Jawetz Medical Microbiology 27Ed (Chap 45)
an increase in the local census of Candida and
Medical Mycology
CANDIDIASIS
 species of the yeast genus Candida are capable of
causing candidiasis
 They are members of the normal flora of the skin,
mucous membranes, and gastrointestinal tract
 Candida species colonize the mucosal surfaces of all
humans soon after birth
 most common agents are Candida albicans, Candida
parapsilosis, Candida glabrata, Candida tropicalis,
Candida guilliermondii, and Candida dubliniensis
 species of Candida cause both cutaneous and
systemic infections, and these clinical
manifestations have different mechanisms of
pathogenesis
Morphology and Identification
 Candida species grow as oval, budding yeast cells
(3–6 μm in size)
 form pseudohyphae when the buds continue to
grow but fail to detach, producing chains of
elongated cells
 it can also produce true hyphae
 Unlike other species of Candida, C albicans is
dimorphic
 Candida species produce soft, cream-colored
colonies with a yeasty odor
 Pseudohyphae are apparent as submerged growth
below the agar surface
 After incubation in serum for about 90 minutes at
37°C, yeast cells of C albicans will begin to form true
hyphae or germ tubes
 on nutritionally deficient media C albicans produces
large, spherical chlamydospores
 Sugar fermentation and assimilation tests can be
used to confirm the identification of C tropicalis, C
parapsilosis, C guilliermondii, Candida kefyr, C
krusei, and C lusitaniae
 C glabrata is unique among these pathogens
because on routine culture media it produces only
yeast cells and no pseudohyphae
Antigenic Structure
 two serotypes of C albicans: A (which includes C
tropicalis) and B
 During infection, mannans, glucans, other
polysaccharides and glycoproteins, as well as
enzymes are released
Pathogenesis and Pathology
 Cutaneous or mucosal candidiasis is established by
damage to the skin
 histology of cutaneous or mucocutaneous lesions is
characterized by inflammatory reactions varying
from pyogenic abscesses to chronic granulomas
 lesions contain abundant budding yeast cells and
pseudohyphae
 administration of broad-spectrum antibacterial
antibiotics often promotes Candidiasis in the GIT,
oral, vaginal mucose
 Systemic candidiasis occurs when Candida enters
the bloodstream and the innate phagocytic host
defenses are inadequate
 yeasts can enter the circulation by crossing the
intestinal mucosa
 Candida can infect the kidneys, attach to prosthetic
heart valves, or produce candidal infections almost
anywhere (arthritis, meningitis, endophthalmitis)
 functional neutrophils capable of ingesting and
killing the yeast cells
 Candida cells elaborate polysaccharides, proteins,
and glycoproteins that not only stimulate host
defenses but facilitate the attachment and invasion
of host cells
 Candida species produce a family of agglutinin-like
sequence (ALS) surface glycoproteins
Clinical Findings
A. Cutaneous and Mucosal Candidiasis
 risk factors associated with superficial candidiasis
include AIDS, pregnancy, diabetes, young or old age,
birth control pills, and trauma
 Thrush can occur on the tongue, lips, gums, or
palate
o patchy to confluent, whitish pseudo-
membranous lesion composed of epithelial
cells, yeasts, and pseudohyphae, which can
lead to the formation of an intractable
biofilm.
 Thrush develops in most patients with AIDS
 risk factors include treatment with corticosteroids
or antibiotics, high levels of glucose, and cellular
immunodeficiency
 Yeast invasion of the vaginal mucosa leads to
vulvovaginitis, characterized by irritation, pruritus,
and vaginal discharge  often predisposed by
conditions such as diabetes, pregnancy, or
antibacterial drugs that alter the microbiota, local
acidity, or secretions
 cutaneous candidiasis = invasion of the skin, which
occurs when the skin is weakened by trauma, burns,
or maceration
 Intertriginous infection = occurs in moist, warm
parts of the body such as the axillae, groin, and
intergluteal or inframammary folds; most common
in obese and diabetic patients
 Newborns are susceptible to diaper rash and skin
infection caused by Candida = infected areas
become red and moist and may develop vesicles
 Candidal invasion of the nails and around the nail
plate causes onychomycosis – painful,
erythematous swelling of the nail fold resembling a
pyogenic paronychia, which may eventually destroy
the nail
B. Systemic Candidiasis
 Candidemia can be caused by indwelling catheters,
surgery, intravenous drug abuse, aspiration
 patients with compromised immune system,
develop occult lesions in kidney, skin
(maculonodular lesions), eye, heart, and meninges
 Systemic candidiasis is most often associated with
chronic administration of corticosteroids, leukemia,
lymphoma, and aplastic anemia
 Candidal endocarditis affects the heart valves
C. Chronic Mucocutaneous Candidiasis
 is a rare but distinctive clinical manifestation
characterized by the formation of granulomatous
candidal lesions on any or all cutaneous and/or
mucosal surfaces
 most common forms present in early childhood and
are associated with autoimmunity and
hypoparathyroidism
 patients may develop chronic, raised, and crusty
highly disfiguring keratitic lesions on the skin, oral
mucosa, and scalp
Diagnostic Laboratory Tests
A. Specimens and Microscopic Examination
 Specimens include swabs and scrapings from
superficial lesions, blood, spinal fluid, tissue
biopsies, urine, exudates
 Tissue biopsies, centrifuged spinal fluid, and other
specimens may be examined in Gram-stained
smears or histopathologic slides for pseudohyphae
and budding cells
B. Culture
 All specimens are cultured on fungal or
bacteriologic media at room temperature or at 37°C
 Yeast colonies are examined for the presence of
pseudohyphae
 C. albicans is identified by the production of germ
tubes or chlamydospores
 CHROMagar(R) is a useful commercial medium for
the rapid identification of several Candida species
based on fungal enzymatic action on chromogenic
substrates
 Positive blood cultures may reflect systemic
candidiasis or transient candidemia due to a
contaminated intravenous line.
 Cultures of skin lesions are confirmatory and
distinguish cutaneous candidiasis from
dermatophytosis or another infection
C. Molecular Methods
 blood cultures for Candida are augmented by real-
time PCR with species-specific primers
D. Serology
 Serum antibodies and cell-mediated immunity are
demonstrable in most people as a result of lifelong
exposure to Candida
 detection of circulating Candida cell wall mannan is
much more specific
Treatment
 Thrush and other mucocutaneous forms = topical
nystatin or oral ketoconazole or fluconazole
 Systemic candidiasis = treated with amphotericin B
 Chronic mucocutaneous candidiasis = oral
ketoconazole and other azoles
 patients have a genetic cellular immune defect and
often require lifelong treatment
 administration of an azole or a short course of low-
dose amphotericin B indicated for febrile or
debilitated patients
Epidemiology and Control
 avoid disturbing the normal balance of microbiota
and intact host defenses
 outbreaks caused by the nosocomial transmission