Severe candidal infections: clinical perspective, immune defense mechanisms, and current concepts of therapy

Cutaneous lesions in disseminated candidiasis mimicking ecthyma gangrenosum

Cutaneous nodules are recognized as a manifestation of disseminated candidiasis. We describe skin lesions clinically identical to ecthyma gangrenosum that, on microscopic examination, were due to Candida emboli rather than Pseudomonas sepsis. Thus, the appearance of necrotic pustules and ulcerative plaques in the immunocompromised patient would raise the possibility of Candida as well as Pseudomonas sepsis, and illustrates the diagnostic importance of skin biopsy in such cases.

Candida pericarditis

Purulent pericarditis due to species of Candida is rare. Only seven cases were found in the literature. Described here is a man with Candida tropicalis colonization of the urinary bladder in whom C. tropicalis pericarditis later developed. Amphotericin B was given intravenously. The amphotericin B level in pericardial fluid was approximately 50 percent of the concentration in serum. Although microbiologic cure was achieved with amphotericin B, the patient died of other causes. Autopsy showed sterile constrictive pericarditis.

Candida endophthalmitis associated with total parenteral nutrition

Candida albicans is the most common fungal infection which can occur in patients receiving total parenteral nutrition therapy. While rare, Candida endophthalmitis also can occur and must be considered as a potential risk of this treatment. Early detection and management of this disorder can alter the visual outcome for these patients. Systemic administration of amphotericin B and fluocytosine is the most common form of treatment for Candida endophthalmitis. In cases not responsive to systemic administration of antifungal agents, surgical management through pars plana vitrectomy can potentially eradicate the infection and preserve vision. We present a case of bilateral Candida endophthalmitis treated with amphotericin B and fluocytosine, and also with pars plana vitrectomy with the intracameral injection of amphotericin B into the anterior vitreous cavity. Systemic and intracameral use of antifungal drug therapy combined with vitrectomy restored useful vision to the patient.

Candida endophthalmitis in the premature infant

An attempt was made to determine the incidence and natural history of Candida endophthalmitis in the premature infant with systemic candidiasis. Each of eight premature infants were examined by indirect ophthalmoscopy within one week of their diagnosis. At this stage, four infants had multiple fluffy white lesions on both the retina and the vitreous, together with a diffuse vitreous haze. Three of the infants had interlesional and lesional-retinal vitreous strands. Three infants treated with amphotericin B and 5-fluorocytosine showed gradual disappearance of the lesions. The fourth infant died early in the course of antifungal therapy, when the eye lesions were progressing. Candida sepsis was particularly prevalent in the very low-birth-weight infant with a prolonged hospital course and treated with multiple broad-spectrum antibiotics. The course of the eye lesions indicates a good prognosis for Candida endophthalmitis, although further follow-up is necessary.

Candida laryngitis in chronic mucocutaneous candidiasis. Its association with Candida esophagitis

Four patients with chronic mucocutaneous candidiasis (CMC) underwent esophagoscopy and microlaryngoscopy. Cultures were obtained by biopsy of the larynx and the esophagus. Three of the four patients with laryngeal disease proven by laryngoscopy and culture also had extensive esophageal disease. One patient with a normal larynx by examination and culture also had a normal esophagus. There appears to be a good correlation between the presence of laryngeal and esophageal disease.

Case report: candida infection presenting as laryngitis

Three patients with acute leukemia are described who developed hoarseness as an initial presentation of candida infection. Two of these patients subsequently developed systemic candidiasis. Patients with acute leukemia who develop hoarseness should be investigated for laryngeal candidiasis and considered for systemic antifungal therapy.

Successful treatment of chronic mucocutaneous candidiasis with ketoconazole

Ketoconazole, a new oral antifungal agent, was evaluated in the treatment of four patients with severe chronic mucocutaneous candidiasis refractory to standard antifungal therapy. Three had Candida esophagitis, and too had previously received intravenous amphotericin B. Initial ketoconazole dosage was 100 mg daily for patients weighing less than 30 kg and 200 mg daily for patients over 30 kg. All four patients showed dramatic improvement on the initial dose; three had complete clearing of mucous membrane and skin lesions within three weeks. Of the three patients with Candida esophagitis, one had complete clearing of esophagitis within one month and two were markedly improved. One patient required 400 mg daily to obtain complete clearing of skin and mucous membrane lesions. Two patients were maintained free of overt disease on one dose three times weekly but two patients relapsed and have required daily ketoconazole therapy to keep them free of Candida. The only side effects were mild nausea (two patients) occasional emesis at higher doses (two patients), and transient hypocholesterolemia (one patient). No adverse hematologic, gastrointestinal, or renal effects were noted. Ketoconazole appears to be a valuable oral antifungal agent for some patients with CMC.

Quantitation of antibody against cell wall mannan and a major cytoplasmic antigen of Candida in rabbits, mice, and humans

Cell wall mannan of type A Candida albicans was purified, conjugated with tyramine, and labeled with 125I. Labeled cell wall mannan was used in a radioimmunoassay to measure serum antimannan antibody levels. An ammonium sulfate-soluble fraction of a cytoplasmic extract of C. albicans contained a large amount of a major cytoplasmic antigen of this organism. When the sulfate-soluble fraction was labeled with 125I, much more 125I attached to this major antigen than to the other antigens present in the sulfate-soluble fraction. Thus, when serum antisulfate-soluble fraction antibody levels were measured by a radioimmunoassay which used the iodine-labeled sulfate-soluble fraction, antibody against this major cytoplasmic antigen was quantitated. Both radioimmunoassays were used to measure antimannan and antisulfate-soluble fraction antibody levels in mice, rabbits, and humans. Irrespective of the procedure used to elicit antibody against C. albicans antigens, mice failed to produce antimannan antibody. By contrast, all strains of mice tested produced antisulfate-soluble fraction antibody after immunization, and the magnitude of this antibody response depended on the strain of mice immunized. Rabbits readily produced antibody against both mannan and sulfate-soluble fraction when immunized by a variety of methods. Antimannan antibody was detected in 100% of sera from a randomly selected sample of 50 hospitalized patients. Only 1 of 50 patients had antisulfate-soluble fraction antibody detectable by radioimmunoassay. In pooled normal human serum, most antimannan antibody was of the immunoglobulin G class.

Purification of cytoplasmic antigens from the mycelial phase of Candida albicans: possible advantages of its use in Candida serology

The serology of candidiasis is complicated by the use of poorly defined antigens. Total extracts of the yeast phase have been commonly used as "cytoplasmic' antigen, without regard to the significant amounts of carbohydrate that may contaminate such preparations. This is particularly true in the case of commercially available antigens that have been used as cytoplasmic antigens but actually are richer in carbohydrate than in protein. Affinity chromatography in concanavalin A - Sepharose provides a simple procedure to separate carbohydrates, mainly mannan, from protein antigens in whole Candida extracts. By using mannan-poor antigens, the specificity of serological reactions can be increased considerably, since both the positive reactions seen in a-symptomatic donors and the cross-reactions seen in patients infected with other fungi are due to anti-mannan antibodies. In contrast, both anti-mannan and anti-cytoplasmic antigen antibodies can be detected in patients suspected of systemic candidiasis. On the other hand, absolute specificity may never be achieved for systemic candidiasis. We have found antibodies against cytoplasmic antigen in a patient allergic to C. albicans, in whom the microorganism was isolated from fecal material. It appears that, under favorable conditions, mucosal sensitization may also trigger as systemic reaction directed against both mannan and cytoplasmic antigens.

An evolution of therapy for mucocutaneous candidiasis

Chronic mucocutaneous candidiasis is a relatively uncommon form of candida infection, and can be found in patients with primary deficiencies of their immune systems. When such infection occurs in patients with non-lethal immune deficiences defects of chemotaxis or cellular immunity can be found. In addition, significant endocrinopathies may occur, particularly involving the parathyroid and adrenal glands. A number of therapies have been devised for the treatment of chronic candidiasis, and have included both local and systemic medications. The most useful of these in the past have included the polyene antibiotics -- most notably, nystatin and amphotericin B. Antifungal activity has also been demonstrated clinically with the use of 5-fluorocytosine (a fluorinated pyramidine) and clotrimazole (a synthetic imidazole derivative). However, long-term therapy with medication has been required, and re-emergence of symptomatic infection has occurred when medications have been stopped. More recently, immune reconstitution with transfer factor has been employed in the treatment of patients who have been found to be anergic to candida. Such treatment in conjunction with chemotherapy has indicated that effective patient remissions can be obtained in those patients who develop and maintain cell-mediated immunity to candida. Twelve patients with chronic mucocutaneous candidiasis are profiled. Sites of involvement in the head and neck included the skin and hair (9), ears (9), nose (4) and throat (12). One patient had candida laryngitis, while five patients had evidence for esophageal disease. Of this latter group, one (a 5-year old boy) developed esophageal stenosis which required gastrostomy and retrograde esophageal dilatations. Nine patients were found to be anergic to candida. In these patients, systemic chemotherapy (as amphotericin B or 5-fluorocytosine) was used to induce remissions of disease and transfer factor was given to induce reactivity to candida. By so doing, topical or oral medications (utilizing miconazole, clotrimazole and nystatin) were found to suffice in maintaining effective local control of infection.

Fungicidal activity of rabbit alveolar and peritoneal macrophages against Candida albicans

We tested the ability of rabbit macrophages to kill Candida albicans in vitro. Resident (unstimulated) alveolar macrophages killed 28.1 +/- 1.9% of ingested organisms in 4 h, whereas resident peritoneal macrophages killed only 15.2 +/- 1.3% (mean +/- standard error of the mean, P < 0.01). Peritoneal macrophages obtained from rabbits treated 3 weeks earlier with complete Freund adjuvant showed enhanced candidacidal activity relative to normally resident peritoneal cells (28.2 +/- 3.1%, P < 0.01). Candidacidal activity by alveolar macrophages recovered from such treated animals was slightly enhanced relative to untreated alveolar macrophages (32.9 +/- 2.3%). Candidacidal activity by peritoneal and alveolar macrophages was not decreased by several agents (cyanide, azide, sulfadiazine, and phenylbutazone) that inhibit the ability of human blood monocytes to kill C. albicans. In contrast, candidacidal activity by alveolar macrophages was greatly diminished by iodoacetate, an ineffective inhibitor of this function in human monocytes. We conclude that rabbit macrophages kill C. albicans by a fungicidal mechanism distinct from the peroxidase-H2O2 mechanism of human granulocytes and monocytes, and that the fungicidal properties of peritoneal and alveolar macrophage populations are enhanced after nonspecific stimulation with complete Freund adjuvant.

Detection of candida antigenemia in human invasive candidiasis by a new solid phase radioimmunoassay

There is a continuing need to develop reliable non-invasive methods to aid in the early diagnosis of disseminatyed candidiasis. We report the development of a solid phase "sandwich" radioimmunoassay (RIA) for the detection of soluble cytoplasmic protein antigens (SPA) of Candida albicans in patients with systemic candidiasis. SPA were prepared by ultrasonic disruption of blastospores of C. albicans. Anti-SPA IgG was covalently linked to a solid phase of polyacrylamide-like microspheres. Standard amounts of patient sample or SPA in pooled normal human serum were reacted with the conjugated microspheres, washed and reacted with anti-SPA IgG-125I. The amount of antigen was directly correlated with the amount of bound 125I-IgG anti-SPA. In a retrospective analysis, circulating SPA in the range of 0.5-1.6 microgram/ml was detected in the serum of 12 of 19 patients (63%) with documented systemic candidiasis. There was no detectable SPA in the serum of 20 hospitalized patients with bacteremia, two patients with aspergillosis, one with cryptococcosis, and three with invasive Candida tropicalis. We observed no crossreaction of the RIA with mannan from C. albicans, coccidioidin or culture filtrate antigen of Aspergillus fumigatus. There was significant inhibition of the RIA by serum samples from two patients with chronic candidiasis suggestive of anti-SPA antibody excess. The solid phase RIA to detect circulating SPA can provide a useful noninvasive method for the diagnosis of systemic C. albicans infection.

Strain variation and morphogenesis of yeast- and mycelial-phase Candida albicans in low-sulfate, synthetic medium

A low-sulfate synthetic medium was developed in which pure cultures of yeast- and mycelial-phase Candida albicans could be cultivated for investigations of the molecular biology of dimorphism. The medium contained ammonium ions, phosphate buffer, salts, glucose, and biotin. Morphogenesis was found to be dependent upon the strain of C. albicans. Of six strains tested in the low-sulfate medium at 37 degrees C, three formed mixed cultures of yeasts, true mycelium and pseudomycelium, two formed pure cultures of true mycelium, and one maintained yeast growth. All six strains produced pure cultures of yeasts at 24 degrees C. The buffering capacity of the medium maintained the pH at 6.9 even at high-density cell growth. The low concentration of sulfate and the absence of amino acids in the medium provided conditions in which to radiolabel cellular constituents with [35S]sulfate. For molecular investigations, the use of two strains is suggested, one forming yeasts and one forming true mycelium in low-sulfate medium at 37 degrees C, thus providing controls for both strain variation and for molecular changes induced by environmental change but unrelated to morphogenesis.

Dermatophytosis in patients with chronic mucocutaneous candidiasis

We review the association of concurrent dermatophytic infections in patients with chronic mucocutaneous candidiasis and add twelve new patients to the seventeen previously reported ones. In sixty patients with chronic mucocutaneous candidiasis studied at the National Institutes of Health (NIH), twelve (20%) also had significant local or diffuse dermatophytosis. A comparison between candidiasis patients with and without dermatophytosis revealed no significant differences in their distribution within the various clinical syndromes of chronic mucocutaneous candidiasis nor in the immunologic responses that were tested. Failure to recognize coexistent dermatophytosis in candidiasis patients may lead to unsatisfactory responses to treatment.

Vertebral disc space infection and osteomyelitis due to Candida albicans in a patient with acute myelomonocytic leukemia

A 67-year old man with acute myelomonocytic leukemia had Candida albicans fungemia during induction chemotherapy. Bilateral pulmonary infiltrates and hepatic granulomata containing yeast forms and septate hyphae developed, but cultures of the hepatic tissue failed to grow a fungus. Although his pulmonary and liver disease improved following appropriate therapy, vertebral osteomyelitis due to Candida albicans developed approximately 12-15 weeks after the original fungemia. The fungal osteomyelitis was successfully treated with amphotericin B and 5-fluorocytosine. This case illustrates the need for early diagnosis and aggressive treatment of fungal infections in patients with leukemia.

Chronic mucocutaneous candidiasis. Immunologic studies of three generations of a single family

A family consisting of eight members in three generations (age 10 months to 53 years) affected with chronic mucocutaneous candidiasis was studied along with three unaffected relatives. Dermatophytosis, loss of teeth and recurrent viral infections were present in some members. Results of tests for endocrinologic, muscle or liver disease, thymoma, iron deficiency, antitissue antibodies and malabsorption were normal in all patients. Antibody function and levels, B cell counts, serum complement, leukocyte enzymes, chemotaxis, phagocytosis and adherence were normal in all members. Plasma inhibitors to lymphocyte transformation and leukocyte inhibitory factor were not found. No unique HLA haplotype or antigen segregated in this family. Evaluation of cell-mediated immunity revealed total cutaneous anergy in three of eight whereas four of the other five had negative lymphocyte transformation and skin tests to Candida but responded normally to other antigens. Leukocyte inhibitory factor was not produced to Candida antigen in all four patients tested. T cell counts were within normal limits in all. Extensive evaluation of all limbs of the immune system in this family revealed a defect in cell-mediated immunity to Candida that appeared to be inherited as a dominant characteristic.

Fungal endocarditis: patients at risk and their treatment

Fungal endocarditis is not rare. It usually develops in patients with abnormal or surgically traumatized hearts, to whose blood fungi have gained access, perhaps during temporary (often iatrogenic) impairment of host defences. Although the blood is cleared rapidly, the fungus can establish itself in the endocardium, where it grows slowly. Thus, clinical and laboratory procedures (including blood and urine cultures) that have permitted early diagnosis and treatment of bacterial endocarditis, are not reliable in early fungal endocarditis. Greater reliance must be placed on serological monitoring of patients who have had transient fungaemia and are at risk of endocarditis. The clinician must consider factors that enhance fungal proliferation and invasion and be cognizant of its dangers - even in the absence of clear signs of infection. Prophylactic measures should be employed to protect the patient at risk, including topical, oral and systemic use of appropriate antifungal agents. Early therapy, the extent and duration of which can be determined by (1) obtaining the MIC of transitory blood or urine isolates - which should not be ignored - and (2) monitoring serology, might eliminate early invaders of the endocardium. Sixty-four reported cures of fungal endocarditis caused by Candida, the most common fungal pathogen, are tabulated, 29 were of classic fungal endocarditis requiring surgery, 3 of whom were seen later by others as fatal recurrences. Those treated early (shortly after candidaemia was diagnosed - mostly in patients on treatment for bacterial endocarditis or after cardiac surgery) survived without need for surgical removal of vegetations or valve replacement. Despite strong suggestive evidence that the first 35 patients tabulated had fungal endocarditis, histological proof exists for only a few who had surgery.

Cures of endocarditis caused by other fungi are noted. Improved surgical and medical therapy has improved the prognosis even of patients with the far-advanced disease. However, development of classic fungal endocarditis has been reported one or more years after cardiac surgery and late recurrences after intensive therapy of fungal endocarditis, that had led to clinical recovery of 2 years or more, have been reported. Serological monitoring of vulnerable patients might alert the physician to recurrence early enough for efficacy of drug therapy, averting fatal outcome or the need for further surgery.

Multiple biotin-dependent carboxylase deficiencies associated with defects in T-cell and B-cell immunity

Three siblings presented in early childhood with central-nervous-system (CNS) dysfunction, candida dermatitis, keratoconjunctivitis, and alopecia. Two were studied immunologically and had absent delayed-hypersensitivity skin-test responses and absent in-vitro lymphocyte responses to candida antigen. One of them had selective IgA deficiency and no antibody response to pneumococcal polysaccharide immunisation, and the other had a subnormal percentage of T lymphocytes in peripheral blood. The first two siblings died with progressive CNS deterioration and overwhelming infection. The third child, who presented with a periorificial candida dermatitis, alopecia, keratoconjunctivitis, and intermittent ataxia at eighteen months of age, had intermittent lactic acidosis and raised excretion of beta-hydroxyproprionate, methylcitrate, beta-methylcrotonylglycine, and beta-hydroxyisovalerate in urine. After four days of oral biotin, 10 mg/per day, the metabolites in her urine were significantly reduced, suggesting a biotin-responsive multiple carboxylase deficiency. These findings, taken with previous reports of immune defects in patients with disorders of branched-chain aminoacid catabolism, suggest a new biochemical basis for primary immunodeficiency disease.

Prevalence of Aspergillus and Candida precipitins in renal dialysis and transplant patients

Serum precipitin tests to Aspergillus and Candida antigens were used to define the rate of infectivity with these fungal organisms in patients on renal dialysis and after kidney transplantation. A total of 58 studies in 53 consecutive patients, of whom 41.5% were post-transplant an average of 14.6 months, failed to detect significantly more precipitin activity than in a normal population. The specificity of this non-immunoreactivity was supported by the absence of clinical or post-mortem evidence of fungal invasion. Since serum precipitins develop despite immunosuppressive therapy, and cases of fungal invasion in transplant recipients may occur sporadically in clusters, monitoring of renal transplant patients with these relatively simple tests should detect endemic occurrences of aspergillosis and candidiasis.