Recurrent Candidiasis Research Articles

Molecular epidemiology of recurrent oral candidiasis in human immunodeficiency virus-positive patients: evidence for two patterns of recurrence.

The causative strains in 22 patients with recurrent oral candidiasis were examined using two DNA probes (a Histoplasma capsulatum DNA probe that cross-hybridizes with Candida albicans and a C. albicans strain-specific probe derived from repetitive sequence DNA). C. albicans was the causative organism in all 22 initial episodes of infection and was also obtained from 17 patients with recurrent oral disease. Molecular analysis showed that in 11 cases, the same isolate was identified in each episode. Six patients had a clearly different isolate of C. albicans causing a later episode of candidiasis. Five patients had different Candida species causing recurrent disease: 4, Torulopsis glabrata; 1, Candida parapsilosis. Patients with a new isolate (either new species or a new C. albicans strain) were more immunosuppressed and were significantly more likely (P < .001) than patients with the same recurrent strain to have received suppressive azole antifungal agents. These data indicate that the epidemiology of recurrent candidiasis in individual patients seropositive for the human immunodeficiency virus is complex and that both failure of eradication of Candida from the oral cavity and new infection occur.

Fluconazole once a week as secondary prophylaxis against oropharyngeal candidiasis in HIV‐infected patients: A double‐blind placebo‐controlled study

To assess the efficacy and tolerance of fluconazole (150 mg oral dose, once a week) in the prevention of recurrent oropharyngeal candidiasis in patients with moderate to severe human immunodeficiency virus (HIV) infection. A randomised, double-blind, placebo-controlled trial. Eighty-four patients with moderate to severe HIV infection who had successfully completed two to four weeks treatment with fluconazole for oropharyngeal candidiasis were randomly allocated to receive either placebo or fluconazole. Pre-treatment clinical and laboratory characteristics were similar in the two groups. Success was classified as absence throughout the course of treatment of clinical evidence of oropharyngeal candidiasis, and failure as recurrence or relapse of symptomatic oropharyngeal candidiasis. Of 73 evaluable patients the median time to relapse was > or = 168 days in the fluconazole group and 37 days in the placebo group (P < 0.0001). One patient in the placebo group and 18 patients in the fluconazole group completed six months' treatment without clinical relapse (P < 0.001). Fluconazole was well tolerated and prevented clinical relapse of oropharyngeal candidiasis in 71% of patients who completed three months of treatment (95% confidence interval [CI], 55-86) and 58% (95% CI, 41-75) who completed six months of treatment.

Thrush Can Be Prevented in Patients With Acquired Immunodeficiency Syndrome and the Acquired Immunodeficiency Syndrome—Related Complex

Recurrent oropharyngeal candidiasis is common in patients with acquired immunodeficiency syndrome and the acquired immunodeficiency syndrome-related complex. It causes local pain and discomfort, loss of taste, and aversion to food and may lead to secondary complications. We examined, in a double-blind study, whether recurrent thrush could be prevented by prophylaxis. Twenty-five patients with one to four previous thrush episodes who had no thrush at the outset of the study were randomized to receive 100 mg of fluconazole or placebo daily for 12 weeks. If thrush occurred, prophylaxis was stopped and patients were treated conventionally, after which prophylaxis was resumed. After the randomized study, some patients were given continuous fluconazole (open phase). In the randomized study, thrush occurred in eight of 13 placebo-treated patients and none of 12 fluconazole-treated patients. Possible side effects were not different between the groups. Dermatophytosis and onychomycosis and cryptococcuria also improved in the fluconazole-treated patients, and fungal colonization was significantly decreased. One episode of thrush occurred in the open phase in an intermittently compliant patient (group total, 71.5 patient-months of fluconazole treatment); in contrast, the 25 patients also had had two episodes of Candida esophagitis, three of cryptococcosis, and 13 of dermatophytosis before entry. Subsequent to entry in the randomized trial, in 92.3 patient-months without fluconazole, there were 35 episodes of thrush, one of esophagitis, one of cryptococcemia, and one of dermatophytosis, and preexisting dermatophytosis and onychomycosis were unchanged or worsened. Individual patients observed with and without fluconazole treatment also showed its efficacy. In conclusion, thrush can be prevented in patients with acquired immunodeficiency syndrome and the acquired immunodeficiency syndrome-related complex with negligible toxic effects. Larger trials to confirm prevention of all mycoses with prophylaxis should be considered.

Successful orthotopic liver transplantation in a patient with refractory biliary candidiasis

The authors present a nonimmunocompromised patient who developed refractory fungal (Candida albicans) cholangitis and who subsequently underwent successful orthotopic liver transplantation for progressive destruction of intrahepatic and extrahepatic bile ducts. Liver biopsy specimens showed periductal abscesses, and cholangiograms showed rapidly progressive destruction of intrahepatic and extrahepatic bile ducts. Standard immunosuppressive therapy and perioperative amphotericin B were administered. At 6 months, the patient was clinically well with no evidence of recurrent biliary candidiasis. The authors suggest that orthotopic liver transplantation may be a reasonable therapeutic option for patients with refractory biliary candidiasis.

Vulvar vestibulitis syndrome: An overview

Vulvar vestibulitis syndrome is a constellation of symptoms and findings involving and limited to the vulvar vestibule that consists of: (1) severe pain on vestibular touch to attempted vaginal entry, (2) tenderness to pressure localized within the vulvar vestibule, and (3) physical findings confined to vulvar erythema of various degrees. Histopathologic findings are consistent with a chronic, nonspecific inflammatory response that is occasionally associated with metaplasia of the minor vestibular glands. The cause is likely multifactorial, and to date the syndrome has been seen in association with subclinical human papillomavirus, chronic recurrent candidiasis, chronic recurrent bacterial vaginosis, chronic alteration of vaginal pH, and the use of chemical and destructive therapeutic agents. Therapy is directed at elimination of these symptoms. When symptoms are unrelieved, a surgical approach consisting of vestibulectomy with vaginal advancement has a high rate of success.

Epidemiologic studies of oral mucosal conditions – methodologic issues

The methods used in the international English-language literature of epidemiologic investigations of oral mucosal conditions were reviewed. Methods used to study leukoplakia, lichen planus, recurrent herpes labialis, recurrent aphthous ulcers, geographic tongue and candidiasis are highlighted. In addition, studies of the full range of pathologies documented in a population were reviewed. The methodologic issues raised by the epidemiologic literature as well as those to be considered for future studies of oral mucosal conditions are presented. Emphasis is placed on study population selection, diagnostic criteria development, type and training of examiners, risk factor assessment and issues related to data collection, analysis and reporting.

Regulation of Candida albicans populations in the gastrointestinal tract: mechanisms and significance in GI and systemic candidiasis.

Colonization of the gastrointestinal (GI) tract by Candida species, and C. albicans in particular, may play an important role in human health and disease, as the GI tract has been implicated as an important source of infection in cases of recurrent vaginitis (104) and systemic candidiasis (94,112,149–151,164). The overgrowth of C. albicans in the intestinal tract and its subsequent passage through the gut mucosa into the host bloodstream, for instance, is believed to be the proximate mechanism leading to systemic candidiasis (151), particularly in patients with acute leukemia (103,112,129). Similarly, colonization of the GI tract by C. albicans and other Candida spp. may lead to involvement in a number of other disease syndromes that include esophageal, gastric and intestinal thrush, gastric and intestinal ulceration, GI bleeding, diarrhea, peritonitis, perianal itch, napkin dermatitis, chronic “irritable bowel” syndrome, and auto-brewery syndrome (12,59,60,80,81,94,102,106,112,117,118,130,131,149–151,156, 164,165,171). The importance of GI colonization by C. albicans therefore should not be underestimated, especially in view of the suggestion that “the most important source of Candida species in human disease is endogenous” (118). On the other hand, GI colonization by C. albicans may also have important beneficial effects on the host in that it apparently results in stimulation of the immune system, leading to a protective response to systemic Candida infection in the noncompromised host (31,32).

Chronic mucocutaneous candidiasis. Antibiotic and immunologic therapy.

Chronic mucocutaneous candidiasis should be viewed as a spectrum of disorders in which the patients have persistent and/or recurrent candidiasis of the skin, nails and mucous membranes. Some of the conditions have genetic predispositions. A common immunologic abnormality is failure of the patient's T lymphocytes to produce cytokines that are essential for expression of cell-mediated immunity to Candida. Antifungal drugs are effective in clearing the infections, and treatments that restore cellular immunity have produced long term remissions.

Odynophagia/Dysphagia in AIDS

Odynophagia and dysphagia are common symptoms of treatable disorders of the esophagus in patients with AIDS. Esophageal candidiasis is the most frequent cause of these symptoms. In patients with AIDS or AIDS-related complex, thrush in combination with odynophagia or dysphagia almost certainly indicates the presence of esophageal candidiasis. Other causes of swallowing disorders in AIDS include opportunistic infection of the esophagus with herpes simplex virus, cytomegalovirus, or, rarely, cryptosporidiosis. Recently, ulcerative esophagitis in AIDS associated with unidentified viral-like particles has been described. Infrequently, Kaposi's sarcoma or lymphoma may involve the posterior pharynx or esophagus, respectively. Because Candida esophagitis is so frequently the cause of odynophagia and/or dysphagia in AIDS, it is suggested that in most cases, a therapeutic trial with an antifungal agent, like ketoconazole, may be appropriate before radiologic or endoscopic examination. Further investigation can be reserved for patients who do not respond to this trial or who have clinical evidence suggesting another esophageal disorder. Herpes simplex and cytomegalovirus esophagitis can be treated with antiviral agents, such as acyclovir and ganciclovir, respectively. Maintenance therapy with antifungal agents to prevent recurrent esophageal candidiasis may be beneficial, but the efficacy and cost effectiveness of this approach remain to be determined. Because of the increasing numbers of patients with AIDS, frequency of esophageal disorders, such as candidiasis, in these patients and the morbidity of these disorders, an expansion of clinical research efforts to determine effective treatment and prophylaxis for these disorders is warranted.

Child Abuse and Neglect

To the Editor.— The article entitled AMA Diagnostic and Treatment Guidelines Concerning Child Abuse and Neglect1provided a useful reference in this area. However, some errors of omission and commission, as well as some limitations in our current knowledge about the true prevalence of child abuse and neglect, should be noted. Signs of Sexual Abuse.— At times, the sexually abused child will be initially seen as a patient with urinary, genital, perineal, or anal symptoms. Since the diagnosis of sexual abuse is often dependent on a diagnosis of a sexually transmitted disease,2it is important to include in this section, entities of proved sexual transmission and exclude or qualify less specific indicators. In the section entitled Physical Signs of Sexual Abuse, recurrent urinary tract infections and candidiasis were included as possible indicators of sexual abuse. While these certainly can coexist with sexual activity, the frequent occurrence of these

A case of immunodeficiency with thymoma

A well encapsulated thymoma, consisting of spindle-shaped epithelial cells and lymphoid cells, was surgically removed for a mediastinal mass. Then a 61-year-old man developed recurrent sore throats and persistent productive cough. He was diagnosed bronchiectasis by bronchogram and immunodeficiency by markedly reduced each class of Ig (120mg% IgG, 21mg% IgM, 11mg% IgA and less than 25IU/ml IgE). Numbers of peripheral blood lymph-cytes (PBL) were normal. E rosetting lymphocytes were 67% of PBL and surface Ig bearing lymphocytes were 3% of PBL. This result was suggested that Ig producing B lymphocytes decreased.Lymphocyte stimulation with mitogens revealed a normal mitotic response to PHA and PWM, but a low response to Con A. Skin tests of PPD, Candida and DNCB were negative.He developed recurrent Gram-positive coccal infection and candidiasis of respiratory tract at end stage. He died of cardiac failure.The histopathologic findings: The germinal centers of spleen and any lymph nodes were not demonstrated and cell components of these paracortical areas were markedly reduced. The funfal vegetations with weak inflammatory reaction were demonstrated in cardiac muscle, lung and kidneys.We think this syndrome is consisted of both humoral and cellular immunodeficiency.

Oral clotrimazole in the treatment of esophageal candidiasis

Several antifungal regimens had failed to relieve severe, recurrent esophageal candidiasis in a 75 year old woman without predisposing disease whose serum transiently inhibited the candidacidal capacity of her polymorphonuclear leukocytes. Treatment with oral nystatin suspension was unsuccessful, whereas intravenous amphotericin B and miconazole induced only transient responses. Oral 5-fluorocytosine induced severe nausea and vomiting, and was discontinued. Oral clotrimazole troches produced prompt and sustained eradication of the patient's candidal esophagitis.

A Case of Chronic Oropharyngo-Esophageal Candidiasis with Immunological Deficiency: Successful Treatment with Miconazole

The case of a 38-year-old male patient with chronic recurrent oropharyngo-esophageal candidiasis since early childhood, resistant to topical therapy with nystatin, is reported. The disease had resulted in impressive oropharyngeal lesions and stricturing of the midesophagus. Extensive in vivo and in vitro immunological studies done before and after successful treatment with miconazole showed a persistent partial deficiency of the cell-mediated immune system, in particular that directed toward candida antigens. Miconazole, a new potent antifungal drug, proved effective in controlling the candidiasis, which had become resistant to conventional treatment.

CANDIDIASIS: STUDIES PERTAINING TO ITS ASSOCIATION WITH ENDOCRINOPATHIES AND PERNICIOUS ANEMIA

Forty-four patients with chronic or recurrent candidiasis of the dermis, mucous membranes, or both, have been studied in relation to associated diseases. Thirty-one patients (Group I) had at least one associated disease. Thirteen (Group II) had only candidiasis. Neonates with oral moniliasis, children with chronic debilitation, and children receiving antibiotics were eliminated from the study. Idiopathic hypoparathyroidism was the most common associated disease of the patients in Group I (26 of 31 patients). Addison's disease also was common (14 of 31 patients). Hypothyroidism, alopecia, cirrhosis, pernicious anemia, and primary gonadal failure also occurred. Evidence for subclinical disease of the thyroid, adrenal cortex, and gastric mucosa, as reflected by tissue specific antibodies, was common in patients with candidiasis. Anti-kidney antibodies also were found in 18 patients, but their significance is unclear. No etiological relationship between the candidiasis and the associated diseases could be demonstrated.