CANDIDIASIS

ANURANJINI K S
Asssociate professor in Medical microbiology
 Candidiasis is a type of systemic fungal infection caused by a yeast
called Candida.

 Candida normally lives on skin and inside the body such as the mouth,
throat, gut and vagina without causing problems.

 It ordinarily cause no ill effects, except among infants and in persons

debilitated by illness such as Diabetes, those who are taking
anticancer therapy and immunocompromised patients ,HIV patients
and so on.
 Calassification of candida
 There are 163 anamorphic species of genus candida with telomorphs in
at least thirteen genera.

 Nearly 20 of these species are considered to be significant pathogens

to human beings. Some species are;
Candida albicans, Candida tropicalis ,Candida krusei, Candida
glabrata ,Candida kefyr, Candida rugosa etc…..

 There are two serotype of Candida albicans named as serotype A and B

based on their differences between mannan components of cell wall.
 Candida belongs to
 Family – Cryptococcaseae
 Order -Moniliales
 Genus – Candida
Candida antigens
 Cell wall antigens (mannan and glucan)
 Cytoplasmic antigens
 Virulence factors

1. Adhesins
 Helps Candida species to adhere host cells which correlate with their
virulence.

2. Enzymes (14 hydrolytic enzymes) Proteases ,Lipases

Phospholipases, Esterases,Phosphatases etc…..

3. Toxins
The glycoprotein extracts of Candida cell walls like bacterial
endotoxins are lethal and pyrogenic and induce anaphylactic shock.
3. Complement receptors.

 Phenotypic switching.(Ability of organisms of single strain to switch

reversibly at high among different colony phenotypes.
 Due to this ability, they can grow in variety of morphological forms

Clinical features
1. Infectious Diseases
Mucocutaneous manifestation
Mucocutaneous manidestation
 A) Mucocutaneous Candidiasis

Oral candidiasis : which is also known as oral thrush.

 It occur in infants, individuals with Diabetic mellitus,those receiving

antibiotics and in patiants infected with HIV.

 The infection may diffuse or remain confined to buccal mucosa,

gums, tongue and palate. There is a conjestive reddening of the
mucous membrane that gives dry , smooth , shiny varnish like
appearance which is accompanied by thirst ,metallic taste and
sensation of dryness and burning at local site.
Oral candidiasis
 Angular Cheilitis the patients present with sore, erythematous
fissured lesions affecting the angles of the mouth. This may be
associated with iron deficiency anemia or vitamin B12 deficiency.
 esophagitis(seen more in HIV patients)

 Vulvovaginitis , Balanitis, Balanoposthitis : This seen

primarily in young and middle aged females ,particularly during their
active reproductive life.

 Mainly caused by C. albicans and C. glabrata. There is curd like

vaginal discharge , itching , burning sensation among these patients.

 On examination vulval erythema and edema may be observed.

Candidal vulvovaginitis
 In males , balanitis , balanoposthitis are also caused by different Candida
species. It mainly affects non circumcised and diabetic men.

 There is pruritis associated with erythema, whitish lesions over the glans
penis.Trasmission of the infection is mainly spead through sexual activity

Chronic mucocutaneous candidiasis:(CMC)

 It common in patients with deficient cell mediated immunity, particularly
beginning in infancy or later in the childhood
 The lesions of oral mucosa may be the initial observation
 There are lesions at mouth skin and fingernails. Hyperplastic and nodule
like lesions with non removable whitish patches and deep fissure are the
most common oral manifestations.
 Various underlying conditions such as hypoparathyroidism
,hypoadrenalism, hypothyroidism and presence of circulating
autoantibodies have been associated with CMC.

Ocular candidiasis :
It is presented as keratoconjunctivitis due to the prolonged use of topical
corticosteroids
 Symptoms are conjunctival edema, cheesy discharge in the conjunctival
sac and corneal ulceration.
 Fungal Endophthalmitis also caused by Candida.
Candida keratitis
 B) Cutaneous manifestations

Intertrigo: This is the inflammatory lesion of the skin folds.It can be

accompanied by lymphangitis and enlarged lymph nodes .
 Occurs predominantly in females
Paronychia and Onychomycosis: It is the inflammation of nail folds of
hands and feet
Infection seen in the distal part of nail.

Diaper dermatitis : Seen in infants.

Maceration and wet diapers predispose infants to this disease.It is also called
napkin candidiasis.
 There are maculopapules and vesicles coalescing in to patches with satellite
pustules.
 Perianal Candidiasis commonly affects young infants and is
charecterised by patchy and confluent erithematous, papulovesicular
lesions.

 Diaper dermatitis commonly become secondarily infected with

polymicrobial organisms.

Candidal granuloma : This condition is commonly seen in children.

 It is seen as primary vascularised papule covered with thick adherent

yellow brown crust over face, scalp ,fingernails, trunk and nails.
C) Systemic manifestations

Predisposing factors

 Infancy, old age and pregnancy

 Changes in local bacterial flora secondary to antibiotics

 Changes in epithelial surface due to moisture and trauma

 AIDS or other immunosuppression

 Diabetic mellitus

 Zinc and iron deficiency.

 Urinary tract Candidiasis : it is commonly seen in females.

 The infection may involve the bladder and kidneys.

 It may be due to disseminated candidiasis, Diabetic mellitus, Pregnancy

and prolonged administration of antibiotics and use of unclean
catheters.
Candiduria : Presence of yeast cells in urine. Commonly seen in
hospitalized patients.

Mostly aymptomatic.
Endocarditis and pericarditis : in patients with previously abnormal
native or prosthetic valves . It can be associated with thoracic surgery and
immunosuppression .

Pulmonary candidiasis : The pulmonary lesions arise from

hemetogenous seeding. Candida pneumonia in the immunocompromised
host should be considered life threatening infection and treated with
systemic antifungals.

Meningitis: It is more common with extremes of age, in low birth

weight neonates with candidemia.
It is also seen in patients with hematologic malignancies, and complicated
neurosurgical procedures .
 Candidemia and Septicemia : It is mainly seen in
immunocompromised individuals.It may be Iatrogenic also. Common
species involved are C.albicans, C.tropicalis and C.krusei.

Disseminated Candidiasis: occurs frequently in individuals with

 Hemetological malignancies
 Patients undergoing broad spectrum antibiotic therapies
 Catheterisation
 In bone marrow and organ transplant recepients.
 Patients undergoing immunosuppressive therapies.
 Use of intravenous catheters
 Post surgical procedures
 Severe burns
 Hyperalimentation
 Diabetic mellitus

Immunocompromised patients develop serious infections of the oropharynx

and upper GIT but rarely experience systemic disease.
Clinical forms of Candidiasis in HIV patients

Asymptomatic oral carriage

Oropharyngeal thrush
Acute atrophic edema
Angular cheilitis
Leukoplakia
Esophagitis
Laryngitis
Vulvovagititis and Balanitis
Arthritis
Prosthetic or rheumatoid joints are prone to infection mainly through
hematogenous route
Mainly due to direct inoculation during joint surgery or intra articular
corticosteroid therapy.
This type of arthritis may leads to distruction of cartilage.
Osteomyelitis
It is also due to hematogenous spread.

Fever and backpain may seen.

Endophthalmitis
This is the manifestation of disseminated infection
Cloudy vision or scotoma may seen.
Deep bulbar pain or feeling of irritation also feel.This may lead to blindness if
an early therapy is not started.

Nosocomial candidiasis
Candidemia is the most common symptoms. Over usage of antibiotics is the
main predisposing factor.
Candida pancreatitis
 LABORATORY DIAGNOSIS

 Direct examination

The clinical specimens are collected depending up on the site of

involvement I .e. superficial lesions or deep seated infections and
whitish patches from the mucous membrane of the skin, vagina, mouth,

Skin or nail scrapings, sputum are collected with the help of sterile
swabs. These are examined with KOH wet mount or normal saline
preparation.

Gram staining shows budding yeast cells and pseudohyphae from budding
yeast cells that remain attached to each other.
Candida- Gram stain
Candida gram stain- budding yeast cells
with pseudohyphae
 The yeast cells are approximately 4-8 micrometer.

 The presence of pseudohyphae indicate colonisation and tissue invasion.

 PAP smear shows presence of fungi in females.

 The biopsy specimens are kept in tube containing KOH for an overnight period at
37 degree and after mincing these are examined under the microscope for yeast
cells and pseudohyphae.

Other stains: H and E,PAS, Gomoris methenamine silver stain( demonstration of

candida in tissue sections)
 Vaginal and oral swabs preferably kept in transport medium before being
processed in the lab.

 Oral lesion specimen also obtained by scrapings. By using this both wet
mount and fixed mount can be done.

 In wet mount preparation , unstained slide prepared in saline or water

or stained with LPCB Or calcofluor white stain.

 fixed mount,attaining is done by using gram stain, Geimsa stain or

methylene blue.
Fungal culture
Routine medium is SDA with antibiotics (Chloramphenicol,Gentamycin or
Tetracyclin) to prevent bacterial overgrowth.
Other medium :SDA with cycloheximide to prevent the growth of airborn
molds.
Incubation at 28 /37 degree for 2-3 days.
Growth can also be observed at 24 hours and some species take more
than 3 days.
From the colones present on the medium ,LPCB mount and gram stain is
done.
For systemic infection like candidemia, blood culture is done in biphasic
medium like brain heart infusion agar and broth and incubated at both
temperatures.
Colony charecters on SDA media

Candida albicans: The colonies are cream coloured ,pasty and smooth.The
production of germ tube may be demonstrated.
Candida tropicalis: colonies look similar to Candida albicans. Colonies are
cream coloured, glistening to dull and smooth or wrinkled.
Candida krusei : The colonies are flat ,dry and dull.After prolonged
incubation,they
Become greenish yellow in colour
Candida parapsilosis : The colony morphology is creamy, sometimes
develop in lacy pattern
Candida albicans on SDA
Candida LPCB mount
Candida glabrata : The colonies are smooth ,glistening, cream coloured and
small.
Candia dubliniensis : similar to other species

CORN MEAL AGAR :

Candida albicans : large thick walled chlamydospores, usually terminal and
present singly or in small clusters around with clusters of round
blasoconidia.
Candida tropicalis : oval blasoconidia singly or in small groups all along
graceful, long psuedohyphae.
Candida krusei : Pseudohyphae with blasoconidia forming crossmatchstick
appearance.
Candida on corn meal agar –Terminal
chlamydospore formation
Candida parapsilosis: Short ,pencil like pseudohyphae with
blastoconidia arranged singly along pseudohyphae.

IN CHROMAGAR CANDIDA :
Candida albicans : Light green colour colonies
C .Dubliniensis : Dark green
C .glabrata: Pink to purple
C.Krusei :pink
C.Parapsilosis : cream to pale pink
C.tropicalis: Blue with pink halo
CROM AGAR Candida
Biochemical tests : urease test, CHO utilization test, CHO fermentation
test

Immunodiagnosis : Immunodifussion, CIE ,RIA , ELISA

Detection of antibodie by -
Slide agglutination test
ID
Phytohemagglutination
Immunopecipitation
Immunoflurescence

Non specific Candida antigens : latex agglutination,

Immunblotting ,Candida Enolase antigen testing etc…
 Germ tube test
 is a screening test which is used to differentiate C.albicans from other
yeasts. Germ tube formation is first reported by Reynolds and Braude.

Principle
 Formation of germ tube is associated with increased systhesis of protein
and RNA.Germ tube solutions contain tryptic soy broth and fetal bovine
serum,which is an essential nutrients of protein synthesis. Germ tube is
one of the virulance factors of C. albicans. This is a rapid test for the
presumptive identification of C.albicans
Procedure
 Put 0.5 ml of sheep or human serum/fetal bovine serum in to a small
tube.
 Using a Pasteur pipette, touch a colony of yeast and gently emulsify it
in the serum.Too largeof an inoculum will inhibit germ tube formation.
 Inculated the tube at 37 degree for 2-4 hrs
 Trasfer a drop of the serum to a slide for examination
 Coverslip and observe microscopically under low and high power
objectives.

Result and interpretation

Positive test : A short hyphal extention arising laterally from a yeast
cell,
With no constriction at the point of origin . Germ tube is half the width
and 3 to 4 times the length of the mother yeast cell and tjhere is no
presence of nucleus.
 Germ tube positive : C. albicans , C.dubliniensis.

 Negative test -No hyphal extension arising from a yeast cell or a

short
hyphal extention constricted at the point of origin.
Eg..C.tropicalis , C.glabrata and other yeast.

QC in germ tube test

positive control : C. albicans (ATCC 10231)
Negative control : C . Tropicalis (ATCC13803)
C.glabrata (ATCC 2001)
Limitations
 C. tropicalis may form early pseudohyphae which may be falsly
interpreted as germ tubes.

 This test is only part of the overall scheme for identification of

yeast . Further testing is required for definite identification
GERM TUBE TEST
GERM TUBE TEST
Skin tests : To evaluate cell mediated immunity invivo.

PNA FISH ( peptide nucleic acid flurescent in situ

hybridisation) :rapid method

T2Candida panel :
new automated diagnosis method for species differentiation of Candida
directly from blood . It is based on T2 magnetic resonance technology which
introduces superparamagnetic particles coated with Candida specific binding
partcles in blood .The binding results in disruption of magnetic fields in
surrounding water molecules which is then detected .This system requires
minimal skill and can detect as low as 1 CFU/ml .
Animal pathogenicity: Mice and rabbits are used as animal models.
PNA -FISH
T2 Candida panel
Treatment and prophylaxis

For mucocutaneous Candiasis :1 percentage gentian violet, Aczole creams

like Clotrimazole ,Miconazole ,Ketoconazole and econazole and
itraconazole.

For systemic Candidiasis –Amphotericin + Flucutosine

Immunotherapy :
As prolonged neutropenia is one of the most important risk factors for
the development of serious candida bloodstream infection hence
cytokine used as a therapeutic agent .
THANK YOU……………..