Clinical Manifestations and Management

Oral candidiasis, also known as oral thrush, is a candidal infection of the oral-pharyngeal mucosa (Figure 98-1). It can affect up to 2% to 5% of otherwise healthy newborn infants and present as early as 7 to 10 days of life. In immunocompetent children, it is most common in infants and presents as adherent white plaques on the buccal or gingival mucosa. Removal of these plaques can result in localized bleeding. It can present with no symptoms or with increased fussiness and decreased feeding. Oral thrush is uncommon in children older than 12 months except after antibiotic use. Without recent antibiotic use, one may consider a primary immunodeficiency, diabetes mellitus, or HIV infection. Pseudomembranous candidiasis can be diagnosed clinically or by the identification of yeast cells and pseudohyphae by Gram stain or potassium hydroxide prep. Thrush can be treated with nystatin applied directly to the oral mucosa for 7 to 10 days. Thrush caused by antibiotic use generally resolves as the offending agent is discontinued. Bottle nipples and pacifiers should be sterilized as well to prevent reinfection.

Figure 98-1 Pseudomembranous candidiasis of the palate.

Candidal diaper dermatitis is characterized as beefy red plaques with satellite papules and pustules. It can affect the entire diaper area with a predilection for skin folds unlike other forms of diaper dermatitis. The treatment is with topical nystatin, clotrimazole, or miconazole.

Vulvovaginitis is a locally invasive candidal infection seen most often in postpubertal women and can affect up to 75% of women at some point during their lifetime. Risk factors for presentation at a younger age include systemic antibiotic use, diaper use, diabetes, and immune deficiency. Vulvovaginitis presents as a non-odorous white discharge, classically described as “cottage cheese,” from the vagina with associated dysuria, vulvar burning, and pruritus. First-line therapy is generally topical therapy as in diaper dermatitis or systemic fluconazole for recurrent or refractory cases.

Candidal infections in the immunocompromised host can vary from superficial mucocutaneous infections to life-threatening systemic infections. The most serious fungal infection is disseminated candidiasis, in which the organism spreads hematogenously to tissues throughout the body, including the eyes, kidney, bones, meninges, lungs, spleen, or heart valves. Mortality can be as high as 47%. Risk factors include exposure to broad-spectrum antibiotics, central venous catheters, parenteral nutrition, renal replacement therapy in the intensive care unit, neutropenia, immunosuppression, and prosthetic devices. Candida spp. are the fourth leading cause of nosocomial bloodstream infections. Diagnosis requires culturing Candida spp. from blood or other sterile body fluids. Recommended treatment of systemic candidiasis includes lipid formulation amphotericin B, caspofungin, or fluconazole with the duration of therapy determined by the extent of disease and response to therapy. Fluconazole may be added for better penetration into the central nervous system. Prophylactic antifungal medication is recommended in two groups of patients—bone marrow transplant recipients and solid organ transplant recipients because of their prolonged neutropenia and immunosuppression.