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SystemicCandidiasis

SystemicCandidiasis

•  Causedbyoverabundanceofnaturalyeast•  Heldincheckby“good”bacteriainourbodies•  Affectstheen=resystem

•  An=bio=cs,loweredimmunesystems,recrea=onaldrugs,diabetes,hormonalcontracep=ves,stress,obesity,poorhygiene,poordiet,manyotherreasons.

•  Species:CandidaAlbicans•  Genus:Candida(80%)•  Firstappearancein1923•  Othergenusnames

– Mycotorula

– Torulopsis•  Otherspeciesnames

– Moniliaalbicans

– Oidiumalbicans

Yeast

•  TheCandidagenusismadeupofyeasts.•  Reproduceviaasexualbuddingorsexualsporecrea=on.

•  Themethodofreproduc=onisgreatlyinfluencedbytheenvironment.– Goodenvironment=budding

– Badenvironment=sexualspores

•  Sporesaremoreresistanttohardercondi=ons.

E=ologicalAgents• AnyspeciesoftheCandidagenus

• 150differentspecies• Specifically,CandidaAlbicans(70‐80%)• ButincludesC.glabrata,C.parapsilosis,C.tropicalis,C.krusei,C.kefyr,C.guilliermondi,C.lusitaniae,andC.dubliniensis(whichaffectsalmostexclusivelyHIVpa=ents)

DifferencesbetweenSpecies•  C.albicansisthemostcommonlyrecoveredfrompa=entswithcandidemia.

•  C.glabratahasbecomemoreimportantrecentlyduetoitsresistancetoazolesandpolyenes.

•  C.kruseiisresistanttoamphotericinBandazolesinmostcases.

•  C.parapsilosisisthemostcommonlyassociatedwithcatheters.

•  C.tropicalisisthemostcommonlyassociatedwithinfec=onsincancerpa=entsandbonemarrowtransplants.

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Epidemiology•  Typicalinpa=entswhoarecri=callyill,inmedicalorsurgicalICUs,andimmunocompromisedindividuals,suchascancerpa=entsorHIVpa=ents.Neonatesarealsoverysuscep=ble.

•  Insystemicinfec=ons,itisthe4thmostcommonlyisolatedpathogensfrombloodculturesandhasreplacedtheCryptococcusspeciesasthemostcommonfungalpathogenworldwide.

•  Systemiccandidiasishascausedmoredeathsthananyothersystemicmycosis.

Symptoms•  Redness•  Itching•  Papularrash•  Muscletenderness

•  Discomfort

•  Burning•  Soreness•  Discharge•  None

Diagnosis

•  Feverandchills•  An=bacterialtherapy•  CTandMRI

•  Difficult

•  Bloodculture

Preven=on

•  An=fungaltherapies•  Garlic•  Yogurt•  Certainmilks

•  Lowsugars•  Reducedalcoholintake

CaseReport‐Pa=ent1

•  30yr.oldmanstartedonbroadspectruman=bio=csforpneumoniaduetoLegionellapneumophila.– Admifedtointensivecareafewdayslater.

•  Confusionalsyndrome,feverandpurplishmaculesandpapulesinvolvingtheface,thorax,andlowerlimbs.

•  Lesionsaffectedhairfolliclesmostly.

– Skinbiopsy•  Perivascularandperiadnexialdermalandhypodermalinflammatoryinfiltratewithlobularnecrosisofthefat.

Pa=ent1

Figure 1 Patient 1. Erythematous ⁄ purplish papules and pustules disseminated on the face, neck and upper thorax. The lesions were well defined and slightly infiltrated on palpation.

Source: Clinical and Experimental Dermatology Journal

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Pa=ent1

Figure 2 Patient 1. Biopsy revealed necrosis of the epidermis and vascular thrombosis of small vessels in the underlying dermis. A sparse perivascular infiltrate was evident with variable degree of leucocytoclasia. Occasional small round fungal elements, predominantly spores, were seen between the inflammatory infiltrate (hematoxylin and eosin, original magnification ・ 200).

Source: Clinical and Experimental Dermatology Journal

Cont…– GramandPeriodic‐Acid‐SchiffStain

• Nobacteria,mycobacteria,orfungi.– Chestx‐ray:

•  ShowedalveolarinfiltratesconsistentwithCandida.

– Ocularfundusexamina=onshowedre=nalinvolvement.

– AmphotericinBtreatmentadministered.•  1gramtotal.

•  Cutaneouslesionsresolvedw/oresidualhyperpigmenta=onwithin4days.

Pa=ent2

•  31yr.oldmanwithchronicmyelocy=cleukemia.– Underwentbone‐marrowtransplanta=onfromhishumanleukocytean=gen‐compa=blebrother.

•  1yr.later,hehadablas=ccrisisandstartedoninduc=onchemotherapytreatment.

• Developederythematousnodulesonlowerlimbsandleiarm20dayslater.

– Approx.10nodules,5‐6mminsize– Well‐definedandslightlyinfiltrated

Pa=ent2

Erythematous ⁄ purplish papules and macules

Source: Clinical and Experimental Dermatology Journal

Pa=ent2

Source: Clinical and Experimental Dermatology Journal

Some of the plaques had a pustule in the centre.

Cont…

– Somelesionshadpustuleonsurface

– Histopathologicalexamina=onshowed• Yeastcellsindermoepidermaljunc=onwithminimalinflammatoryinfiltrate.

• Candidatropicaliswasisolatedfromblood.

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Cont…

– Computedtomographyscanshowed:• Hepa=c,splenicandrenalfocallesions,consistentwithandinfec=ousorigin.

– Pa=entstartedonCaspofunginandVoriconazoletreatment• Mostlesionsresolvedinafewdays,withresidualhyperpigmenta=on.

Pa=ent3• Mathaietal.,JournalofForensicandLegalMedicine.(2009)16:31‐34.

• A63year‐oldmalewasadmifedtohospitalaieratrafficaccident

• Receivedtreatmentforaheadinjuryandmul=plefractures

Pa=ent3

•  Pa=entwasunconsciousuponadmissionthenlaterplacedonaven=lator

•  Correc=vesurgerieswereperformedformul=plefractures

Pa=ent3

•  Laboratoryinves=ga=onsyieldednormalresults

•  Washospitalizedforfourmonthsbeforedying

Pa=ent3

•  AutopsyFindings– Kidneyswereenlargedaswellashavingirregulargrayishwhite“patchyareas”

– Necrosiswasfoundthroughoutthemedullaandcortex

– MicrocoloniesofCandidaspecieswerefoundininters==umandtubules

Pa=ent3

Fig. 1. Cut surface of the kidney showing grayish white irregular areas involving the entire renal cortex and medulla.

Source: Journal of Forensic and Legal Medicine

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Pa=ent3

•  Autopsy(cont.)– Nootherobserva=onspertainingtoCandidaspecieswerefoundinothermajororgans

– Diagnosedwithrenalcandidiasis• Whilenotcauseofdeath,wasconsideredacontributorycauseofdeath

Pa=ent3

Fig. 4. Periodic acid-Schiff stain and Gram’s stain highlighting the yeast like budding cells with pseudohyphae in (a) and (b), respectively, (original magnification 1000).

Source: Journal of Forensic and Legal Medicine

Treatment•  Thedrugofchoiceisfluconazoleduetoitseaseofuseandlowertoxicitytothenephronsofthekidneys.

•  Animportantcomponentistheremovalofthefocusoftheinfec=on,suchasthecatheters.

•  Some=mes,surgicalremovalofthecandidalabscessesisrequired,whichcanleadtoreplacementsurgeriesinsomeorgans,suchasvalvereplacementforendocardi=s.

•  AmbisomeandAbelcet

WorksCited•  BilgenH,OzekE,KortenV,EnerBandMolbayD.(1995).Treatmentof

SystemicNeonatalCandidiasiswithFluconazole.Correspondence,58(6),394.

•  Candidiasis:[Print]‐eMedicineInfec=ousDiseases.eMedicine‐MedicalReference.RetrievedJuly15,2009,from:hfp://emedicine.medscape.com/ar=cle/213853‐print

•  Candidiasis.(2008,March27).DepartmentofHealthandHumanServices:CentersforDiseaseControlandPrevenBon.RetrievedJuly10,2009,from:hfp://www.cdc.gov/nczved/dsmd/disease_lis=ng/candidiasis_=.html

•  DiggsC,EskenasyG,SutherlandJandWiernikP.(1976).FungalInfec=onofMuscleinAcuteLeukemia.Cancer,38,1771‐1772.

•  EladS,WexlerA,GarfunkelAA,ShapiraMY,BitanMandOrR.(2006).Oralcandidiasispreven=onintransplanta=onpa=ents:acompara=vestudy.ClinicalTransplantaBon,20,318‐324.

•  Fisher,M.D.andZaou=s,M.D.(2008).TreatmentofCandidiasisinImmunocompromisedPediatricPa=ents.PediatricDrugs,10(5),282‐298.

•  MathaiAM,MenezesRG,NaikR,KanchanT,KumarS,BhatG,ChauhanAandRaiM.(2008).Anautopsycaseofrenalcandidiasis.ForensicandLegalMedicine,16,31‐34.

•  MooreN,LeefJandPangY.(2003).SystemicCandidiasis.RadioGraphics,23(5),1287‐1290.

•  PedrazJ,Delgado‐JimenezY,Perez‐GalaS,Nam‐ChaS,Fernandez‐HerreraJandGarcia‐DiezA.(2008)BlackwellPublishingLtd.ClinicalandExperimentalDermatology,34,106‐110.

•  SvobodaPandKantorovaI.(2006).SystemicCandidaInfec=onintheICU.YearbookofIntensiveCareandEmergencyMedicine,2006(15),595‐603.

•  SystemicCandidiasis.(2005,January).TheBody:TheCompleteHIV/AIDSResource.RetrievedJuly10,2009,from:hfp://www.thebody.com/content/art4977.html

•  SystemicCandidiasis.CandidiasisCure:Whatisitandwhatcanyoudoaboutit.RetrievedJuly13,2009,from:hfp://www.candidiasiscure.com/systemic‐candidiasis.html

•  SystemicCandidiasis‐Causes,SymptomsandCurefor‘Candida’.(2009,April25).ArBclesbase.RetrievedJuly17,2009,from:hfp://www.ar=clesbase.com/women's‐health‐ar=cles/systemic‐candidiasis‐causes‐symptoms‐and‐cure‐for‐candida‐885999.html

•  Yeast‐LifeCycle.ScienceEncyclopedia.RetrievedJuly15,2009,from:hfp://science.jrank.org/pages/7438/Yeast‐Life‐cycle.html