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Recurrent Vaginal Candidiasis

Importance of an Intestinal ReservoirMary Ryan Miles, MD; Linda Olsen, MS; Alvin Rogers, PhD

To test the hypothesis that all cases of vaginal candidiasis are associ-ated with a "reservoir" of this organism in the bowel, paired specimens offeces and vaginal material were cultured for Candida albicans simulta-neously. Ninety-eight young women who complained of recurrent vaginitiswere selected in sequence. The results showed that if C albicans was cul-tured from the vagina, it was always found in the stool. Conversely, if it wasnot isolated from the stool, it was never found in the

vagina.These data are

presented a s a n explanation for the recurrent nature of Candida vaginitis,and thus a cure of vaginitis would not be possible without prior eradicationof C albicans from the gut. The gut-reservoir concept may well apply to otherforms of candidiasis.

(JAMA 238:1836-1837, 1977)

CANDIDA ALBICANS is found so

frequently in the gut (stools) ofhealthy individuals that its presencein this location is generally acceptedas a normal occurrence. In the follow

ing paper, the term candidiasis will

therefore be used only in connectionwith patients who exhibit manifestations of infection outside the gut,that is, in the vagina, perianal skin,and elsewhere.

Vaginitis caused by C albicans hasbecome one of the most troublesomeforms of vaginitis because it is so frequently a recurrent problem. The reasons that some persons present withrepeated episodes of vaginitis andother forms of mucocutaneous candidiasis are not known although precip

itatingevents are known. Cellular

and humoral immunological data arerapidly accumulating,13 but as yet,have contributed little knowledge inunderstanding the pathogenesis orcontrol of candidiasis.

This paper presents evidence thatthe intestine acts as a reservoir for C

albicans, where it may live in harmony with the rest of the host's fecalflora. Minor alterations in the milieuof the host (ie, pregnancy and inges

tion of broad-spectrum antibiotics)facilitate change from commensal toparasite in/on mucocutaneous surfaces. The most common sites of in

fection are contiguous to the anus, ie,cutaneous candidiasis of the diaper orcrural area and vaginitis. The resultsof this study demonstrate that vaginal candidiasis does not occur natu

rally46 without the concomitant presence of C albicans within the largebowel and that a "cure" is not likelyas long as the vagina remains the

onlytreatment

target.PATIENTS AND METHODS

Patients.-Healthy, nonpregnant, femalepatients, 18 to 20 years of age, who pre-

sented themselves for treatment of recurrent vaginitis (three or more episodes) atMichigan State University Health Centerwere chosen in sequence and on a volunteer basis. Cultures were obtained fromthe vagina and feces of each participantand further processed in the Fee Medical

Microbiology Laboratory of MichiganState University.Cultures.Raulin's medium was used for

primary isolation of C albicans. This medium was designated to inhibit the growthof most micro-organisms but to allow thegrowth of Candida species. Yeast growthis evident as early as 24 hours after inoculation, but optimal growth may be expected between five and seven days whenincubated at 24 C. Approximately 1 gm offecal material and swabs containing vaginal specimens were inoculated directly intothe media. Chlamydospore formation oncornmeal plus polysorbate-80 agar was

used for positive identification of C albicans.

RESULTS

Ninety-eight patients were involved in the study. Fifty-one (52%)were found to harbor C albicans inboth vagina and fecal material; 46(47%) were Candida free in both sites(Table 1). Thus, there was 100% correlation between the presence or absence of C albicans in the feces and

vagina of this population (Table 2).A review of the patient's clinical

records supported the recurrent nature of candidiasis. In approximatelyone third of the patients, there hadbeen no prior laboratory confirmation

Table 1.Incidence of C Albicans Isolation From Stool and Vagina*

Stool Vagina

_No.(%)_No. (%)Candidapositive_52(53)_51 (52)Candidanegative_46 (47)_47 (48)Total_98 (100)_98 (100)

'Samples from 98 young women with recurrent vaginitis.

From the Departments of Human Develop-ment (Dr Miles), Microbiology and Public Health(Dr Olsen), and Student Health Center (DrMiles), Michigan State University (Dr Rogers),East Lansing, Mich.

Reprint requests to Health Center, WestGeorgia College, Carrollton, GA 30117 (DrMiles).

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Table 2.Correlation Between Presence or Absence of C Albicans'

C albicans

Stool, positiveStool, negative

Vagina, PositiveNo. (%)51 (98)

Vagina, NegativeNo. (%)

1(2)46(100)

'Candida albicans isolated from stool and vagina of 98 patients with recurrent vaginitis.

of clinical impressions. However, in

no case was Candida previously isolated from the vagina of those whosubsequently proved to be yeast-free.

COMMENT

Candida albicans, unlike otherCandida species, is rarely found outside of the natural animal host.57

However, it is isolated from manysites in healthy persons, especiallyfrom the stools.8,9 Finding Candida inthe gut of persons with clinical candidiasis elsewhere is not new infor

mation.In

the late1950s and

1960s,clinicians were well aware of this correlation, but since a practical meansof eradicating the organism from theintestinal tract of adults was not

known, the subject was never thoroughly pursued.

The data presented in this papershow 100% correlation between the

presence of C albicans in the vaginaand in the bowel (a level of correlation that is rare in any biological system). It would appear that permanentclinical cure of vaginal candidiasis isimpossible no matter what drug isused to treat it topically.

Transmission from one adult orchild to another has not been sat

isfactorily demonstrated. Many authorities state that candidiasis is

venereally transmitted,51012 and sexual partners may present concomi-tantly with genital candidiasis. Butactive vaginitis rarely causes lesionsin men. Preliminary data from ourlaboratory and extrapolation of thebowel-reservoir concept suggest that

crural candidiasis may develop inthose men who also harbor C albicansin the gut. The rare lesions of bala-nitis attributed to C albicans containno organisms and may represent anallergic reaction to a water solubleantigen produced by C albicans in thecoital partner.13

A biological model in which support

of an organism on mucus membraneor skin depends on the organism'shabitation within an intestinal reservoir may not be unique. A recentstudy by Badri et al14 suggests thatthe gastrointestinal tract may be theprimary site of colonization in pregnant women who harbor the organism in the vagina.

The authors can find no evidencethat C albicans, once it becomes partof the fecal flora, ever leaves the hostspontaneously during his or her lifetime. The reported incidence of C al

bicans beingisolated from unselected

healthy populations over the yearshas varied widely, but roughly 35% to50% of humans harbor this yeast inthe gut. There is little variation in the

constancy of this figure from infancyto the grave, which may imply a continuous relationship beginning atbirth.

Candida albicans has been culturedfrom both mouth and stool of new-

borns as early as 24 hours afterbirth.15 In 1960, Kozinn et al1G demonstrated the passage of p-32 labeled Calbicans from the vaginae of mice totheir offspring thus verifying theseworkers' previous studies in humansin which maternal vaginal candidiasisappeared to be the primary source ofneonatal thrush and diaper dermatitis.17

Many papers have appeared in thepdiatrie literature linking C albicanspathological conditions in infantswith the presence of this yeast in thebowel.1819 The hiatus of years between the Candida problems of

babies and those beginning at puberty may simply reflect a milieu lessfavorable to Candida proliferationduring the middle years.

Of economic importance is theknowledge that Candida vaginitiscannot be cured by vigorously treating the vagina. Millions of consumerdollars are spent yearly in the vain

hope of accomplishing this. It hasbeen our policy to use the least expensive medication for the shortest period of time to suppress symptoms.Discussing the nature of the problemwith the patient, eliminating contributing causes when possible, and giving her access to subsequent treatment as she needs it, has been

reassuring and comforting to her.Extending the gut-reservoir concept may help to explain other formsof candidiasis and the immunologicalphenomena found in some people.

References

1. Taschdjian CL, Seelig MS, Kozinn PJ: Sero-logical diagnosis of candidal infections. CRCCrit Rev Clin Lab Sci 4:19-59, 1973.

2. Young RC, Bennett JE, Geelhoed GW, et al:Fungemia with compromised host resistance.Ann Intern Med 80:605-611, 1974.

3. KozinnPJ,

GalenRS, Taschdjian CL,

et al:The precipitin test in systemic candidiasis.JAMA 235:628-629, 1976.

4. Hesseltine HC: Factors relating to mycoticand trichomonal infections. Ann NY Acad Sci-83:245-252, 1959.

5. Monif GRG: Infectious Diseases in Obstet-rics and Gynecology. Hagerstown, Md, Harper &Row, 1974, pp 242-267.

6. Meisels A, Toth B van O: Microbiology ofthe female reproductive tract as determined inthe cytologic specimen: II. In the presence of dia-betes mellitus. J Reprod Med 2:91-95, 1969.

7. Drake TE, Maiback HI: Candida and candi-diasis. Postgrad Med 53:83-88, 120-126, 1973.

8. Epstein B: Studien zur soorkrankheit jahrbkinderheilk. 104:129-182, 1924.

9. Schnoor TG: The occurrence of Monilia innormal stools. Am J Trop Med 19:163-169, 1939.

10. DeCosta EJ: Infections of the vagina andvulva. Clin Obstet Gynecol 12:198-218, 1969.

11. Waisman M: Genital moniliasis as a conju-gal infection. Arch Dermatol Syph 70:718-722,1954.

12. Weech AA: Commencement address, Col-lege of Medicine, University of Florida. J FlaMed Assoc 63:995-999, 1976.

13. Rippon JW: Medical Mycology. Phila-delphia, WB Saunders Co, 1974, p 183.

14. Badri MS, Zawaneh S, Cruz AC, et al: Rec-tal colonization with group B streptococcus: Re-lation to vaginal colonization of pregnantwomen. J Infect Dis 135:308-312, 1976.

15. Anderson NA, Sage DN, Spaulding EH:Oral moniliasis in newborn infant. Am J DisChild 67:450-456, 1944.

16. Kozinn PJ, Taschdjian CL, Burchall JJ, et

al: Transmission of P-32 labeled Candida albi-cans to newborn mice at birth. Am J Dis Child99:31-34, 1960.

17. Kozinn PJ, Taschdjian CL, Wiener H: Inci-dence and pathogenesis of neonatal candidiasis.Pediatrics 21:421-429, 1958.

18. Taschdjian CL, Kozinn PJ: Laboratory andclinical studies on candidiasis in the newborn in-fant. J Pediatr 50:426-433, 1957.

19. Kozinn PJ, Taschdjian CL, Dragutsky D,et al: Cutaneous candidiasis in early infancy andchildhood. Pediatrics 20:827-833, 1957.

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