Mucosal candidiasis

Fungal infections in primary immunodeficiencies

Patients with phagocytic, cellular, combined and other primary immunodeficiencies exhibit immune deficits that confer increased susceptibility to fungal infections. A number of yeasts and moulds, most commonly Candida and Aspergillus but also Cryptococcus, Histoplasma, Paecilomyces, Scedosporium, Trichosporon, Penicillium and other, rarely isolated, fungal organisms, have been variably implicated in causing disease in patients with chronic granulomatous disease, severe combined immunodeficiency, chronic mucocutaneous candidiasis, hyper-IgE syndrome, myeloperoxidase deficiency, leukocyte adhesion deficiency, defects in the interferon-gamma/interleukin-12 axis, DiGeorge syndrome, X-linked hyper-IgM syndrome, Wiskott-Aldrich syndrome and common variable immunodeficiency. Differences in the spectrum of fungal pathogens as well as in the incidence and clinical presentation of the infections may be observed among patients, depending upon different immune disorders. Fungal infections in these individuals may occasionally be the presenting clinical manifestation of a primary immunodeficiency and can cause significant morbidity and potentially fatal outcome if misdiagnosed or mistreated. A high degree of suspicion is needed and establishment of diagnosis should actively be pursued using appropriate imaging, mycological and histological studies. A number of antifungal agents introduced over the last fifteen years, such as the lipid formulations of amphotericin B, the second-generation triazoles, and the echinocandins, increase the options for medical management of these infections. Surgery may also be needed in some cases, while the role of adjunctive immunotherapy has not been systematically evaluated. The low incidence of primary immunodeficiencies in the general population complicates single-center prospective or retrospective clinical studies aiming to address diagnostic or therapeutic issues pertaining to fungal infections in these patients.

Methylrosaniline chloride stained vaginal smears for the diagnosis of vulvovaginal candidiasis

OBJECTIVE

To study the sensitivity and specificity of methylrosaniline chloride stained vaginal smears for the diagnosis of vulvovaginal candidiasis (VVC).

METHOD

Between September 2005 and February 2006, 214 cases of patients with VVC and 102 cases of controls were investigated at Peking University Shenzhen Hospital. All strains were identified with the API Candida system.

RESULTS

The average age of the patients was 29.87 years. The sensitivity and specificity of methylrosaniline chloride stained vaginal smears for the diagnosis of vulvovaginal candidiasis were 88.3% (189/214) and 96.1 (98/102). The sensitivity of the vaginal smears for the diagnosis of recurrent vulvovaginal candidiasis, mild vulvovaginal candidiasis and severe vulvovaginal candidiasis were 85.2% (46/54), 74.7% (71/95) and 99.2% (118/119).

CONCLUSION

Methylrosaniline chloride stained vaginal smears for the diagnosis of vulvovaginal candidiasis are reliable and inexpensive.

Sequence resources at the Candida Genome Database

The Candida Genome Database (CGD, ) contains a curated collection of genomic information and community resources for researchers who are interested in the molecular biology of the opportunistic pathogen Candida albicans. With the recent release of a new assembly of the C.albicans genome, Assembly 20, C.albicans genomics has entered a new era. Although the C.albicans genome assembly continues to undergo refinement, multiple assemblies and gene nomenclatures will remain in widespread use by the research community. CGD has now taken on the responsibility of maintaining the most up-to-date version of the genome sequence by providing the data from this new assembly alongside the data from the previous assemblies, as well as any future corrections and refinements. In this database update, we describe the sequence information available for C.albicans, the sequence information contained in CGD, and the tools for sequence retrieval, analysis and comparison that CGD provides. CGD is freely accessible at and CGD curators may be contacted by email at candida-curator@genome.stanford.edu.

[Extensive cutaneous candidiasis revealing cutaneous T-cell lymphoma: 2 cases]

BACKGROUND

During the course of immunodeficiency diseases, severe candidiasis can occur with extensive cutaneous and mucous membrane lesions. However, blood dyscrasias are very rarely revealed by diffuse candidiasis. We report two case of cutaneous T-cell lymphoma revealed by extensive and atypical cutaneous candidiasis.

PATIENTS AND METHODS

Case No. 1:A 72-year-old woman presented a pruritic rash of circinate, serpiginous patches on glabrous skin and skinfolds with multiple intertrigo and rapidly worsening palmoplantar keratoderma. All mycological skin specimens tested positive for Candida albicans. Histological examination of a biopsy sample from a serpiginous patch revealed the presence of fungal elements while palmoplantar keratoderma biopsy showed an epidermotropic lymphocytic infiltrate in the superficial dermis evocative of mycosis fungoides. Blood tests showed a white cell count of 28 600/mm3 with 14% circulating Sezary cells and a T-cell clone. The T-cell lymphoma was treated with methotrexate, but the disease worsened a few months later, progressing to CD30- large T-cell pleomorphic lymphoma. The patient died of severe sepsis. Case No 2:A 60-year-old man presented a macular rash over the face, trunk and skinfolds as well as erythematous scaly annular plaques of the glabrous skin with lymphadenopathy. Cultures of skin scrapings were all positive for Candida albicans. Blood tests showed a white cell count of 15 000/mm3 with 30% circulating Sezary cells. A trunk patch biopsy revealed the histological appearance of mycosis fungoides. There was a T-cell clone in the peripheral blood and skin.

DISCUSSION

In both cases, the patients presented with widespread annular and erythematous scaly lesions of the glabrous skin and skinfolds with evidence of Candida albicans on fungal tests of all skin scrapings. The discovery of circulating Sezary cells on a systematic smear for hyperleukocytosis led us to suspect underlying cutaneous T-cell lymphoma, which was confirmed by biopsy of the skin lesions accompanying the mycoses. Widespread cutaneous candidiasis can occur in patients with cell-mediated immunodepression. Cutaneous T-cell lymphoma can enhance such candidiasis through interference with skin integrity and impairment of cell-mediated immunity, with large amounts of IL10 and TGF-B, increased secretion of soluble interleukin-2 receptors (CD25) and impaired CD8 suppressor cell function.

Treatment of sexually transmitted infections in pregnancy

Sexually transmitted infections remain a major public health concern in the United States. An estimated 19 million infections occur each year. The economic burden imposed by sexually transmitted infections is impressive: direct medical costs have been estimated as high as 15.5 billion US dollars annually. Sexually transmitted infections are relatively common during pregnancy, especially in indigent, urban populations. Education, screening, treatment, and prevention are important components of prenatal care for women at increased risk for these infections. Treatment of these sexually transmitted infections is clearly associated with improved pregnancy outcome and reductions in perinatal mortality.

Trends in prescribing for vulvovaginal candidiasis in the United States

PURPOSE

To describe trends in visits to office-based physicians in the United States by females 15-64 years of age for vulvovaginal candidiasis and related antifungal prescribing. Since January 1991, intravaginal antifungal medications have been available over-the-counter in the United States to treat vulvovaginal candidiasis.

METHODS

Data from the 1985 through 2001 National Ambulatory Medical Care Surveys (NAMCS) were examined. NAMCS is an annual national probability sample survey that collects data on the utilization of services provided by office-based physicians.

RESULTS

The average annual visit rates for symptoms of vaginitis and a diagnosis of vulvovaginal candidiasis decreased by 55 and 72%, respectively. The intravaginal antifungal prescribing rate for vulvovaginal candidiasis declined by 41%. No trend was found for total antifungal prescribing; however, during the late 1990s, fluconazole was prescribed at approximately one-third of visits with a diagnosis of vulvovaginal candidiasis.

CONCLUSION

These data suggest an increased trend in self-diagnosis and use of over-the-counter intravaginal antifungal medications. The shift from prescribing intravaginal antifungal preparations to fluconazole raises concern about the possible development of azole drug resistance. Educational efforts are needed to counter potential misuse of these medications that may contribute to increased infection with innately azole resistant non-albicans Candida species and chronic infection.

Oral fungal infections

Candidiasis is the most common oral fungal infection diagnosed in humans. Candidiasis may result from immune system dysfunction or as a result of local or systemic medical treatment. Because oral candidiasis is generally a localized infection, topical treatment methods are the first line of therapy, especially for the pseudomembranous and erythematous variants. Patients with dental prostheses should also be advised to disinfect the prosthesis routinely during the candidal treatment period, because the prosthesis may serve as a source of reinfection. Additionally, patients should be advised that oral hygiene aids, such as toothbrushes and denture brushes, may also be contaminated and should be discarded or disinfected. A disinfecting solution of equal parts of hydrogen peroxide and water may be used. Likewise, 2% chlorhexidine gluconate solution may be used asa disinfecting solution for dental prostheses and oral hygiene aids. Occasionally the clinician encounters a more resistant form of oral candidiasis such as the hyperplastic variant or a variant that does not respond to topical therapy. Appropriate systemic therapy should be employed for the treatment of these infections. Additionally, a biopsy should be undertaken in individuals with the hyperplastic variant of Candida because there is some degree of risk for malignant transformation. Deep fungal infections should be managed in association with appropriate medical specialists to rule out other systemic involvement. The dental health care provider plays an important part in the diagnosis and management of fungal disease, and therefore clinicians should be aware of the presenting signs and symptoms or oral fungal disease.

A Randomized, Double-Blind Trial of Anidulafungin versus Fluconazole for the Treatment of Esophageal Candidiasis

Anidulafungin is a novel antifungal agent of the echinocandin class. This randomized, double-blind, double-dummy study compared the efficacy and safety of intravenous anidulafungin to that of oral fluconazole in 601 patients with endoscopically and microbiologically documented esophageal candidiasis. Patients received intravenous anidulafungin (100 mg on day 1, followed by 50 mg per day) or oral fluconazole (200 mg on day 1, followed by 100 mg per day) for 7 days beyond resolution of symptoms (range, 14-21 days). At the end of therapy, the rate of endoscopic success for anidulafungin (242 [97.2%] of 249 treated patients) was found to be statistically noninferior to that for fluconazole (252 [98.8%] of 255 treated patients; treatment difference, -1.6%; 95% confidence interval, -4.1 to 0.8). The safety profile of anidulafungin was similar to that of fluconazole; treatment-related adverse events occurred in 9.3% and 12.0% of patients, respectively. Laboratory parameters were similar between treatment arms. Anidulafungin is as safe and effective as oral fluconazole for the treatment of esophageal candidiasis, when assessed at the completion of therapy.

Mid-esophageal ulceration and candidiasis-associated distal esophagitis as two distinct clinical patterns of tetracycline or doxycycline-induced esophageal injury

BACKGROUND

Tetracyclines may cause esophageal injury.

GOALS

The aims of this study are to describe 2 distinct clinical patterns of esophageal injury induced by tetracycline or its derivate doxycycline and to compare these patterns with respect to demographic, endoscopic, and clinical characteristics of the patients.

STUDY

Forty-eight patients with the diagnosis of doxycycline- or tetracycline-induced esophageal injury by endoscopy were analyzed retrospectively. The patients were considered in 2 groups according to the type and the location of esophageal lesions (Group A: mid-esophageal ulceration, n = 18; Group B: distal esophagitis, n = 30).

RESULTS

Patients in Group A were significantly younger than in Group B (P = 0.0014). In Group A, 15 patients (83%) had single ulceration, 2 (11%) double, and 1 (6%) circumferential at the mid-esophagus. In Group B, all patients had multiple micro-ulcerations in the distal esophagus. Development of mid-esophageal ulceration was induced predominantly by doxycycline, whereas distal esophagitis was induced by tetracycline. The description of drug ingestion with little or no water by patients in Group A was significantly more frequent than in Group B (94% vs. 10%, P < 0.001). Associated medical and benign gastric diseases and esophageal candidiasis were significantly more frequent in Group B (P = 0.006, P < 0.001, P < 0.001, respectively). Prompt response to medical therapy was observed in both groups with no significant difference (P = 0.093).

CONCLUSIONS

The type of tetracyclines used by patients may give some clues to physicians on the pattern of esophageal injury because mid-esophageal ulceration seems to be more frequently associated with doxycycline and distal esophagitis with or without candidiasis with tetracycline.

Treatment of sexually transmitted diseases in women

Guidelines for the treatment of patients with sexually transmitted infection are developed by the Centers for Disease Control and Prevention after consultation with a group of professionals knowledgeable in the field. This article briefly introduces various infections, reviews new diagnostic information, and presents the latest guidelines for therapy. All recommended and alternative regimens are drawn from the most recent treatment guidelines. Although this article focuses primarily on therapy, it also emphasizes the importance of counseling and prevention. Clinicians have the opportunity and obligation to provide education and counseling to patients. Prevention messages should be tailored to the individual patient with consideration given to her specific risk behaviors.

[Therapy of severe fungal infections]

Severe fungal infections increase in numbers in the Western world. This is due to more intensive therapies against cancers leading to severe and prolonged immunosuppression. For many years treatment of severe fungal infections had to be done solely with amphothericin B desoxycholate and 5-fluorocytosine. With the advent of triazoles such as fluconazole, lipid formulations of amphotericin B and the development of echinocandines such as caspofungin also severe candidiasis and invasive aspergillosis has become treatable. In particular, caspofungin for invasive candidiasis and voriconazole for invasive aspergillosis seem at least equivalent to amphotericin B. A clear advantage is the advent of lipid formulations of amphotericin B. This regards especially side effects which are reduced with these newer formulations, i.e. nephrotoxicity. Due to the fact that prospective trials are difficult to conduct because patient populations may vary considerably (especially the underlying disease) many comparisons were not yet performed. Nevertheless, promising results indicate that certain combinations of antifungals may enhance prognosis of refractory fungal infections with a so far very serious prognosis.

Epidemiology of Candida species infections in critically ill non-immunosuppressed patients

A substantial proportion of patients become colonised with Candida spp during hospital stay, but only few subsequently develop severe infection. Clinical signs of severe infection manifest early but lack specificity until late in the course of the disease, thus representing a particular challenge for diagnosis. Mostly nosocomial, invasive candidiasis occurs in only 1-8% of patients admitted to hospitals, but in around 10% of patients housed in intensive care units where it can represent up to 15% of all nosocomial infections. We review the epidemiology of invasive candidiasis in non-immunocompromised, critically ill patients with special emphasis on disease trends over time, pathophysiology, diagnostic approach, risk factors, and impact. Recent epidemiological data suggesting that the emergence of non-albicans candida strains with reduced susceptibility to azoles, previously linked to the use of new antifungals for empiric and prophylactic therapy in immunocompromised patients, may not have occurred in the critically ill. Management of invasive candidiasis in these patients will be addressed in the December issue of The Lancet Infectious Diseases.