is C. albicans, although other species are
occasionally involved. |
| Morphology:
Although we think of C.
albicans as primarily a yeast, it can also be found in filamentous
forms. Typically branching pseudohyphae are seen along with occasional
budding yeast and rare true hyphae. Candida albicans is large and
can be seen easily in a gram stain from a skin swab. |
| Anatomy:
Candida sp. can
cause both deep and superficial fungal infections, though the latter are
much more common. In superficial infections, fungal elements are found
sparsely distributed in the cornified layer. (FigureAMC 2) Additional
pathologic findings of candidosis are non-specific, showing various
degrees of inflammation. A psuedomembrane (of epithelial and
inflammatory cells) can be seen in acute oral candidosis. |
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Other:
Candida albicans is
a commensal orgnism commonly found in the GU and GI tracts.
A number of factors
predispose to candidosis.
| A
Few Common Risk Factors for Candidal Infections: |
Hiv and other
immunodeficiency states
Antibiotics
Topical or oral steroids
Skin trauma or occlusion
Diabetes and other endocrinopathies
Nutritional deiciencies
Age (very young or very old)
Malignancies.
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| Figure 5. A few
common risk factors for candidal infections. Adapted from
Freedberg et al. table 207-2 p. 2359. |
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Chronic
Mucocutaneous Candidosis:
The umbrella of acute mucocutaneous candidosis includes several
entities that can be somewhat chronic in nature (e.g. atrophic oral
candidosis). However, chronic mucocutaneous candidosis (CMC) is
actually a distinct clinical entity. The name is given to a syndrome
occurring in patients with defective cellular immunity (several
different defects have been described including some endocrinopathies).
Affected patients are very susceptible to Candida infections of the
skin, nails and oropharynx, many of them from an early age.
Disfigurement can result from the chronic, resistant infections.
Systemic candidiasis is actually quite rare. (Figure AMC 1)
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Figure
AMC 1.
Chronic mucocutaneous candidosis. This young girl was affected
with the disease at an early age. Multiple hyperpigmented,
hyperkeratotic, non-healing plaques are present on her face. (Courtesy
of J. Francis, MD.)
©Current Medicine 1995
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Figure
AMC 2.
Biopsy of mucocutaneous candidosis. This PAS stained tissue
sample shows scattered pseudohyphae and yeast in the stratum corneum.
(Courtesy of K. Abson, MD.)
©Current Medicine 1995
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Acute
Mucocutaneous Candidosis Clinical Picture:
Candida sp. can produce a wide
variety of superficial fungal infections. The list below is certainly not
inclusive, but should give you a good feel for the spectrum of disease.
Oral Candidosis:
What:
1)
Pseudomembranous candidosis
(more commonly known as thrush): As the name might suggest, a white,
creamy pseudomembrane (composed of fungal elements, epithelial
debris, fibrin and white blood cells) is formed on oral surfaces.
Several separate or confluent plaques may be present. Plaques can
usually be scraped away with a tongue depressor to reveal a raw, red
base. The disease can be asymptomatic or can cause local pain,
odynophagia, or changes in taste. (Figure AMC 3)
2)
Atrophic candidosis: Chronic erythematous, sharply
demarcated erosions are often sore or painful.
3) Angular
chelitis (perleche): Characteristic features are
inflammation and cracking at the angle of the mouth. The area is
usually sore and demonstrates erythema, fissures and crust. Chronic
eczematous changes can occur over time. Mixed infections are common.
Where:
1)
Pseudomembranous candidosis:
Buccal mucosa,
palate, gums in normal hosts; can affect tongue, pharynx or
esophagus in the immunosuppressed.
2)
Atrophic candidosis: The palate and gums, primarily
areas covered by dentures.
3) Angular
chelitis (perleche): The angle of the mouth.
Who:
1) Pseudomembranous
candidosis: The largest risk is among patients with HIV /
AIDS or neutropenia. Individuals with recent broad spectrum
antibiotic therapy of those who improperly inhale steroids are more
susceptible. Young infants may also be affected.
2) Atrophic
candidosis: It is most prevalent in denture wearers, more
commonly women.
3) Angular
chelitis (perleche): Patients who frequently lick their lips
or have excess saliva production seem to be more susceptible.
(Figure AMC 4)
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Figure AMC 3.
Pseudomembranous oral candidosis. The pseudomembrane is
composed of yeast, inflammatory cells, epithelial debris and even food
particles. Involvement of the tongue is more common in patients with
HIV. (Courtesy of Jan Hirschmann, MD.)
©Current Medicine 1995
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Figure AMC 4.
Angular Chelitis. Observe the erythema and fissures extending
from the corner of this man's mouth. Chronic exposure to saliva (drool
or excessive licking of the lips) is a risk factor. (Courtesy of Dr.
Wiklund)
©Current Medicine 1995
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The Diagnosis: Light
microscopy of oral swab is usually diagnostic. Culture is usually
necessary only for treatment failures.
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The Differential:
Oral hairy leukoplakia, oral florid papillomatosis, white sponge nevus,
lichen planus, chronic graft versus host disease.
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Candida Intertrigo:
What:
It presents with moist
intertriginous areas of erythema with irregular edges. Maceration,
scale and satellite lesions (red pustules or papules) are often
present. Pain and pruritis are common. (Figure AMC 5)
Where:
It is found in skin
folds: commonly beneath the breasts, in abdominal skin creases, in
the axilla, in the groin and between the web spaces of the toes or
fingers (also called erosio blastomycetica interdigitalis). (Figure
AMC 6) When it occurs in the groin, scrotal involvement is common
(recall that tinea cruris rarely affects the scrotum).
Who:
It is most common in
obese patients and diabetics. Interdigital candidiasis occurs
frequently in people whose hands are often wet due to occupational
exposure (e.g. dishwashers, bartenders and hairdressers).
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Figure AMC 5.
Candida Intertrigo. The submammary erythematous plaques
demonstrate typical scale and maceration. Satellite lesions are also
present. Warm, moist areas of skin-skin contact are ideal environments
for the growth of Candida.
©Current Medicine 1995
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Figure AMC 6.
Erosio blastomycetica interdigitale. Chronic moisture exposure
is a primary risk factor for this disease. In this gentleman, notice
the maceration of this 3rd web space caused by moisture trapped under
a ring. (Courtesy of J. Hirschmann, MD)
©Current Medicine 1995
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The Diagnosis: KOH
prep of swabs or scrapings of affected skin is usually adequate.
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The Differential:
Dermatophyte infection, intertrigo, eczema, erythrasma, bacterial
folliculitis.
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Vulvovaginitis
What:
The ?prototypical? picture (erythematous
patches, red papular satellite lesions and white curd like vaginal
discharge) is occasionally seen. However, many patients only
complain of vaginal burning, pruritus or a watery discharge.
Dyparunia or dysuria can also be present.
Where:
Vulva and vagina.
Who:
The disease is very
prevalent. Alteration of the hormonal environment (OCP?s, pregnancy,
IUD?s) and diabetes are risk factors. It can be sexually
transmitted.
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The Diagnosis: Often
clinical, but can be confirmed by microscopic exam of vaginal swab.
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The Differential:
STD's or UTI.
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Candida Balanitis:
What:
Tender red papules,
pustules and erosions are common. White exudate is sometimes
present.
Where:
Glans and shaft of the
penis.
Who:
Diabetics and men with
an uncircumcised penis are at higher risk. Like vulvovaginitis, it
can be acquired or transmitted through sexual intercourse.
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The Diagnosis: KOH
of a skin swab is usually diagnostic.
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The Differential:
Psoriasis, eczema, genital warts, molluscum contagiosum.
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Diaper (Napkin)
Candidiasis :
What:
The diaper area
exhibits mild to intense erythema, pustules and satellite lesions.
(Figure AMC 7)
Where:
The diaper area.
Who:
Any infant can be
affected, but infants left longer in wet diapers are more
susceptible.
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The Diagnosis: KOH
examination of a sample from the rashes edge or from a pustule is
needed.
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The Differential:
Diaper dermatitis, atopic dermatitis, psoriasis, seborrheic
dermatitis, cellulitis, impetigo.
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Figure AMC 7.
Diaper candidiasis. An initial irritant dermatitis (from
prolonged exposure to a wet diaper) placed this infant at risk for
candida infection. This disease is also known as napkin candidiasis
(napkin is used in Britain for diaper). (Courtesy of J. Francis,
MD.)
©Current Medicine 1995
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Acute
Mucocutaneous Candidosis Treatment:
| Oral
Candidosis |
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1. Pseudomembranous
candidosis:
Fluconazole 200mg x 1
Or - Fluconazole 100mg po qd x 5-14 days
Or - clotrimazole troches 5x/day x 14 days
Or - nystatin pastilles qid x 14 days
2. Atrophic candidosis:
Vigilant denture cleaning
And - one of the above measures.
3. Angular chelitis:
Topical azole cream bid until rash clears
And - Group VI steroid cream
And - Lip balm or ointment
Possibly - oral or topical antibiotics for bacterial
superinfection.
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| Candida
Intertrigo |
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Burrows Solution of Cool
Compresses
And - an antifungal cream bid until rash clears
Later - absorbent powder for prevention.
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| Vulvovaginitis |
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Flucanozole 15 mg po x 1
Or - Itraconazole 200mg po bid
Or - one of several antifungal vaginal troches.
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| Candida
Balanitis |
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Topical azole bid for 10
days
For poor response to the above - Itraconazole 200mg po qd
for 3-7 days
Or - flucanazole 150mg po qd for 1-3 days.
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| Diaper
(Napkin) Candidiasis |
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Changing diapers more
frequently
Barrier ointments
Topical azole bid x 7-14 days
Mild topical steroid (for irritant component) x 7-14 days.
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