Demonstration of candida in blood smears

Adhesins in Candida albicans

The adherent properties of Candida albicans blastoconidia and germ tubes have long been appreciated, but little is known about the mechanisms responsible for adherence. Recently, three genes, ALA1, ALS1 and HWP1, encoding proteins with adherent properties and motifs consistent with linkage to the beta-1, 6-glucan of C. albicans cell walls have provided insight into the topology of protein adhesins. Hwp1, a developmentally regulated adhesin of germ tubes and hyphae, attaches to buccal epithelial cells by an unconventional, transglutaminase-mediated mechanism of adhesion.

Postoperative Candida infections of the heart in children: clinicopathologic study of a continuing problem of diagnosis and therapy

Fungal infections of the heart are infrequent postoperative complications in children, yet, when present are often fatal. Children autopsied at The Johns Hopkins Hospital from 1889 to the present were studied for cardiac fungal infection. Among the 14 children so identified, 8 developed cardiac fungal infection after surgery. All postoperative cardiac infections were caused by Candida species. All were autopsied since 1959. Gastrointestinal surgery was performed in 6 patients and cardiac surgery in 2. Candida infection was not confined to the endocardium; endocarditis developed in 2 patients, pericarditis in 1, and myocarditis in 5. None received cytotoxic agents or corticosteroids. Two patients died from direct cardiac involvement. Other deaths were related to Candida sepsis or bronchopneumonia. A clinical diagnosis of cardiac fungal infection was never made. Prolonged administration of multiple antibiotics, central venous catheterization, prematurity and immune deficiency predisposed to cardiac and systemic candidiasis. Clinical features facilitating early diagnosis are discussed. Removal of central venous catheters infected with Candida did not eliminate the source of continued sepsis, since Candida-laden vegetations related to the catheter adhered to the superior vena cava and endocardial surface. Postoperative cardiac candidiasis is a relatively new and persistent problem of early diagnosis and therapy. The post-surgical pediatric patient has major predisposing factors for cardiac candidiasis, which, if unrecognized, may be a source for continued dissemination or may in itself be the cause of death.

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.