Laryngeal candidiasis in children

Laryngeal Infections

The following chapter is a review of the most common viral and bacterial etiologies of pediatric laryngeal infections. The chapter reviews the diagnostic approach to laryngeal infections, focusing on key points of the history and physical exam, including concerning signs and symptoms suggestive of airway distress. Viral and bacterial laryngitis, croup, epiglottis, recurrent respiratory papillomatosis, as well as some less common causes of bacterial infections are discussed in detail with each etiology’s epidemiology, clinical features, associated diagnostic evaluation, and management reviewed.

An interesting entity mimicking malignancy: laryngeal candidiasis

Primary candidiasis in the laryngeal mucosa is rare but has many predisposing factors, in particular immune insufficiency and long-term antibiotic use. This study involved a reassessment of 530 laryngeal biopsy specimens originally examined between 2004 and 2009, from which 11 cases of hyperplastic laryngeal candidiasis were identified according to their clinical and histopathological features. Among possible predisposing factors, immune insufficiency was identified in three patients, there was long-term antibiotic use in two cases, use of inhaled corticosteroids in four cases, smoking in eight cases and reflux symptoms in four cases. Dysplasia as well as hyperplasia was seen in two cases. Endolaryngeal lesion excision was performed in eight cases and biopsy leading to radical surgery was done in three. In clinical follow-up no lesions were observed in nine cases while two had new leukoplakic lesions.

Concomitant Candida epiglottitis and disseminated Varicella zoster virus infection associated with acute lymphoblastic leukemia

Acute epiglottitis by nonbacterial pathogens is an uncommon but life-threatening clinical entity. Herein, we report the concomitant occurrence of Candida epiglottitis and mucosal and visceral Varicella zoster virus infection in a child with acute lymphoblastic leukemia. Both infections were atypical in their presentation, occurred in a severely immunocompromised host, and required invasive procedures for diagnosis.

Oral versus intravenous therapy in the treatment of systemic mycosis

The great majority of systemic fungal infections require long-term therapy that often extends 6-12 months, particularly in immunosuppressed patients. It can be difficult to comply with this requirement when the drug to be used is only available for intravenous administration, because problems related to maintaining a permeable venous pathway for long periods arise. The availability of an intravenously (IV) and orally (PO) administered drug can solve this problem by making sequential therapy possible. Voriconazole is a new antifungal agent that, apart from satisfying this requirement because it has a high oral bioavailability, presents a broad spectrum of antifungal activity that makes its use possible, a priori, in the initial and/or sequential IV/PO treatment of any systemic mycotic infection. Based on current costs there is potential for savings compared with liposomal amphotericin B.

Histopathology of candidal hyperplastic lesions of the larynx

Candidiasis of the larynx is rare, and candidal involvement of the larynx mostly occurs after pulmonary, pharyngeal and esophageal candidiasis, or as part of disseminated disease. We here report our morphologic observations made in five cases of laryngeal candidiasis. These cases had the following morphologic features in common: 1. pronounced epithelial hyperplasia, which may show a verrucous pattern, 2. prominent ortho-parakeratosis, and 3. predominantly neutrophilic infiltration located in the upper layers of the mucosal epithelium. Our morphologic observations were similar to the morphologic changes encountered in chronic hyperplastic candidosis of the oral mucosa. As this type of candidal lesions contains fewer hyphae than the usual thrush, fungal infection may be easily overlooked. Pronounced epithelial hyperplasia and prominent ortho-parakeratosis may mimic squamous cell and verrucous carcinomas. In conclusion, we suggest performing special stains for fungi of laryngeal biopsies that have the morphologic features mentioned above. In that way, it is possible to detect a candidal infection, keeping in mind that the fungal organisms may be very few in number and morphologically distorted.

Management of Candidiasis in Critically Ill Patients

Fungal infections have been increasing at an alarming rate in critically ill patients. Candida is now the fourth most common pathogen isolated from the bloodstream and is associated with significant morbidity, mortality, and economic consequences. Novel antifungals have been developed in recent years to provide alternatives to amphotericin B, which continues to be the standard therapy for most invasive fungal infections. These alternatives include lipid-based amphotericin B, ketoconazole, fluconazole, itraconazole, caspofungin, and potentially voriconazole. Optimal therapy for the various forms of candidiasis remains controversial. A standardized antifungal susceptibility testing method for Candida isolates has been developed to assist drug selection, but its clinical relevance remains to be determined. The relative susceptibility of Candida isolates can be estimated by the species. Specifically, C krusei is resistant to azoles, C glabrata may be resistant to azoles, and C lusitaniae may be resistant to amphotericin B Candida infections can affect any organ system, and the diagnosis of such infections remains difficult. The Infectious Diseases Society of America recently developed guidelines for the management of candidiasis. This review includes a brief discussion of systemically administered antifungal agents and provides a synopsis of the practice guidelines for the management of candidiasis.

Practice guidelines for the treatment of candidiasis. Infectious Diseases Society of America

Infections due to Candida species are the most common of the fungal infections. Candida species produce a broad range of infections, ranging from nonlife-threatening mucocutaneous illnesses to invasive process that may involve virtually any organ. Such a broad range of infections requires an equally broad range of diagnostic and therapeutic strategies. This document summarizes current knowledge about treatment of multiple forms of candidiasis and is the guideline of the Infectious Diseases Society of America (IDSA) for the treatment of candidiasis. Throughout this document, treatment recommendations are scored according to the standard scoring scheme used in other IDSA guidelines to illustrate the strength of the underlying data. The document covers 4 major topical areas. The role of the microbiology laboratory. To a greater extent than for other fungi, treatment of candidiasis can now be guided by in vitro susceptibility testing. The guidelines review the available information supporting current testing procedures and interpretive breakpoints and place these data into clinical context. Susceptibility testing is most helpful in dealing with infection due to non-albicans species of Candida. In this setting, especially if the patient has been treated previously with an azole antifungal agent, the possibility of microbiological resistance must be considered. Treatment of invasive candidiasis. In addition to acute hematogenous candidiasis, the guidelines review strategies for treatment of 15 other forms of invasive candidiasis. Extensive data from randomized trials are really available only for therapy of acute hematogenous candidiasis in the nonneutropenic adult. Choice of therapy for other forms of candidiasis is based on case series and anecdotal reports. In general, both amphotericin B and the azoles have a role to play in treatment. Choice of therapy is guided by weighing the greater activity of amphotericin B for some non-albicans species (e.g., Candida krusei) against the lesser toxicity and ease of administration of the azole antifungal agents. Flucytosine has activity against many isolates of Candida but is not often used. Treatment of mucocutaneous candidiasis. Therapy for mucosal infections is dominated by the azole antifungal agents. These drugs may be used topically or systemically and have been proven safe and efficacious. A significant problem with mucosal disease is the propensity for a small proportion of patients to suffer repeated relapses. In some situations, the explanation for such a relapse is obvious (e.g., relapsing oropharyngeal candidiasis in an individual with advanced and uncontrolled HIV infection), but in other patients the cause is cryptic (e.g., relapsing vaginitis in a healthy woman). Rational strategies for these situations are discussed in the guidelines and must consider the possibility of induction of resistance over time. Prevention of invasive candidiasis. Prophylactic strategies are useful if the risk of a target disease is sharply elevated in a readily identified group of patients. Selected patient groups undergoing therapy that produces prolonged neutropenia (e.g., some bone-marrow transplant recipients) or who receive a solid-organ transplant (e.g., some liver transplant recipients) have a sufficient risk of invasive candidiasis to warrant prophylaxis.