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Opportunistic Fungal Infections

Candida
Susan Richardson
January 11, 2010
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Opportunistic Fungal Infections

Require impairment of host immunity to cause serious infection


Clinical infection - localized to severe systemic infection
Yeasts:
Candida spp. (albicans, tropicalis, parapsilosis, krusei, glabrata, lusitaniae,
kefyr, guilliermondii etc.)
Cryptococcus neoformans
Filamentous fungi:
Aspergillus spp. (fumigatus, niger, flavus)
Zygomycetes (Rhizopus, Mucor, Rhizomucor, Absidia)
Fusarium spp.
Penicillium spp. (marneffei)
Pseudallescheria boydii (Scedosporium apiospermium)
Curvularia spp.

Predisposing Factors
(Immunologic)

Cancer (esp. hematological malignancy)


Key defect: Neutropenia

Organ Transplantation (bone marrow, liver,


lung, kidney)
Key defect: Neutropenia, Impaired T cell function

Cellular Immune Dysfunction (AIDS,


lymphoma, CMC)
Key defect: Impaired T cell function
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Predisposing Factors
(Non-Immunologic)
Chemotherapy (cytotoxic) - mucosal damage
of GI, respiratory, GU tracts
Antibiotics - Broad spectrum; loss of normal
flora, esp. anaerobic
Invasive devices - breach skin/mucosal
defences, i.e. intravenous lines, urinary
catheters, tracheostomies
Invasive procedures - surgery, diagnostic
biopsies

Transmission of Opportunistic
Fungi

Candida, Trichosporon, Malassezia


ENDOGENOUS
unique strain
colonization precedes infection
antibiotic suppression of normal flora, fungal
overgrowth

EXOGENOUS
hand carriage health care worker
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Transmission of Opportunistic
Fungi

Aspergillus, Zygomycetes, other


filamentous fungi, Cryptococcus
EXOGENOUS
inhaled conidia
ventilation systems, construction, heliports, plants,
environment
direct contact - dressings, arm boards, burns,
wounds
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Candida

MOST COMMON invasive fungal infection in


immunocompromised patients
4th most common cause of nosocomial blood stream infection
Species implicated in human disease most often:

C. albicans
C. tropicalis
C. parapsilosis
C. krusei (fluconazole resistant)
C. glabrata
C. lusitaniae (amphotericin B resistant)

Candida
Thick

cell wall of mannan and glucan


polysaccharides
Unicellular, budding (asexual)
reproduction (blastospores)
Filament formation
Pseudohyphae (buds stay attached, constricted,
chains of elongated blastospores)
Hyphae (buds germinate)
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Cell wall Candida albicans

Candida - Pathogenicity / Virulence


Factors
C. albicans >>> virulent than other Candida
species
Rapid switching of expressed phenotype

Enhanced ability to reassort and regulate genetic


expression by chromosomal rearrangement and
recombination
phenotypic - nutrient stress produces different colony forms
virulence factors (including antifungal resistance, e.g. C.
lusitaniae vs. amphotericin B)

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Candida - Pathogenicity / Virulence


Factors

Hyphal formation
Hyphal formation is associated with tissue invasion
( yeast forms associated with epithelial colonization)
spontaneous C.albicans non-hyphae-forming mutant
shows decreased pathogenicity in a rat Candida vaginitis
model
Experimental renal infection - yeast and hyphae initiate
renal lesions, but hyphae are essential for invasion of the
renal pelvis.

Hyphae adhere more readily to host epithelial surfaces than do


yeast cells (50x more adherent)
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Candida - Pathogenicity / Virulence


Factors

Contact sensing - growth of hyphae on filters or


membranes (thigmotropism)
When placed on agar medium grow through pores and
along grooves. Tissue penetration may be aided by
following surface discontinuities and microscopic breaks

Surface hydrophobicity
Hydrophobic C. albicans at 25 C >>virulent than more
hydrophilic C. albicans at 37 C
Hydrophobic CA show increased adherence and more
rapid hyphal germ tube formation
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Candida Pathogenicity / Virulence Factors

Surface virulence molecules (receptors,


adhesins, pyrogens, and immunomodulators)
Candida adhere to:
epithelial cells (buccal, cervical, corneal, urinary,
gastrointestinal mucosa), vascular endothelial cells,
spermatozoa, plastics

Candida form ligands to host components C3d, iC3b, fibrinogen, laminin, fibronectin,
fucose receptors, N-acetylglucosamine receptors
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Candida
Pathogenicity / Virulence Factors

Molecular mimicry
Surface coat of molecules that mimics host components
(decreases recognizability)
C. albicans cells in the bloodstream become rapidly coated with
host platelets via the fibrinogen-binding ligand.

Lytic enzymes
Hydrolases with broad substrate specificities (proteinase,
phospholipase(s), lipase(s), acid phosphomonoesterase).
Aspartyl proteinase - most potent or thoroughly studied.

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Candida
Pathogenicity / Virulence Factors

Growth rate and undemanding nutrient


requirements
Virulent strains have shorter doubling times than
attenuated strains
C. albicans not fastidious, but nutritionally deprived
mutants (auxotrophs for adenine, lysine, serine, uracil
and heme) show decreased virulence

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Candida

Human commensal (endogenous)


skin, gastrointestinal, genitourinary tracts
5 - 15% carriage rate in normal people
increased carriage with use of antibiotics

Environmental (exogenous)
much less common
food, animals, soil hospital environment
outbreaks have occurred
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Candida - Clinical

Mucous membrane infections


Thrush (oropharyngeal)
Esophagitis
Vaginitis
Cutaneous infections
Paronychia (skin around nail bed)
Onychomycosis (nails)
Diaper rash
Balanitis
Chronic mucotaneous candidiasis
children with T-cell abnormality
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Mucosal candidiasis

Oral thrush
Vaginal candidiasis

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Cutaneous candidiasis

Diaper dermatitis
Balanitis

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Cutaneous candidiasis

Onychomycosis and paronychia

Chronic mucocutaneous candidiasis


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Candida - Clinical

Urinary tract infection

Fungemia

Disseminated (systemic, invasive) infection


Immunocompromised patients
Cancer/chemotherapy
Neonatal candidiasis

Endophthalmitis (eye)
Liver and spleen
Kidneys
Skin
Brain
Lungs
Bone

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Clinical profile
Central catheter
Parenteral nutrition
Broad-spectrum
antibiotics
Neutropenia

Very low birth weight22

Disseminated candidiasis

Endophthalmitis

Disseminated skin lesion

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Disseminated candidiasis

Hypo-echoic splenic lesions

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Candida - Laboratory Diagnosis 1


Specimens - Blood, tissue (biopsy or autopsy),
sterile fluid, urine, CSF, skin, respiratory secretions
Microscopy (direct on specimen - except blood and
urine)

Gram stain, Calcofluor

Histopathology (tissues)
H & E - stain poorly
GMS, PMS - stain well

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Candida species
Top: Calcofluor White x400: Yeast and
pseudohyphae

Bottom: Gram stain x1000: Yeast and


pseudohyphae

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Pathology of disseminated
candidiasis

Yeast-like cells and septate hyphae


GMS

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Pathology of disseminated
candidiasis

Esophagus, vascular invasion, blastoconidia and pseudohyphae, PAS

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Pathology of disseminated
candidiasis

Hematogenous renal candidiasis. Disseminated miliary abscesses,


cortex and medulla. Necrotic papillae.
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Candida - Laboratory Diagnosis 2

Culture (all specimens)


Colony morphology
White, smooth, creamy, sometimes wrinkled
Laboratory identification
Unique color on chromagar
Chlamydospore production (terminal vesicle)
Germ tube production (in horse serum)
beginning of true hypha (no constriction)
C. albicans - Germ tube positive
Other Candida - Germ tube negative
Carbohydrate assimilation and fermentation (API 20C, Vitek2, RapID and
reference)
Urea and nitrate
Microscopic morphology on Cornmeal Tween 80

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Yeast Identification

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Candida species
Candida albicans
Sabouraud Agar
Morphology: Creamy white yeast,
may be dull, dry irregular and
heaped up, glabrous and tough
Chromagar
producing green pigmented colonies
on specially designed medium to
speciate certain yeasts based on
color they produce
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Candida species
Germ tube: inoculation of yeast in horse
serum incubated at 370C for 2 to 3 hours
Germ Tube: Positive
Germ tube is a continuous filament
germinating from the yeast cell without constriction
at the point of attachment.
e.g. C. albicans, C. dubliniensis
Germ Tube: Negative
Shows constriction at the attachment site
e.g. other Candida species, esp. C. tropicalis
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Candida species
Candida albicans
Oxgall Agar
large round and thick
walled chlamydospores
x400
Cornmeal Agar
clusters of
blastospores along
pseudohyphae at regular
intervals

x1000
x400
x1000
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Yeast identification

C. parapsilosis
Short, curved pseudohyphae

C. guilliermondii
Few, short pseudohyphae
Clusters of blastoconidia at septae

C. lusitaniae
Slender, branched, curved pseudohyphae
short chains of blastoconidia

C. lipolytica

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Elongated blastoconidia in short chains

Yeast identification

C. dubliniensis
Terminal chlamydospores

C. krusei
Elongate blastoconidia
Cross-matchsticks, tree-like

C. tropicalis

Graceful long pseudohyphae


Single/small groups blastoconidia along pseudohyphae

C. glabrata
No pseudohyphae, small blastoconidia

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Candida - Laboratory Diagnosis 3


Candida

antigen, antibody and


metabolite detection
NOT useful in routine practice
Low sensitivity and specificity

Polymerase chain reaction


No more sensitive than blood culture in
studies to date
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Candida - Treatment
Remove infected intravenous lines
Antifungal therapy for systemic infection

Amphotericin B IV
Azoles (fluconazole, itraconazole,
voriconazole, posaconazole) orally, intravenous
Flucytosine (only with Ampho B because of
resistance)
Echinocandins (caspofungin, micafungin)
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Candida antifungal resistance

Primary (inherent) resistance


C. lusitaniae (amphotericin B)
C. glabrata (fluconazole)
C. krusei (fluconazole)

Secondary (acquired) resistance


Fluconazole, other azoles
Amphotericin B
5-FC
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Candida antifungal susceptibility


testing

Testing methodology
Reference broth microdilution (CLSI)
Commercial broth microdilution with alamar
blue (Sensititre, YeastOne)
E-test
Disk diffusion (CLSI
Vitek 2

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Candida antifungal susceptibility


testing

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Candida antifungal susceptibility


testing

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