INTERNATIONAL CLASS MAKALAH

CANDIDIASIS

NAMA : IRWAN BIN AB AZIZ ID NO : C 111 06 252

TROPICAL MEDICINE MEDICAL FACULTY HASANUDDIN UNIVERSITY 2009

Introduction
Definition = Candidiasis is an infection by fungi of the Genus Candida, generally C.albican, most commonly involving the skin, oral mucosa(thrush), respiratory tract, or vagina rarely there is a systemic infection or endocarditis.
Dorland`s Pocket Medical Dictionary 27th Edition

Epidemiology
The increase in infections due to Candida over the past decade is significant. This is particularly true for hospitalized patients where the rate of blood-stream infection due to Candida spp. has increased by almost 500% over the decade of the 1980s. This increase is accompanied by a significant excess mortality and a prolonged length of stay in the hospital. This trend continues into the 1990s where in the US Candida spp. remains the fourth most common blood-stream pathogen, accounting for 8% of all hospital-acquired blood-stream infections. Notably, more than one-third of candidal blood-stream infections are caused by species other than C. albicans. The majority of these infections arise from an endogenous focus of colonization; however, the documentation of nosocomial transmission or 'cross-infection' and the recognition of resistance to antifungal agents pose new and significant problems. Recent studies indicate that Candida may be isolated from the hands of 15-54% of health care workers in the intensive care unit setting and that the strain of Candida carried on the hands may be shared by infected patients. These studies are facilitated by molecular typing and careful epidemiological investigation and suggest that cross-infection is an important and preventable feature of candidal blood-stream infection. Both endogenous and exogenous sources of infection are now well-documented and such information should help direct measures to prevent infections in high risk individuals.

Etiology
C.albicans, an oval yeast varying in size (2-6 mikrometer by 3-9 mocrometer). Polymorphism is displayed as yeast forms, building yeast, pseudohyphae, and true hyphae. Besides C.albicans, >100 species of the genus have been identified, most of which are neither commensal nor pathogenic for humans. Other pathogenic species, usually in the setting of

immunocompromise, include C.tropicais, C.parapsilosis, C.guilliermondii, C.crusei, C.glabata. More than 100 species of Candida exist in nature; only a few species are recognized causes of disease in humans.

The medically significant Candida species include the following:

o o o o o o o o o

C albicans, the most common species identified (50-60%) Candida glabrata (15-20%) C parapsilosis (10-20%) Candida tropicalis (6-12%) Candida krusei (1-3%) Candida kefyr (less than 5%) Candida guilliermondi (less than 5%) Candida lusitaniae (less than 5%) Candida dubliniensis, primarily recovered from patients who are positive for HIV

Ecology
C.albicans and other species frequently colonize GI tract. Colonization may occur during birthing from the birth canal, during infancy, or later. Oropharyngeal colonization is present in approximately 20% of healthy individuals, the rate being higher in hospitalized patients. Fecal colonization is higher than in mouth, with a rate of 40-68%; the rate increase with antibacterial agents. Serologic and skin test studies indicate that a significant proportion of those not colonized have been exposed to Candida in the past. Antibiotic therapy increase the incidence of carriage, the number of organisms present, and the chances for tissue invasion. Candida albicans is the most frequent disease-causing fungus. It is a normal inhabitant of the oral cavity, gastrointestinal tract, and vagina in many individuals.

Candida is normally present on the skin, in the intestinal tract, and in women- in the genital region. Usually, Candida in these areas does not cause problems. Sometimes, however, the fungus can cause infection of the skin or the mucous membrane of the mouth or vagina. Such infections can develop in people with a healthy immune system but they are more common or persistent in people with diabetes, cancer, or AIDS and in pregnant women. Candidiasis is also common in people who are given antibiotics because bacteria that normally compete with Candida are killed and the fungus is able to grow unchecked. Some people, mainly those with a weakened immune system, developed candidiasis that spread through the bloodstream to other parts of the body.

Pathophysiology
In Candidiasis, the Candida penetrates the epidermis after it binds to intergrin receptors and adhesion molecules. The secretion of proteolytic enzymes by the organism facilitates tissue invasion. An inflammatory response results from the attraction of neutrophils to the area and from activation of the complement cascade.

Candidiasis may be divided into the following types:

Oral candidiasis Perlche Candidal vulvovaginitis Candidal intertrigo Diaper candidiasis Congenital cutaneous candidiasis Perianal candidiasis Candidal paronychia Erosio interdigitalis blastomycetica Chronic mucocuntaneous candidiasis Systemic candidiasis Candidid Antibiotic candidiasis

Symptoms and Diagnosis

Infection of the mouth causes creamy, white, painful patches to form inside the mouth. Skin infections can cause a burning rash. Patches in esophagus cause pain with swallowing. More serious infections such as those in the heart valves, can cause fever, heart murmur and enlargement of the spleen. An infection of the retina and inner parts of the eye can cause blindness. An infection of the blood or kidney can cause fever, very low blood pressure, and a decrease in urine production. Many candidal infections are apparent from the symptoms alone. To confirm the diagnosis, however, a doctor must identify the fungi in a skin sample under a microscope. Samples of blood or spinal fluid that have been cultured may also reveal the presence of the fungus.
The MERCK MANUAL if Medical Information 2nd Home Edition

Cutaneus Candidiasis can present in many different forms, including infection of the nail proper(onychomycosis), nail folds(paronychia), hair follicles (folliculitis), moist, intertriginous skin such as armpits or webs of the fingers and toes, and penile skin(balanitis). Diaper rash is a cutaneus candidial infection seen in the perineum of infants, in the region of contact of wet diapers. Chronic mucocutaneous candidiasis is a chronic refractory disease afflicting the mucous

membranes, skin, hair, and nails. It is associated with underlying T-cell defects. Associated conditions include endocrinopathies and the presence of autoantibodies. Disseminated candidiasis is rare in this diasease. Candida vaginitis is an extremely common form of vaginal infection in women, especially those who are diabetics or pregnant or on oral contraceptive pills. It is usually associated with intense itching and a thick, curd-like discharge.
Robin Basic Pathology 7th Edition SAUNDERS

Sign and Symptom

1. superficial papules and pustules caused by proteolytic enzyme destruction of keratin. 2. erythematous and edematous areas of the infected epidermis or mucous membrane caused by release of possible toxins by the fungus. 3. severe pruritus amd pain at the lesion sites 4. white coating tongue and possibly lesions in the mouth (thrush)

Cutaneus Candidiasis
History Intertrigo(erythema,pruritus,tenderness,pain),Occluded skin(under cast, on back in hospitalized patient), Diaper Dermatitis(irritability,discomfort with urination, defecation, changing diapers). Physical examination Skin Lession Intertrigo initial pustules on erythematous base become eroded and confluent. Subsequently, fairy sharply demarcated, polycyclic, erythematous, eroded patches with small pustular lesions at the periphery. >distribution Inframammary, axillae, groins, perineal, intergluteal cleft. Interdigital Erosio interdigitalis blastomycetica. Initial pustule become eroded, with formation of superficial erosion or fissure, sourrounded by thickened white skin. May be associated with Candida onychia or paronychia. >distribution-on hands,feet. Diaper dermatitis erythema,edema with popular and pustular lesions; erosions, oozing, collarette-like scaling at the margins of lesions involving perigenital and perianal skin, inner aspects of thighs and buttocks.

Management -Topical treatment > Castellani`s paint, Glucocorticoid preparation -Topical antifungal agents > Nystatin cream, Azole cream -Oral antifungal > nystatin(suspension, tablets, pastille) -Systemic antifungal

Oropharyngeal Candidiasis
Occur with minor variations of host factors such as antibiotics therapy, glucocorticoid therapy, age, immunocompromise. Candida can invade through eroded mucosa, with resultant candidemia. Classification Superficial Mucosal Candidiasis > May be associated with mild to moderate impairment of cell-mediated immunity. Oropharyngeal Candidiasis > Pseudomembranous candidiasis; erythematous candidiasis; candidal lekoplakia; angular cheilitis Deep Mucosal Candidiasis > Occur in states of advanced immunocompromise

Physical examination Mucosal Lesions Pseudomembranous Candidiasis (Thrush) >white-to creamy plaque on any mucosal surface. Eryhtematous(Atrophic) Candidiasis > smooth, red, atrophic patches Candidal Leukoplakia >white plaque that cannot be wiped of but regress with prolonged anticandidal therapy. Angular Cheilitis > erythema,fissuring

Host factors
Immunocompromise, DM, obesity, hyperhidrosis, heat, maceration, polyendocrinopathies, systemic and topical glucocorticoids, chronic debilitation.

Immunologic factors
Reduced cell-mediated immunity is the most significant factor. Decreased specific anti-Candida IgA salivary antibody may be a factor. Defects in neutrophil or macrophage functions are factors in invasive candidiasis.

Laboratory Examination
Direct microscopy-KOH preparation visualizes pseudohyphae and yeast forms Culture Fungal The Skin Biopsy The skin biopsy is the most important aid to a dermatologist in making a diagnosis. This relatively simple sounding technique is beset with hidden pitfalls for the unwary. Some amount of thought is necessary on the need for, technique of, and type of skin biopsy. Types punch biopsy scalpel biopsy shave biopsy
Tropical Dermatopathology, Mc Graw Hill

Laboratory diagnosis
Clinical Material Skin and nail scrapings; urine, sputum and bronchial washings; cerebrospinal fluid, pleural fluid and blood; tissue biopsies from various visceral organs and indwelling catheter tips. Direct Microscopy (a) Skin and nails should be examined using 10% KOH (b) Exudates and body fluids should be centrifuged and the sediment examined using either 10% KOH and Parker ink or calcofluor white mounts and/or gram stained smears; (c) Tissue sections should be stained using PAS digest, Grocott's methenamine silver (GMS) or Gram stain. Note Candida may be missed in H&E stained sections. Examine specimens for the presence of small, round to oval, thin-walled, clusters of budding yeast cells (blastoconidia) and branching pseudohyphae. Candida pseudohyphae may be difficult to distinguish from Aspergillus hyphae when blastoconidia are not observed as often happens in liver biopsies.

10%KOH mount showing the presence of budding yeast cells and pseudohyphae in a skin scraping.

PAS stained smear showing the presence of budding yeast cells and pseudohyphae in a urine specimen.

Culture Colonies are typically white to cream colored with a smooth, glabrous to waxy surface.

Typical moist colonies of Candida. Serology Various serological procedures have been devised to detect the presence of Candida antibodies, ranging from immunodiffusion to more sensitive tests such as counter immunoelectrophoresis radioimmunoassay (RIA). However, these are often negative in the immunocompromised patient, especially at the beginning of an infection. The production of four or more precipitin lines in CIE tests has been reported to be diagnostic of candidiasis in the predisposed patient .
It must be stressed that the interpretation of serological tests for Candida, especially in the neutropenic patient, is often difficult and must be correlated with other diagnostic methods. False-negatives and false-positive results do occur. Hopwood and Evans (1991) provide an excellent review of the current serological methods available.

(CIE),

enzyme-linked

immunosorbent

assay

(ELISA),

and

Identification The genus Candida is characterized by globose to elongate yeast-like cells or blastoconidia that reproduce by multilateral budding. Most Candida species are also characterized by the presence of well developed pseudohyphae, however this characteristic may be absent, especially in those species formally included in the genus Torulopsis. Arthroconidia, ballistoconidia and colony pigmentation are always absent. Within the genus Candida, fermentation, nitrate assimilation and inositol assimilation may be present or absent, however, all inositol positive strains produce pseudohyphae.

Complication
secondary bacterial infections of wounds opened by scratching ulcers with chronic forms candidal meningitis, endocarditis, or septicemia caused by systemic disseminating candidiasis.

Treatment
-topical antifungal -oral therapy -eliminating risk factors -oral nystatin and topical miconazole -IV amphotericin B or oral ketoconazole
Handbook of Pathophysiology 2nd Edition Lippincott

Candidiasis that occurs only on the skin or in the mouth or vagina can be treated with antifungal drugs that are applied directly to the affected area (clotrimazole,nystatin). A doctor may prescribe the antifungal drug fluconazole to be taken by mouth. Candidiasis that has spread throughout the body is severe, progressive, and potentially fatal infection that is usually treated with intravenous amphotericin B, although fluconazoleis effective for some people. Certain medical conditions, such as diabetes, can be worsen candisiasis. In people with diabetes, control of the blood sugar levels facilities cure of the infection.
The MERCK MANUAL if Medical Information 2nd Home Edition

References
1. Dorland`s Pocket Medical Dictionary 27th Edition 2. The MERCK MANUAL if Medical Information 2nd Home Edition 3. Robin Basic Pathology 7th Edition 4. Fitzpatrick`s Color atlas & synopsis of Clinical Dermatology 5th edition, Mc GRaw Hill 5. Tropical Dermatopathology, Mc Graw Hill 6. Handbook of Pathophysiology 2nd Edition Lippincott 7. http://images.search.yahoo.com/search/images?p=candidiasis&ni=18&ei=UTF8&fr=yfp-t-501&fr2=tab-web&xargs=0&pstart=1&b=1 8. http://en.wikipedia.org/wiki/Candidiasis 9. http://www.mycology.adelaide.edu.au/Mycoses/Cutaneous/Candidiasis/ 10. www.doctorfungus.org/mycoses/human/candida/neonatal.htm