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Invasive disease caused by Candida spp, especially C. albicans, and manifested by septicemia, endocarditis, hepatosplenic disease, meningitis, or rarely, osteomyelitis. Candidiasis involving the esophagus, trachea, bronchi, or lungs is a defining disease for AIDS.
Etiology, Incidence, and Pathology
The infections are usually caused by C. albicans or by C. tropicalis in immunosuppressed patients. Superficial candidiasis (thrush) is worldwide in distribution and particularly prevalent in AIDS patients. Patients with neutropenia (from leukemia or other malignancies or from their treatment), with indwelling intravascular lines, or receiving parenteral alimentation or antibacterial therapy are especially prone to Candida septicemia. Candida (frequently C. parapsilosis) endocarditis is related to intravascular trauma such as cardiac catheterization, surgery, or indwelling intravascular lines. An endogenous alcohol syndrome that has been attributed to fermentation of carbohydrates by the fungus in the gut is undoubtedly spurious.
Symptoms and Signs
Candida endocarditis resembles bacterial disease, with fever, heart murmur, splenomegaly, and anemia; large vegetations and emboli to major vessels are frequently differential features. Renal involvement is usually found on laboratory and autopsy examination. Candida septicemia often resembles gram-negative bacterial sepsis in frequency of fever, shock, azotemia, oliguria, renal shutdown, and fulminant course occurrences. Retinitis or panophthalmitis is a complication that may result in blindness. Candida meningitis is chronic, like cryptococcal meningitis, but lacks the latter's usually fatal outcome when untreated. Candida pyelonephritis and pulmonary disease are less well characterized. Osteomyelitis and a related disease, spondylodiscitis (infection of the intervertebral disk) have been encountered, notably in IV drug users. Pericarditis and hepatosplenic disease have recently been encountered in oncology patients.
Diagnosis
Because Candida spp are human commensals, their culture from sputum, mouth, vagina, urine, stool, or skin must be interpreted cautiously. To confirm the diagnosis, the culture must be complemented by a characteristic clinical lesion, exclusion of other etiology, and histologic evidence of tissue invasion. Culture from blood, CSF, pericardial fluid, or tissue (liver biopsy), however, establishes infection and supports the appropriate clinical impression: septicemia or endocarditis, meningitis, pericarditis, or hepatosplenic disease, respectively.
Prognosis and Treatment
All forms of systemic disease should be considered serious, progressive, and potentially fatal. Such predisposing conditions as diabetic acidosis must be controlled. In systemic candidiasis, amphotericin B IV is the preferred therapy (see General Therapeutic Principles, above). As an alternative, flucytosine has limited usefulness, since sensitivity of the isolate must be determined before treatment, and resistant fungi may be selected out during treatment. Ketoconazole (see General Therapeutic Principles, above) is preferred for chronic mucocutaneous candidiasis. Fluconazole may be effective, but controlled comparative studies have not yet been reported. For superficial mucosal or skin disease (thrush), topical therapy (eg, clotrimazole, miconazole, nystatin) is preferable.
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