candidiasis

Candidiasis is a fungal infection caused by yeasts from the genus Candida. C albicans is the predominant cause of the disease.

Essential update: FDA issues warning for antifungal medication ketoconazole

The FDA announced that clinicians should no longer prescribe ketoconazole (Nizoral, Janssen Pharmaceuticals) tablets as a firstline therapy for any fungal infection, including Candida and dermatophyte infections, because of the risk for severe liver injury, adrenal insufficiency, and adverse drug interactions. The FDA also cautioned that ketoconazole tablets should not be prescribed for any patient with underlying liver disease. The labeling changes do not apply to topical formulations of ketoconazole in creams, shampoos, foams, and gels. Oral ketoconazole is now indicated only for endemic mycoses in patients who fail to respond to or cannot tolerate other treatments.

Ketaconazole tablets were also withdrawn from the market in the European Union in July.^{[1, 2]}

Signs and symptoms

Chronic mucocutaneous candidiasis

Findings reveal disfiguring lesions of the face, scalp, hands, and nails. Chronic mucocutaneous candidiasis is occasionally associated with oral thrush and vitiligo.

Oropharyngeal candidiasis

The patient usually has a history of HIV infection, wears dentures, has diabetes mellitus, or has been exposed to broad-spectrum antibiotics or inhaled steroids. Although patients are frequently asymptomatic, when symptoms do occur they can include the following:

• Sore and painful mouth
• Burning mouth or tongue
• Dysphagia
• Thick, whitish patches on the oral mucosa

Physical examination reveals a diffuse erythema and white patches that appear on the surfaces of the buccal mucosa, throat, tongue, and gums.

The following are the 5 types of OPC:

• Membranous candidiasis - One of the most common types; characterized by creamy-white, curdlike patches on the mucosal surfaces
• Chronic atrophic candidiasis (denture stomatitis) - Also thought to be one of the most common forms of the disease; presenting signs and symptoms include chronic erythema and edema of the portion of the palate that comes into contact with dentures.
• Erythematous candidiasis - Associated with an erythematous patch on the hard and soft palates
• Angular cheilitis - Inflammatory reaction characterized by soreness, erythema, and fissuring at the corners of the mouth
• Mixed - A combination of any of the above types is possible

Esophageal candidiasis

Patients may be asymptomatic or may have 1 or more of the following symptoms:

• Normal oral mucosa - >50% of patients
• Dysphagia
• Odynophagia
• Retrosternal pain
• Epigastric pain
• Nausea and vomiting

Physical examination almost always reveals oral candidiasis.

Nonesophageal gastrointestinal candidiasis

The following symptoms may be present:

• Epigastric pain
• Nausea and vomiting
• Abdominal pain
• Fever and chills
• Abdominal mass (in some cases)

Genitourinary tract candidiasis

The types of genitourinary tract candidiasis are as follows:

• Vulvovaginal candidiasis (VVC) - Erythematous vagina and labia; a thick, curdlike discharge; and a normal cervix upon speculum examination^[3]
• Candida balanitis - Penile pruritus and whitish patches on the penis
• Candida cystitis - Many patients are asymptomatic, but bladder invasion may result in frequency, urgency, dysuria, hematuria, and suprapubic pain
• Asymptomatic candiduria - Most catheterized patients with persistent candiduria are asymptomatic
• Ascending pyelonephritis - Flank pain, abdominal cramps, nausea, vomiting, fever, chills and hematuria
• Fungal balls - Intermittent urinary tract obstruction with subsequent anuria and ensuing renal insufficiency

See Clinical Presentation for more detail.

Diagnosis

Diagnostic tests for candidiasis include the following:

• Mucocutaneous candidiasis - For a wet mount, scrapings or smears obtained from skin, nails, or oral or vaginal mucosa are examined under the microscope; a potassium hydroxide smear, Gram stain, or methylene blue is useful for direct demonstration of fungal cells
• Cutaneous candidiasis - Using a wet mount, scrapings or smears obtained from skin or nails can be examined under the microscope; potassium hydroxide smears are also useful
• Genitourinary candidiasis - A urinalysis should be performed; evidence of white blood cells (WBCs), red blood cells (RBCs), protein, and yeast cells is common; urine fungal cultures are useful
• Gastrointestinal candidiasis - Endoscopy with or without biopsy

See Workup for more detail.

Management

• Cutaneous candidiasis - Most localized cutaneous candidiasis infections can be treated with any number of topical antifungal agents (eg, clotrimazole, econazole, ciclopirox, miconazole, ketoconazole, nystatin)
• Chronic mucocutaneous candidiasis - This condition is generally treated with oral azoles
• Oropharyngeal candidiasis - This can be treated with either topical antifungal agents or systemic oral azoles
• Esophageal candidiasis - Treatment requires systemic therapy with fluconazole