Makindo Medical Notes

🍄 Candida is a ubiquitous commensal fungus found on skin, in the oral cavity, and the genital tract. ⚠️ In critically ill or immunocompromised patients, it can become invasive, particularly with broad-spectrum antibiotics, central lines, or ventilation in ICU. 💡 Isolation of Candida from a sterile site (e.g., blood culture) = always significant → systemic antifungal treatment under microbiology guidance.

📖 About

• Opportunistic infection: Most due to Candida albicans, but also C. glabrata, C. krusei, C. tropicalis.
• At-risk groups: ICU, chemotherapy, neutropenia, TPN, IV drug use, HIV/AIDS.
• Disseminated disease: Endophthalmitis, hepatosplenic abscesses, fungal endocarditis.

🧬 Aetiology & Risk Factors

• Normal commensal in GI tract, mouth, vagina, skin.
• Disruption of flora: antibiotics, steroids, chemotherapy.
• Immunosuppression: HIV, transplant, diabetes, neutropenia.
• Foreign bodies: central lines, urinary catheters, prosthetic valves.

🩺 Clinical Presentations

• 👄 Oropharyngeal Candidiasis (Thrush): White plaques, painful, scrapeable; risks: antibiotics, dentures, HIV.
• 👩 Vaginal Candidiasis: Pruritus, cottage-cheese discharge, vulvovaginitis.
• 🫁 Oesophageal candidiasis: Odynophagia, dysphagia (AIDS-defining illness).
• 🌡️ Acute Disseminated Candidiasis: Fever, malaise, candidaemia → endophthalmitis, renal/hepatic abscesses.
• 🕰️ Chronic Disseminated (Hepatosplenic): Seen post-neutropenia recovery, multiple hypodense liver/spleen lesions.
• 🖐️ Chronic Mucocutaneous Candidiasis: Severe thrush, nail disease, recurrent vaginitis; often with endocrine/immune syndromes.
• 💔 Invasive Complications: Endocarditis, meningitis, osteomyelitis, pyelonephritis.

⚠️ Overdiagnosis of Oral Candida

Not every white tongue is thrush! Candida is frequently overdiagnosed, especially in patients with nonspecific tongue changes. If there is no pain or discomfort then consider alternative diagnosis.

• Normal variants: Coated tongue (debris, bacteria), dehydration, or poor oral hygiene can mimic candidiasis.
• Elongated filiform papillae: “Hairy tongue” due to papillary overgrowth (e.g., smokers, antibiotic use, xerostomia) → white, brown, or black discolouration, but not thrush.
• Geographic tongue: Benign migratory glossitis with depapillated red patches bordered by white keratin — easily mistaken for Candida.
• Clue for true Candida: White plaques that can be wiped off to reveal an erythematous base underneath.
• Confirmatory test: Swab/scraping with microscopy (pseudohyphae) if in doubt.

💡 Teaching point: Avoid reflex antifungal prescriptions. Always consider alternative diagnoses and risk factors (immunosuppression, recent antibiotics, steroids, HIV, diabetes).

🔬 Investigations

• 🧪 Microscopy: Scrapings → yeast + pseudohyphae.
• 🧫 Cultures: Blood, urine, tissue. Beware: urine often colonisation unless symptomatic.
• 🩸 Blood cultures: Always significant → systemic evaluation.
• 🖼️ Imaging: CT/USS abdomen → hepatosplenic abscesses. CXR → bronchopneumonia.
• 🔎 Other: OGD for oesophageal lesions, echocardiography for suspected fungal endocarditis, fundoscopy for endophthalmitis.

💊 Management

• 🎯 General principles: – Control underlying risk (e.g., diabetes, immunosuppression). – Remove catheters/lines if possible.
• 👄 Mucocutaneous: – Topical clotrimazole 1% cream, miconazole oral gel, or nystatin. – Vaginal pessaries or oral fluconazole for vulvovaginitis.
• 🌡️ Systemic/Disseminated: – First-line: Echinocandins (caspofungin, micafungin, anidulafungin). – Alternative: Fluconazole (if susceptible, not critically ill). – Amphotericin B (lipid formulations) for resistant/severe cases. – Duration: at least 14 days after last positive culture & symptom resolution.
• 💔 Endocarditis/Endophthalmitis: – Requires prolonged IV antifungals ± surgical removal of infected prostheses.

🧾 Clinical Pearls

• 🔎 Always do a fundoscopy in candidaemia (rule out endophthalmitis).
• 🧬 Species ID matters: C. krusei = resistant to fluconazole; C. glabrata = dose-dependent sensitivity.
• 💉 Central line removal is often as important as antifungals.
• 🧪 Beta-D-glucan (fungal marker) may help in diagnosis in ICU patients.

📚 References

• NICE Guidance
• UpToDate: Candida Infections
• CDC: Candidiasis