Fingernail Analysis, part III

8 Health Warnings Your Fingernails May Be Sending 

Source

Your eyes may be the window to your soul, but, in many ways your, nails are the window to what’s going on inside your body. Here are some common nail problems and what they mean: 

Take a good look at your fingernails and you may notice subtle variations in the texture or color; white spots, a rosy tinge, rippling or bumps in the surface to mention a few. These imperfections may not look like much to you, but it’s more important than you might think to maintain healthy fingernails. That’s because to the trained eye, nails can provide valuable indications about your overall health. 

Hold a hand level with your nose about a foot out from your face and scrutinize each one. Look at the grooves, curves, ridges and dips. Notice how thick or thin they are and if there are any stark differences. Are your nails are chipped or broken. Make a note of the color of the nail itself, the skin under it as well as the skin around the nail. You need to get into the habit of knowing your nails and any changes that can occur. Changes are a good indication of the onset of several health problems. Here are 8 of the most common nail issues:

1. RIDGES: Healthy nails should have no obvious ridge lines and should be virtually smooth to the naked eye. Ridges can indicate several health issues including:

• Inflammatory arthritis
• Iron deficiency
• Lupus (with red lines at the base of your nails)

Don’t ignore these ridges by using a nail buffer to smooth the surface – these are warnings to be noticed!

2. THICK NAILS: It is fairly obvious is you have a thickening of the nails and they can have several causes including:

• Thick/separated nails can indicate thyroid disease or psoriasis
• Thick/rough-surfaced nails can be a sign of fungal infection
• Unusually thick nails could be a symptom of a circulation problem
• Thick nails alone could even signal lung disease

Thickening is fairly easy to notice when it first appears but please note that allergic reactions to some medications manifest themselves as thick nails!

3. DISCOLORED NAILS: A healthy nail bed should be pink with a slight pinky white moon shape at the base. Streaks of any other stronger shades or colors can indicate health issues, as can nails that are tinged by other colors such as:

• Dark stripes towards the top of the nail are associated with aging and congestive heart failure
• Blueish tinge to the nails can be a sign of depleted oxygen levels in your blood
• Green nails are usually a sign of a bacterial infection
• White nails indicate liver disease, such as hepatitis
• Red streaks on the nail bed could be a warning of an infection of the heart valves
• Dull nails in general mean a deficiency of vitamins

Inspect your nails when they are clean and you should know when the color changes.

4: PITTED NAILS: Sometimes small dips can just be the result of a bash to the hand in general, but sometimes more attention should be paid as they can be a symptom of:

• Zinc deficiency (usually the pit will form a line across the middle of the nailbed)
• Connective tissue disorder
• Psoriasis
• Alopecia areata, which is an autoimmune disorder that results in hair loss

Learn the difference between an injury related imperfection which should not last too long, and a potential disease related imperfection which will not clear up.

5. DRY AND BRITTLE NAILS: Healthy nails should not require cuticle oil and moisturizers as they should maintain themselves. Excessively dry or brittle nails can be a sign of a hormonal balance problem or a bacterial infection.

• Thyroid disease can result in brittle, dry nails that also crack and split very easily
• Fungus can cause nails to become dry or even crumbly and is a common problem

Both these potential problems can be treated and the nails will return to good health once a full growing cycle has passed (hand nails grow at about 1 mm per week so on average the full life cycle of human nail is about 6 months). 

6. CONCAVE OR SPOON SHAPED NAILS: What are known as ‘full spoon’ nails are very soft and curve upwards with the dip being pronounced enough to hold a drop or two of liquid. This usually is an indication of:

• Heart disease
• Iron deficiency (usually from anemia)
• Hypothyroidism
• Hemachromatosis, which is a liver disorder caused by the body absorbing too much iron

If medical intervention clears up the root cause then the nails will return to a normal healthy shape with time.

7. CLUBBED NAILS: This is when the skin around the nail bed can appear inflamed or unusually puffy. This can mean:

• Liver disease
• Lung disease, especially if you already have trouble breathing
• Inflammatory bowel disease
• AIDS

Most of these health issues will often have already given you other symptoms but the corresponding nail condition can help with diagnosis.

8. SPLIT NAILS: Often our nails split if we have injured them. But when no trauma has occured but the nail flakes away layer by layer it can be a result of several issues:

• Chronic malnutrition
• Deficiency of Vitamin C, folic acid or proteins
• Split nails together with a pitted nail bed can indicate psoriasis

Eating a healthy well balanced diet can eliminate many of these causes. 

Obviously our fingernails will not be the only signs of these diseases, but they can provide confirmation or else the motivation to seek further medical attention.

Strong, healthy nails reflect a strong, healthy you. Share with anyone you know may need to pay attention to their nails.

To read the former postings on fingernail analysis, go to: 

Fingernail Analysis, part I
Fingernail Analysis, part II

Fancy a Fungus?

More info on mushrooms being "from the gods"

In ancient Egypt the Pharaohs prized mushrooms as delicacies. They became the preserve of the royal family. The Romans called mushrooms food of the gods and served them only on special occasions. The ancient Greeks held mushroom feasts and believed that mushrooms empowered their warriors for battle. Today, however, mushrooms are not just for the elite; people are enjoying them all over the world and they are easily available in stores and produce stands. 

The following is an interview of an Australian and his wife from Sydney, Australia who drove to Mittagong a picturesque town in the southern highlands of New South Wales to search out Noel Arnold's mushroom farm and interview Noel on the cultivation of mushrooms.

Mushroom Cultivation

Noel is a microbiologist and mushroom expert, who studied mushroom cultivation in several countries before returning to Australia to grow them commercially. "Mushrooms are fungi, a family of organisms that includes mildews and molds," he explains. "Biologists formerly thought that fungi were plants, but we now know that they are very different from plants. For example, fungi do not make their food from photosynthesis as do nearly all plants. They can grow in the dark. Their bodies secrete powerful enzymes that convert organic material into basic nutrients, which they absorb as food. This unique digestive process also distinguishes fungi from animals. Since fungi are neither plants nor animals, biologists now classify them in a realm of their own - the fungi kingdom."

"In the wild, mature mushrooms release millions of tiny spores that mix with other mushroom spores and germinate. If the spores land in a cold, damp place with plenty of food, they can grow into new mushrooms. Commercial mushroom growers aim to replicate this process using controlled conditions to improve crop yields and quality."

Noel further explained about how different mushroom varieties require different growing conditions. For example, while white, or button, mushrooms, the world's most popular variety, grow best on pasteurized farm compost, other varieties flourish in bags of plant waste, bottles of cereal grains, whole wooden logs, or logs of compressed sawdust. Of the thousands of known mushroom species, only about 60 are commercially cultivated.

Noel allows his mushrooms to mature and fruit in an old abandoned railway tunnel near Mittagong. "It's cool, damp, and perfect for growing mushrooms," he states. There in the tunnel are an array of bags, pots, and bottles sprouting thousands of mushrooms of all shapes and sizes. Some evoke memories of blooming roses, others resemble fluted lilies or look like floral bouquets or squat umbrellas. In total, it was a splendid color display.

Tasty and Versatile

"Many people love the look of exotic mushrooms but may not know how to prepare them. Yet, they are easy to cook. Some people chop them up for stir-fries, soups and salads, or they cook them whole for a barbecue. Personally, I enjoy oyster mushrooms crumbed and fried in oil. And shiitake mushrooms have a rich, meaty flavor that tastes great in omelets."

Shiitake mushrooms

Edible mushrooms are highly nutritious and are a valuable source of fiber, protein, minerals and vitamins. Some 2,000 varieties are also known to have medicinal properties. According to one medical review, mushroom extracts have more than 100 medicinal uses, including combating cancer, hepatitis, AIDS, Alzheimer's disease, and high cholesterol.

It can be very dangerous to gather mushrooms in the wild, however. The death cap mushroom (Amanita phalloides), among others, closely resembles edible varieties yet is deadly. So follow the rules: NEVER eat mushrooms from the wild unless a mushroom expert identifies them as safe to eat.  

This article was taken (and slightly altered) from the Jehovah's Witness monthly magazine Awake! March 2012 issues, article entitled "Fancy a Fungus?" I post here on the article because the various forms of candida are in the fungi family and Noel gave some interesting commentary on the characteristics of the fungi: it grows in moist, dark places that has a food supply for supporting them (translated to mean, they feed off a host). They do not need photosynthesis to reproduce. Every mushroom likes feeds off a different environment, and in a different temperature controlled zone ... Valuable information for knowing the enemy and being better able to use countermeasures for eliminating it.

Collodial Silver and Candida

Candida and Colloidal Silver
(source of this article borrowed in full) 

"Yeast and mold infections are among the most difficult to treat of human ailments. Some of them are also among the most debilitating, such as candida yeast. Candida yeast will readily grow in any moist area of the body, such as the mouth ("thrush"), groin ("jock itch"), vagina ("yeast infection"), and intestines. Candida yeast is found naturally in the body, but is normally kept under control by friendly bacteria, such as acidophilus. But candida yeast often gets out of control following the use of antibiotics. The antibiotic kills off the friendly acidophilus and aerobic bacteria but does not affect the yeast. Without the friendly organisms such as the multiple strains of acidophilus to control it, candida grows fast.

The excess sugar of diabetes will also provide food for yeast, causing it to proliferate. Diabetics are therefore especially prone to this type of problem.

The intestines form perfect breeding grounds for candida. If the condition becomes bad enough, eventually the candida irritates an area of the intestine so much that their toxins penetrate the intestinal wall into the blood stream, where they can break down the immune system. Soon the candida infection itself passes through the intestinal wall and the white blood cells are consumed in their struggle to control the infection, further destroying the immune system. Thus, candida is a common contributor to many diseases and conditions, such as AIDS, cancer, chronic fatigue syndrome, colds, flus, etc.. Almost all disease and health problems are greatly aggravated by candida.

Candida can sometimes be controlled by increasing the acidity of the body, especially the area the yeast is growing in. This can be done by eating acid foods, such as vinaigrette salad dressings, and by applying vinegar mixed with water to the problem area. The best antibiotic commonly used to treat this condition is Nystatin. But Nystatin is only marginally effective against yeast, and remember that the problems probably started with the use of antibiotics to begin with.

Normally the body can handle minor yeast infections. However, when the yeast reaches the infectious stage wherein it is poisoning the blood and the immune system grows weak, such infections as athlete's foot, vaginal yeast infections, and fungus infections under the nails cannot be fought off.

A common treatment for the general infection is a diet completely free of all sugars, even fruit and starches along with taking Nystatin. However, anyone who has tried this treatment will tell you that this very strict diet is almost impossible to follow and does little more than keep the infection from proliferating.

The most effective tools against yeast infections of all kinds are acidophilus (yogurt), colloidal silver, and upper colonics. Combined, they can rid the body of yeast infections about as fast as the body can dispose of the toxins from dead cultures. However, disposing of these toxins can be a real problem, for two reasons. First of all, if the intestinal infection is killed off too sudden, it is possible for the intestines to become blocked. Obviously this can be serious and sometimes requires professional treatment to clear the bowels. Second, the body tends to dispose of toxins from the blood through the skin, which causes an itchy rash when the process is too fast. Toxins from dead spores can also strain the liver and kidneys. Therefore, it is wise to take as much acidophilus as is convenient, but to build up the use of colloidal silver gradually, usually starting with four oz. of colloidal silver a day, of about ten parts per million, or the equivalent. This is usually increased by about one oz. per day until a breaking out appears or the conditions are relieved. [The blogger is copying directly these obviously incorrect numbers. Sorry for the confusion.]

The colloidal silver provides a three-fold attack on the problems of candida. First, the colloidal silver kills off anaerobic bacteria and virii wherever it comes in contact with them. Therefore, the colloidal silver virtually provides a secondary immune system against all types of disease and infections, while treating the candida. Thus much of the problems of candida are treated immediately, before the candida can be cleaned out of the system. Second, colloidal silver is unusually effective in treating the candida infection itself. And third, colloidal silver has a strange and dynamic way of healing injured and damaged tissues fast. Since yeast infections of all kinds usually attack and consume the living tissue, a healing process is badly needed, and colloidal silver has a very unique way of healing these tissues fast.

Users continually report that colloidal silver will cure athlete's foot, vaginal yeast infections, as well as candida infections of the skin very quickly and then heals the damaged tissues. However, these are often signs of an inner infection. Until the yeast infection within the body is cured, external infections keep on returning. That is no reason not to treat these conditions. But if they return, it is time to look to the source of the problems as being inward. One can, of course, find explanations for the sources of the reinfection. However, a healthy body seldom succumbs to these infections.

Colloidal silver used internally and locally is the most effective treatment available today for all of these conditions. (refer to "The Candida Problem under Health")"

[News Article written by Marvin Robey (Marvin Robey is one of the premiere researchers in the field of Colloidal Silver.)]

OTHER (ABRIDGED) SOURCES ON COLLODIAL SILVER

Holistic Health Talk with Cynthia Perkins, MEd

"Colloidal silver is a popular choice for many people in their arsenal against candida. It is believed to work not by attacking the pathogen, but rather deactivating enzymes that are responsible for the metabolism of the organism ... as I just don’t feel comfortable ingesting a metal for a long period of time. However, I would use it intermittently with other products ... BTW, a condition know as Argyria, a permanent discoloration of the skin – blue-gray, has occurred in people who ingest too much for too long. Although this is extremely rare. There’s a lot of controversy even in the health field about the use of silver. Some people swear by it’s healing properties, while others think it holds too many risks. ... That said, many people find colloidal silver to be very effective against not only candidiasis, but viruses and bacteria as well. It is touted to relieve everything from acne to yeast infections, from boils to strep throat and believed to be effective against over 650 organisms. I’m sorry I can’t give you a personal opinion on whether it’s effective or not, because I haven’t been able to take the product. When I’ve tried taking even 1/16 of a teaspoon it gives me a migraine within 20 minutes. I’m not sure if that is a result of die off or a reaction to the silver itself ..."

Collodial Silver Candida Treatment

"Two popular and natural means to rid the body of Candida infections are to change the body's PH through diet, or to treat the affected area either topically or internally, using a colloidal silver Candida treatment ... The colloidal silver Candida treatment fights fungi on contact both internally and externally. Topically, colloidal silver is safely applied without worry of adverse affects. Recommended applications are two to three times per day until the symptoms subside. Internally, colloidal silver dosage should be small at first, about 1 tablespoon a couple of times per day. It should be noted that when a person begins treating Candida internally, the release of toxic waste by the abundant dying fungus can cause a person to feel initially worse. This is referred to as Candida die off. For this reason it is suggested to begin treating the internal infection gradually at first, with small amounts of colloidal silver, in order to keep the waste substances to a level that is manageable for the body to expel ...  Colloidal silver naturally leaves the body via the urine so that there is no buildup in the body. It is one of the oldest forms of medicine that our civilization has used to treat a myriad of health issues."

Treating Candida Infections with Collodial Silver

"The main theme of Candida infection treatment is strengthening of the human immune system. Colloidal silver is the right choice in this regard as it is well known for its capability of fighting against fungus infections. Colloidal silver is nothing but very fine particles of pure silver, suspended in water. Colloidal silver has antimicrobial properties. A lot of research has been done recently on its functioning. Certain bacteria are essential to healthy body function, such as acidophilus. Several researchers claim colloidal silver only attacks the unfriendly pathogens and will not harm the friendly bacteria. But one must wonder how it can possibly differentiate. One explanation is that the friendly bacteria are aerobic, while unfriendly bacteria are anaerobic. Also, it is said that the silver does not attack bacteria directly, but rather decomposes certain enzymes the anaerobic bacteria, viruses, yeast, and molds require. The silver acts as a catalyst and is not consumed in the process. It is probable that the reason the bacteria cannot develop a resistance to silver, as they do to antibiotics, is because silver does not [affect] them directly, but rather destroys the enzymes they depend on. This is in quite contrast to normal antibiotics, which kills friendly bacteria as well.

The germ fighting properties of colloidal silver has been adopted in soap making and such soaps are in vogue. Regular use of such soap not only helps in keeping the skin clean and healthy but also enhances the body immune system, thus preventing further infections of Candida. Even dermatologists recommend soaps with colloidal silver for the patients with candida infection. However, one must be selective while purchasing such soaps. Soaps containing colloidal silver with 20 ppm are considered the best for daily usage and they have optimum effect on fight against Candida infection."

Cancer, Candida and the Effects of Collodial Silver

"Heavy metals are bad for you. I’ve done a lot of research, and I’ve learned that the metal-based chemical toxins that you should avoid are aluminum, cadmium, carbon monoxide, chlorine, copper, fluoride, hexavalent chromium, industrial and agricultural chemicals, lead, mercury, nitrates and nitrites, nitrogen dioxide and ozone, polynuclear aromatic hydrocarbons, synthetic and chemical drugs, and tobacco smoke. Silver, gold, and titanium are not on that list. Silver, gold, and titanium are HEALTHY TO INJEST (at the colloidal/monoatomic level), and they are actually EXTREMELY GOOD FOR YOU!!! Silver actually helps the body remove heavy metals through a chelating process!

One cup of 30ppm colloidal silver per day for a month can cost around $1000. Rich people fed their babies with silver spoons because they knew that it was good for them. The British royal family didn’t get the plague at a time when they were eating off of 100% silver plates. One cup of 30ppm colloidal silver per day for a month WILL get rid of the candida in your body, and then the cancer will fall like a house of cards when someone opens a window.

And you can monitor the progress with “the spit test”.

Pau D’Arco is also good against candida, but you never know if the brand you’re buying has enough of the active ingredient. And even if you buy Pau D’Arco tablets that have enough of the active ingredients, the tablets come in gelcaps (aka gelatin capsules). ALL gelcaps have MSG. MSG is an excitotoxin which actually provokes cancer growth. Many great cancer fighting herbs come in gelcaps, and the gelcaps cancel or weaken their effect.

Garlic is a good fighter against candida, but colloidal silver is the best. Well, colloidal titanium is the best, but I don’t know how long you take that. Silver it’s a month at one cup a day.

It’s important to use a high quality colloidal silver product. There are cases of people who used improperly made or home-made colloidal silver and ended up turning themselves BLUE (Argyria). This is not a side effect of colloidal silver, but a side effect of improperly made colloidal silver. Always be confident in the sources of any products that you choose to use."

Infectious Diseases: Candida species

INTRODUCTION

Background: Candida species are ubiquitous fungi and are the most common fungal pathogens that affect humans. The growing problem of mucosal and systemic candidiasis reflects the enormous increase in the pool of patients at risk and the increased opportunity that exists for Candida species to invade tissues normally resistant to invasion. Candida species are true opportunistic pathogens that exploit recent technological advances to gain access to the circulation and deep tissues.

The increased prevalence of local and systemic disease caused by Candida species has resulted in numerous new clinical syndromes, the expression of which is primarily dependent on the immune status of the host. Candida species produce a wide spectrum of diseases, ranging from superficial mucocutaneous disease to invasive illnesses, such as hepatosplenic candidiasis, Candida peritonitis, and systemic candidiasis. Management of serious and life-threatening invasive candidiasis remains severely hampered by delays in diagnosis and the lack of reliable diagnostic methods that allow detection of both fungemia and tissue invasion by Candida species.

Advances in medical technology, chemotherapeutics, cancer therapy, and organ transplantation have had a major impact on reducing the morbidity and mortality of life-threatening disease. Patients who are critically ill and in medical and surgical ICUs have been the prime targets for opportunistic nosocomial fungal infections, primarily due to Candida species. Studies suggest that the problem is not under control and, in fact, show it is worsening. On a daily basis, virtually all physicians are confronted with a positive Candida isolate obtained from one or more various anatomical sites. High-risk areas for Candida infection include neonatal, pediatric, and adult ICUs, both medical and surgical. Candida infections can involve any anatomical structure.

Pathophysiology: Candida species are yeastlike fungi that can form true hyphae and pseudohyphae. For the most part, Candida species are confined to human and animal reservoirs; however, they are frequently recovered from the hospital environment, including on foods, counter tops, air-conditioning vents, floors, respirators, and medical personnel. They are also normal commensals of diseased skin and mucosal membranes of the GI, genitourinary, and respiratory tracts.

Candida species also contain their own set of well-recognized virulence factors. Although not well characterized, several virulence factors may contribute to their ability to cause infection. The main virulence factors are surface molecules that permit adherence of the organism to other structures (eg, human cells, extracellular matrix, prosthetic devices), acid proteases, and the ability to convert to a hyphal form.

As with most fungal infections, host defects also play a significant role in the development of candidal infections. Numerous host defects are associated with candidal infections. Host defense mechanisms against Candida infection and their associated defects that allow infection are as follows:

· Intact mucocutaneous barriers - Wounds, intravenous catheters, burns, ulcerations

· Phagocytic cells - Granulocytopenia

· Polymorphonuclear leukocytes - Chronic granulomatous disease

· Monocytic cells - Myeloperoxidase deficiency

· Complement - Hypocomplementemia

· Immunoglobulins - Hypogammaglobulinemia

· Cell-mediated immunity - Chronic mucocutaneous candidiasis, diabetes mellitus, cyclosporin A, corticosteroids, HIV infection

· Mucocutaneous protective bacterial florae - Broad-spectrum antibiotics

Risk factors associated with candidiasis include the following:

· Granulocytopenia

· Bone marrow transplantation

· Solid organ transplantation (liver, kidney)

· Parenteral hyperalimentation

· Hematologic malignancies

· Foley catheters

· Solid neoplasms

· Recent chemotherapy or radiation therapy

· Corticosteroids

· Broad-spectrum antibiotics

· Burns

· Prolonged hospitalization

· Severe trauma

· Recent bacterial infection

· Recent surgery

· GI tract surgery

· Central intravascular access devices

· Premature birth

· Hemodialysis

The first step in the development of a candidal infection is colonization of the mucocutaneous surfaces. The factors outlined above are all associated with increased colonization rates. The routes of candidal invasion are (1) disruption of a colonized surface (skin or mucosa), allowing the organisms access to the bloodstream, and (2) persorption via the GI wall, which may occur following massive colonization with large numbers of organisms that pass directly into the bloodstream."

Frequency .... (refer to original source)

Mortality/Mordibidty (in brief):

·   Mucocutaneous candidiasis - usually do not cause mortality 

·   Candidademia and disseminated candidiases - unknown mortality but guestimated to be in the range of 30-40%.

Sex ... equally among men and women, however, vaginitis is the second most common cause of infection

Age ... highest in the extremes of ages

CLINICAL

History: Infections due to Candida species can manifest in a wide spectrum of clinical syndromes as described below. The clinical presentation can vary depending on the type of infection and the degree of immunosuppression. Clinical syndromes associated with Candida infection are the following:

Cutaneous candidiasis syndromes

· Generalized cutaneous candidiasis: This is an unusual form of cutaneous candidiasis that manifests as a diffuse eruption over the trunk, thorax, and extremities. The patient has a history of generalized pruritus, with increased severity in the genitocrural folds, anal region, axillae, hands, and feet. Physical examination reveals a widespread rash that begins as individual vesicles that spread into large confluent areas.

· Intertrigo: The patient has a history of intertrigo affecting any site where the skin surfaces are in close proximity, providing a warm and moist environment. Pruritic red rash occurs. Physical examination reveals a rash that begins with vesiculopustules, which enlarge and rupture, causing maceration and fissuring. The area involved has a scalloped border with a white rim consisting of necrotic epidermis that surrounds the erythematous macerated base. Satellite lesions are frequently found and may coalesce and extend into larger lesions.

· Metastatic skin lesions: Characteristic skin lesions occur in approximately 10% of patients with disseminated candidiasis and candidemia. The lesions may be numerous or few. Lesions are generally described as erythematous, firm, nontender macronodular lesions with discrete borders. Biopsy specimens of these lesions demonstrate yeast cells, hyphae, or pseudohyphae, and cultures are positive for Candida species approximately 50% of the time.

· Candida folliculitis: The infection is found predominantly in the hair follicles and, rarely, can become extensive.

· Paronychia and onychomycosis: Frequently, paronychia and onychomycosis are associated with immersion of the hands in water and with diabetes mellitus. The patient has a history of a painful and erythematous area around and underneath the nail and nail bed. Physical examination reveals an area of inflammation that becomes warm, glistening, tense, and erythematous and may extend extensively under the nail. It is associated with secondary nail thickening, ridging, discoloration, and occasional nail loss.

Chronic mucocutaneous candidiasis

Chronic mucocutaneous candidiasis describes a group of Candida infections of the skin, hair, nails, and mucous membranes that tends to have a protracted and persistent course.

· History: Most infections begin in infancy or the first 2 decades of life; onset in people older than 30 years is rare.

oMost patients survive for prolonged periods and rarely experience disseminated fungal infections. The most common cause of death is bacterial sepsis.

oChronic mucocutaneous candidiasis is frequently associated with endocrinopathies, such as the following:

§ Hypoparathyroidism

§ Addison disease

§ Hypothyroidism

§ Diabetes mellitus

§ Autoimmune antibodies to adrenal, thyroid, and gastric tissues (approximately 50%)

§ Thymomas

§ Dental dysplasia

§ Polyglandular autoimmune disease

§ Antibodies to melanin-producing cells

· Physical examination: Findings reveal disfiguring lesions of the face, scalp, hands, and nails. This is occasionally associated with oral thrush and vitiligo.

GI tract candidiasis

· Oropharyngeal candidiasis

oThe patient has a history of HIV infection, denture wear, diabetes mellitus, or frequent use of broad-spectrum antibiotics or inhaled steroids. Patients may be asymptomatic, but variable symptoms may include the following:

§ Sore and painful mouth

§ Burning mouth or tongue

§ Dysphagia

§ Whitish, thick patches on the oral mucosa

oPhysical examination reveals a diffuse erythema and white patches that appear on the surfaces of the buccal mucosa, throat, tongue, and gums. The following are the 5 types of OPC:

§ Membranous candidiasis: This is one of the most common types and is characterized by creamy-white curdlike patches on the mucosal surfaces.

§ Erythematous candidiasis: This is associated with an erythematous patch on the hard and soft palates.

§ Chronic atrophic candidiasis (denture stomatitis): This type is also thought to be one of the most common forms of the disease. The presenting signs and symptoms include chronic erythema and edema of the portion of the palate that comes into contact with dentures.

§ Angular cheilitis: An inflammatory reaction, this type is characterized by soreness, erythema, and fissuring at the corners of the mouth.

§ Mixed: A combination of any of the above types is possible.

· Esophageal candidiasis

oThe patient's history usually includes chemotherapy, the use of broad-spectrum antibiotics or inhaled steroids, or the presence of HIV infection or hematologic or solid organ malignancy. Patients may be asymptomatic, but variable symptoms may include the following:

§ No oral disease (>50% of patients)

§ Dysphagia

§ Odynophagia

§ Retrosternal pain

§ Epigastric pain

§ Nausea and vomiting

oUpon physical examination, oral candidiasis is nearly always present.

· Nonesophageal GI candidiasis

oMost commonly, the patient's history includes an association with neoplastic disease of the GI tract. The stomach is found to be the second most commonly infected site after the esophagus. With less frequency, patients may have chronic gastric ulcerations, gastric perforations, or malignant gastric ulcers with concomitant candidal infection. The third most common site of infection (20%) is the small bowel. The frequency of candidal infection in the small bowel is the same as in the large bowel. Approximately 15% of patients develop systemic candidiasis.

oPhysical examination findings are variable and depend on the site of infection. The diagnosis, however, cannot be made solely on culture results because approximately 20-25% of the population is colonized by Candida. The following symptoms may be present:

§ Epigastric pain

§ Nausea and vomiting

§ Abdominal pain

§ Fever and chills

§ Occasionally, abdominal mass

Respiratory tract candidiasis

The respiratory tract is frequently colonized with Candida species, especially in hospitalized patients. In ambulatory patients, 20-25% of the population is colonized by Candida species.

· Laryngeal candidiasis: This is very unusual but may be a source for disseminated candidiasis. Laryngeal candidiasis is primarily observed in patients with hematologic malignancies. The patient may present with a sore throat and hoarseness. Physical examination findings generally are unremarkable, and the diagnosis is made by direct or indirect laryngoscopy.

· Candida tracheobronchitis: This is a rare form of candidiasis. Most patients with Candida tracheobronchitis are seropositive for HIV or are severely immunocompromised, reporting fever, productive cough, and shortness of breath. Physical examination reveals dyspnea and scattered rhonchi. The diagnosis is generally made after bronchoscopy.

· Candida pneumonia: It does not exist alone and occurs only rarely as part of disseminated candidiasis. The most common form is multiple abscesses due to hematogenous dissemination of Candida species. The high degree of colonization and isolation of Candida species from the respiratory tract makes diagnosing this entity difficult. The patient's history reveals similar risk factors for disseminated candidiasis, and patients report shortness of breath, cough, and respiratory distress. Physical examination reveals fever, dyspnea, and variable breath sounds, from clear to rhonchi to scattered rales.

Genitourinary tract candidiasis

· Vulvovaginal candidiasis: This is the second most common cause of vaginitis. The patient's history includes vulvar pruritus, vaginal discharge, dysuria, and dyspareunia. Approximately 10% of women experience repeated attacks of VVC without precipitating risk factors. Physical examination findings include a vagina and labia that are usually erythematous, a thick curdlike discharge, and a normal cervix upon speculum examination.

· Candida balanitis: Patients report itchiness of the penis. Lesions and whitish patches are present. Candida balanitis is acquired through sexual intercourse with a partner who has VVC. Physical examination reveals vesicles on the penis that develop later into patches resembling thrush. The rash may spread to the thighs, gluteal folds, buttocks, and scrotum.

· Candida cystitis: Many patients frequently are asymptomatic. However, bladder invasion may result in frequency, urgency, dysuria, hematuria, and suprapubic pain. Candida cystitis may or may not be associated with the use of a Foley catheter. Physical examination may reveal suprapubic pain; otherwise, examination findings are unremarkable.

· Asymptomatic candiduria: Most catheterized patients with persistent candiduria are asymptomatic, similar to noncatheterized patients. Most patients with candiduria have easily identifiable risk factors for Candida colonization. Thus, the distinction between invasive disease and colonization cannot be made solely on culture results because approximately 5-10% of all urine cultures are positive for Candida.

· Ascending pyelonephritis: The use of stents and indwelling devices, along with the presence of diabetes, is the major risk factor predisposing patients to ascending infection. The patient frequently has a history of flank pain, abdominal cramps, nausea, vomiting, fever, chills, and hematuria, Physical examination reveals abdominal pain, costovertebral-angle tenderness, and fever.

· Fungal balls: This is due to the accumulation of fungal material in the renal pelvis. The condition may produce intermittent urinary tract obstruction with subsequent anuria and ensuing renal insufficiency.

Hepatosplenic candidiasis

A variety of systemic candidiasis patients have an underlying hematologic malignancy and are in the recovery phase of a prolonged episode of neutropenia. The patient's history includes the following:

· Fever unresponsive to broad-spectrum antimicrobials

· Right upper quadrant pain

· Abdominal pain and distension

· Jaundice (rarely)

Physical examination findings include right upper quadrant tenderness and hepatosplenomegaly (less than 40%).

Systemic candidiasis

Systemic candidiasis can be divided into 2 major categories, which are candidemia and disseminated candidiasis (organ infection by Candida species). Deep organ infections due to Candida species are generally observed as part of the disseminated candidiasis syndromes, which may be associated with either single or multiorgan involvement.

· Candidemia

oCandida species currently are the fourth most commonly isolated organism in blood cultures, and Candida infection generally is considered a nosocomially acquired infection. The patient's history commonly reveals the following:

§ Several days of fever that is unresponsive to broad-spectrum antimicrobials; frequently the only marker of infection

§ Prolonged intravenous catheterization

§ A history of several key risk factors (see Pathophysiology)

§ Possibly associated with multiorgan infection

oPhysical examination is remarkable for the following:

§ Fever

§ Macronodular skin lesions (approximately 10%)

§ Candidal endophthalmitis (approximately 10-28%)

§ Occasionally, septic shock (hypotension, tachycardia, tachypnea)

oOther causes of candidemia without invasive disease include the following:

§ Intravascular catheter-related candidiasis: This entity usually responds promptly to catheter removal and antifungal treatment.

§ Suppurative thrombophlebitis: For the most part, this is observed secondary to prolonged central venous catheterization. Suppurative thrombophlebitis manifests as fever and candidemia, which persist despite antifungal therapy and catheter removal. Sepsis also may be present.

§ Endocarditis: The frequency of endocarditis has increased in the past few years. Endocarditis is the most common cause of fungal endocarditis and is primarily due to Candida albicans (>60% of cases). The most common valves involved are the aortic and mitral. The 2 different forms of endocarditis are exogenous, which is secondary to direct infection during surgery, and endogenous, which is due to secondary spread during candidemia and disseminated candidiasis. Endocarditis is frequently associated with 4 main risk factors. These are (1) intravenous heroin use, which is frequently associated with infection due to Candida parapsilosis; (2) chemotherapy; (3) prosthetic valves (approximately 50%); and (4) prolonged use of central venous catheters. The physical examination in patients with endocarditis reveals a broad range of manifestations, which include fever unresponsive to antimicrobials, hypotension, shock, new or changing murmurs, and large septic emboli to major organs, a characteristic of fungal endocarditis.

· Disseminated candidiasis: This is frequently associated with multiple deep organ infections or may involve single organ infection. Unfortunately, of patients with disseminated candidiasis, as many as 40-60% may have blood culture results negative for Candida species. The history of a patient with presumptive disseminated candidiasis reveals a fever unresponsive to broad-spectrum antimicrobials and negative results from blood culture. Physical examination reveals fever (may be the only symptom) with an unknown source and sepsis and septic shock.

· Candida endophthalmitis: The 2 forms of Candida endophthalmitis are the exogenous form and the endogenous form. Exogenous endophthalmitis is associated with either accidental or iatrogenic (postoperative) injury of the eye and inoculation of the organism from the environment. Endogenous endophthalmitis results from hematogenous seeding of the eye. It is found in 10-28% of patients with candidemia. The use of hematogenous candidal endophthalmitis as a marker of widespread disseminated candidiasis is important.

oThe patient's history reveals a broad range of manifestations.

§ Eye injury

§ Ophthalmic surgery

§ Underlying risk factors for candidemia

§ Asymptomatic and detected upon physical examination

§ Ocular pain

§ Photophobia

§ Scotomas

§ Floaters

oPhysical examination reveals fever.

oUpon funduscopic examination, early lesions are the size of a pinhead, are off-white in color, and are found in the posterior vitreous with distinct margins and minimal vitreous haze. Classic lesions are large and off-white, similar to a cotton-ball, with indistinct borders covered by an underlying haze. Lesions are 3-dimensional and extend into the vitreous off the chorioretinal surface. They may be single or multiple.

· Renal candidiasis

oThis most frequently is a consequence of candidemia and disseminated candidiasis. Patient history includes fever that is unresponsive to broad-spectrum antimicrobials. Frequently, patients are asymptomatic and lack symptoms referable to the kidney.

oPhysical examination generally is unremarkable, and renal candidiasis is diagnosed after urinalysis and renal biopsy. Otherwise, this condition is commonly diagnosed at autopsy.

· CNS infections due to Candida species

oCNS infections due to Candida species are rare and difficult to diagnose. The 2 primary forms are exogenous infection and endogenous infection. Exogenous infection results from postoperative infection, trauma, lumbar puncture, or shunt placement. Endogenous infection results from candidemia, thus involving the brain parenchyma and multiple small abscesses (eg, disseminated candidiasis).

oAs with other organ infections due to Candida species, patients usually have underlying risk factors for disseminated candidiasis. CNS infections due to Candida species are frequently found in patients hospitalized for long periods in ICUs. The spectrum of this disease includes the following:

§ Meningitis

§ Granulomatous vasculitis

§ Diffuse cerebritis with microabscesses

§ Mycotic aneurysms

§ Fever unresponsive to broad-spectrum antimicrobials

§ Mental status changes

oPhysical examination reveals the following:

§ Fever

§ Nuchal rigidity

§ Confusion

§ Coma

· Candida arthritis, osteomyelitis, costochondritis, and myositis

oIn the past, musculoskeletal infections were rare; currently, they are more common, due to the increased frequency of candidemia and disseminated candidiasis. The most common sites of involvement are the knee and vertebral column. The pattern of involvement is similar to the pattern observed in bacterial infections. The infection may be exogenous or endogenous. The exogenous infection is frequently due to direct inoculation of the organisms, such as postoperative infection or trauma. Affected sites include the following:

§ Ribs and leg bones (less than 20 y)

§ Vertebral column and paraspinal abscess (adulthood)

§ Flat bones (any age group)

§ Sternum - Generally observed postoperatively after cardiac surgery

oThe patient frequently is asymptomatic, and the patient's history reveals underlying risk factors of disseminated candidiasis and localized pain over the affected site. The physical examination frequently is unremarkable; otherwise, it may reveal tenderness over the involved area, erythema, and bone deformity, occasionally with a draining sinus.

§ Arthritis: Generally, arthritis is a complication of disseminated candidiasis, but it may be caused by trauma or direct inoculation due to surgery or steroid injections. Most cases are acute and begin as a suppurative synovitis. A high percentage of cases progress to osteomyelitis. In addition, developing Candida arthritis after joint replacement is not uncommon.

§ Osteomyelitis: The 2 forms of osteomyelitis are exogenous infection and endogenous infection. The exogenous infection is frequently due to either direct inoculation of the organisms, such as through postoperative infection, trauma, or steroid injections. The endogenous form of osteomyelitis generally is a complication of disseminated candidiasis. Most cases due to hematogenous seeding infect the vertebral disks and progress to diskitis with extension into the vertebrae from contiguous spread. Other bones affected include the wrist, femur, scapula, and proximal humerus.

§ Costochondritis: This is rare and usually has 2 forms. Costochondritis usually results from either hematogenous spread or direct inoculation during surgery (median sternotomy). Frequently, costochondritis is associated with localized pain over the involved area.

§ Myositis: This occurs infrequently, and an association with disseminated candidiasis is common. Most patients are neutropenic. People with myositis have a history of muscular pain.

· Myocarditis-pericarditis: This is due to hematogenous spread in association with disseminated disease and is rarely due to direct extension from the sternum or esophagus. Myocarditis-pericarditis occurs as diffuse abscesses scattered throughout the myocardium with normal cardiac tissue. In persons with disseminated candidiasis, the rate has been documented to be as high as 50%. The patient history reveals serious complications in 10-20% of cases without valve disease and fever and chills. Physical examination reveals fever, hypotension, shock, tachycardia, and new murmurs or rubs (changes in previously detected murmurs).

· Candida peritonitis

oThe patient history frequently reveals an association with GI tract surgery, viscous perforation, or peritoneal dialysis. Candida peritonitis tends to remain localized, and only in 15% of cases does the infection disseminate into the blood stream. The range of manifestations is broad and includes fever and chills, abdominal pain and cramping, nausea and vomiting, and constipation.

oPhysical examination is significant for the following:

§ Fever

§ Abdominal distention

§ Abdominal pain

§ Absent bowel sounds

§ Rebound tenderness

§ Localized mass

· Candida splenic abscess and hypersplenism: Both are manifestations of disseminated candidiasis and are usually simultaneously associated with liver involvement. Manifestations of hypersplenism are common (see Hepatosplenic candidiasis).

· Candida cholecystitis: This is rare and generally is associated with bacterial cholangitis and ascending cholangitis. Most commonly, Candida cholecystitis is diagnosed at the time of surgery when a culture is obtained.

Physical: See History for physical examination findings paired with clinical syndromes.

Causes: More than 100 species of Candida exist in nature; only a few species are recognized causes of disease in humans.

· The medically significant Candida species include the following:

oC albicans, the most common species identified (50-60%)

oCandida glabrata (15-20%)

oC parapsilosis (10-20%)

oCandida tropicalis (6-12%)

oCandida krusei (1-3%)

oCandida kefyr (less than 5%)

oCandida guilliermondi (less than 5%)

oCandida lusitaniae (less than 5%)

oCandida dubliniensis, primarily recovered from patients who are positive for HIV

· C glabrata and C albicans account for approximately 70-80% of yeast isolated from patients with invasive candidiasis. C glabrata has recently become important because of its increasing incidence worldwide, and it is intrinsically less susceptible to azoles and amphotericin B.

· C krusei is important because of its intrinsic resistance to ketoconazole and fluconazole (Diflucan); additionally, it is also less susceptible to all other antifungals, including itraconazole (Sporanox) and amphotericin B.

· Another important Candida species is C lusitaniae; although not as common as some Candida species, it is of clinical significance because it is frequently resistant to amphotericin B, although it remains susceptible to azoles and echinocandins.

· C parapsilosis is an important species to consider in hospitalized patients with vascular catheters.

· C tropicalis has been considered an important cause of candidemia in patients with cancer (leukemia) and in those who have undergone bone marrow transplantation.

WORKUP—TREATMENT

Lab Studies:

· Unfortunately, findings from the laboratory studies are often nonspecific. Clinicians are required to act definitively and early based on a high index of suspicion. In the past, many patients with life-threatening candidiasis died without receiving antifungal therapy. Patients who remain febrile despite broad-spectrum antibiotic therapy, with either persistent neutropenia or other risk factors and persistent leukocytosis, should be suspected of having systemic candidiasis. To be effective, therapy should be provided early and empirically in such patients.

· Cultures of nonsterile sites, although not useful for establishing a diagnosis, may demonstrate high degrees of candidal colonization. Always consider positive culture results from sterile sites to be significant and evidence of infection.

· Mucocutaneous candidiasis

oFor a wet mount, scrapings or smears obtained from skin, nails, oral mucosa, or vaginal mucosa are examined under the microscope for hyphae, pseudohyphae, or budding yeast cells.

oWith a potassium hydroxide smear, the Gram stain methylene blue is useful to directly demonstrate fungal cells.

oCultures of affected nails are helpful to diagnose onychomycosis versus noninfectious causes.

· Candidemia and disseminated candidiasis

oBlood cultures are helpful but are positive in only 50-60% of cases of disseminated disease.

oUrinalysis may be helpful, and results may be indicative of either colonization or renal candidiasis.

oThe serum 1-3 D-glucan detection assay (Glucatell, Fungitell) is a nonculture test, which was approved for use in the United States in May 2004. This assay measures the level of beta-glucan (a fungal cell wall component). In a large multicenter study, the assay had a high specificity and positive predictive value with highly reproducible results.

oCultures of nonsterile sites, although not useful for establishing a diagnosis, may be useful for initiating antifungal therapy in patients with fever that is unresponsive to broad-spectrum antimicrobials. Therefore, appropriate interpretation is required. Positive results from blood cultures and cultures from other sterile sites imply the presence of invasive disease. Always consider positive results from these sites to be significant and to be evidence of infection.

oGI, respiratory, and urinary tract culture results positive for Candida may not represent invasive disease; however, consider the GI, respiratory, and urinary tracts sites of colonization.

· Cutaneous candidiasis: Use a wet mount. Scrapings or smears obtained from skin or nails are examined under the microscope for hyphae, pseudohyphae, or budding yeast cells. Potassium hydroxide smears are also useful.

· Genitourinary candidiasis: Perform a urinalysis. Evidence of WBCs, RBCs, protein, and yeast cells can be found. Additionally, urine fungal cultures are useful.

· Respiratory tract candidiasis

oSputum Gram stain demonstrates WBCs and yeast cells.

oSputum culture demonstrates Candida species.

oLung biopsy is mandatory to definitively establish the diagnosis of respiratory tract candidiasis because the respiratory tract is frequently colonized with yeast.

· GI candidiasis: Endoscopy with or without biopsy is necessary to establish the diagnosis.

· Focal hepatosplenic candidiasis: Elevation of the serum alkaline phosphatase level is common.

· Species identification

oC albicans, C dubliniensis, and Candida stellatoidea can be identified morphologically by germ-tube formation (hyphae are produced from yeast cells after 2-3 h of incubation) or biochemical assays.

oCHROMagar Candida allows for the presumptive identification of several Candida species by using color reactions in specialized media that demonstrate different colony colors, depending on the species of Candida.

oAPI20C and API 32C are biochemical assays that allow the identification of the different Candida species with more precision. These assays evaluate the assimilation of a number of carbon substrates and generate profiles used in the identification of different fungal species.

· Antifungal susceptibility testing

oIn vitro susceptibility testing for Candida species is now standardized, using the National Committee for Clinical Laboratory Standards (NCCLS) microbroth dilution methodology (NCCLS M27-A2).

oAlthough not used as a standard of care, this method may be helpful in guiding difficult therapeutic decisions. Most of the difficult decisions are observed in antifungal, refractory, oral, or esophageal candidiasis in patients with advanced HIV disease.

· Nonculture Candida detection assays

oThe Candida mannan assay has a sensitivity of 31-90% (less for non-albicans Candida species).

oThe Candida heat labile antigen assay has a sensitivity of 10-71%.

oThe D-arabinitol assay has a sensitivity of 50% but is not useful for infection with C krusei or C glabrata.

oThe enolase assay has a sensitivity of 55-75%, which improves with serial testing.

oThe 1-3 beta-D-glucan assay is an amebocyte lysis assay with a sensitivity of 75-100% and a specificity of 88-100% (broad-spectrum assay that detects Aspergillus, Candida, Fusarium, Acremonium, and Saccharomyces species). Beta-D-glucan is a component of the cell wall of a wide variety of fungi and can be detected by its ability to activate factor G of the horseshoe crab coagulation cascade. The Fungitell assay is used in the evaluation of invasive fungal infections caused by the species mentioned above to guide diagnosis. It does not detect infections caused by Cryptococcus neoformans and Zygomycetes.

oMolecular assays such as polymerase chain reaction tests and DNA probes are still under development and in the early investigational phases, but they appear promising.

Imaging Studies:

· Imaging studies are not required or useful in the diagnosis of cutaneous candidiasis, OPC, or VVC.

· Chest radiography may be useful in differentiating a bacterial pneumonia as the cause of fever in patients who are hospitalized. Patients with bronchopneumonia due to hematogenous candidiasis usually have multilobar involvement.

· Esophagography/upper GI studies may be useful for detecting abnormalities in the esophagus and stomach. Unfortunately, this study is not helpful for determining the microbiologic origin of the disease entity.

· Ultrasonography may be useful for diagnosing a hepatosplenic abscess. The classic bull's eye, or target, lesions are observed in the liver and spleen.

oEchogenic foci with degrees of shadowing

oIntra-abdominal abscess formation

oCholelithiasis

oRenal abscess

oRenal fungus balls

· CT scanning with contrast enhancement may be useful for diagnosing the following:

oHepatosplenic candidiasis

oIntra-abdominal abscess or peritonitis

oRenal abscess

oPyelonephritis

· Echocardiography may be useful for excluding or including Candida endocarditis as the diagnosis. It is extremely useful because fungal endocarditis is frequently associated with large vegetations that are easily observed using standard echocardiography.

Procedures:

· For candidemia and disseminated candidiasis, obtaining a tissue biopsy sample of the involved areas is frequently helpful for establishing the presence of Candida infection and invasion.

· Bronchoscopy with bronchoalveolar lavage and transbronchial biopsy provide adequate tissue to make the diagnosis of pulmonary candidiasis.

· Endoscopy provides direct examination of the esophagus and stomach, one of the organ systems most commonly infected with Candida species. In addition, it is necessary for excluding other causes of esophagitis.

· Echocardiography may be useful for excluding or including Candida endocarditis as the diagnosis. It is extremely useful because fungal endocarditis is frequently associated with large vegetations that are easily observed using standard echocardiography.

Histologic Findings: Fixed tissues can be stained with hematoxylin and eosin. In addition, fungal hyphae may be demonstrated with Grocott silver-methenamine, methylene blue, or periodic acid-Schiff staining. The classic appearance demonstrates the Candida species as either round or ovoid yeast cells, hyphae, or pseudohyphae.

Medical Care: Treatment of Candida infections varies substantially and is based on the anatomic location of the infection, the patients' underlying disease and immune status, the patients' risk factors for infection, the specific species of Candida responsible for infection, and, in some cases, the susceptibility of the strain to antifungal drugs. In January 2004, the Infectious Disease Society of America published updated practice guidelines for the treatment of candidiasis. These latest recommendations include newer antifungal agents, such as caspofungin and voriconazole, in several specific indications. The therapeutic options for the management of invasive candidiasis and candidemia continue to increase with the addition of newer echinocandins.

· Cutaneous candidiasis: Most localized cutaneous candidiasis infections may be treated with any number of topical antifungal agents (eg, clotrimazole, econazole, ciclopirox, miconazole, ketoconazole, nystatin). If the infection is a paronychia, the most important aspect of therapy is drainage of the abscess, followed by oral antifungal therapy with either fluconazole or itraconazole. In cases of extensive cutaneous infections, infections in immunocompromised patients, folliculitis, or onychomycosis, systemic antifungal therapy is recommended. For Candida onychomycosis, oral itraconazole (Sporanox) appears to be the most efficacious. Two treatment regimens are available, the single daily dose of itraconazole taken for 3-6 months or the pulsed-dose regimen that requires a slightly higher dose daily for 7 days, followed by 3 weeks off therapy. The cycle is repeated every month for 3-6 months.

· GI candidiasis

oOPC may be treated with either topical antifungal agents (eg, nystatin, clotrimazole, amphotericin B oral suspension) or systemic oral azoles (fluconazole, itraconazole). In HIV-positive patients, the infections tend to be slower to respond, and approximately 60% of patients experience a recurrence within 6 months of the initial episode. Approximately 3-5% of patients with advanced HIV (CD4 cell counts less than 50/mL) may experience refractory OPC. In these situations, besides attempting to correct the immune dysfunction with HAART, use higher dosages of fluconazole (as high as 800 mg/d) or itraconazole (as high as 600 mg/d) prior to using parenteral amphotericin B. If amphotericin B is used, low doses (0.3-0.7 mg/kg) have been shown to be effective.

oCandida esophagitis requires systemic therapy, usually with fluconazole or itraconazole for at least 14-21 days. Parenteral therapy with fluconazole may be required initially if the patient is unable to take oral medications. Daily suppressive antifungal therapy with fluconazole at 100-200 mg/d is effective for preventing recurrent episodes, but it should only be used if the recurrences become frequent or are associated with malnutrition due to poor oral intake and wasting syndrome. The US Food and Drug Administration (FDA) recently approved voriconazole and micafungin for esophageal candidiasis treatment.

· Genitourinary tract candidiasis

oVVC can be managed with either topical antifungal agents or single-dose oral fluconazole. Recently, the FDA approved single-dose oral fluconazole for acute episodes of VVC; this has been shown to have clinical and microbiological efficacy as good as or better than topical antifungal agents. A small percentage (less than 5%) of women experience chronic recurrent VVC infections, which often require long-term or prophylactic oral azole therapy for control. In women who experience recurrent attacks, the standard recommended regimen includes fluconazole at 150 mg every other day for 3 doses, followed by weekly fluconazole at 150-200 mg for 6 months. Using this regimen, more than 80% of women do not experience recurrent VVC infections.

oFor asymptomatic candiduria, therapy generally depends on the presence or absence of an indwelling Foley catheter. The candiduria frequently resolves with changing of the Foley catheter (20-25% of patients). Thus, when candiduria is associated with a Foley catheter, most clinicians believe that it should not be treated most of the time. However, eradicating candiduria prior to any form of instrumentation or urological manipulation is prudent.

oCandida cystitis in noncatheterized patients should be treated with fluconazole at 200 mg/d orally for at least 10-14 days.

oFor Candida cystitis in catheterized patients, the first step is always to remove the nidus of infection. Thus, the Foley catheter should be discontinued or replaced prior to initiating antifungal therapy. If the candiduria persists after the catheter change, then patients can be treated with 200 mg/d of fluconazole orally for 14 days. Alternative therapy includes amphotericin B bladder irrigation. However, its use for the treatment of funguria is significantly limited, primarily because of the required maintenance of a urinary catheter; lack of adequate studies to define the dose, duration, and method of administration; restriction of its use to uncomplicated lower urinary tract infections; and availability of more convenient treatment options (eg, oral fluconazole therapy). The use of amphotericin B bladder irrigation is a strategy rarely needed. Administering intravenous amphotericin B to treat candiduria is rarely necessary.

· Renal candidiasis: Regardless of the route of infection, whether it involves hematogenous dissemination to the kidney or ascending infection (pyelonephritis), systemic antifungal therapy is required. The most recent comparative studies indicate that fluconazole at 400-800 mg/d intravenously or orally is as effective as amphotericin B without the toxicities normally associated with amphotericin B. For amphotericin B, the daily dose is 0.5-0.7 mg/kg intravenously for a total dose of 1-2 g administered over a 4- to 6-week period.

· Candidemia: This requires treatment in all patient populations. For most situations, fluconazole has been the drug of choice in the management of candidemia and disseminated candidiasis. Studies conducted by the Mycosis Study Group have demonstrated that fluconazole at a dose of 400 mg/d is as efficacious as amphotericin B. In addition, fluconazole has several advantages, including lower nephrotoxicity rates (less than 2%) and ease of use because of the high degree of bioavailability and the long half-life of the drug. Thus, once the GI tract is functional, the parenteral dose may be switched to the oral formulation, with the same efficacy. Alternative options listed below need to be considered depending on history of previous exposure to antifungals, the probability of fluconazole resistance, the presence of comorbid conditions, and the clinical status of the patient.

oThe standard recommended dose for most Candida infections is fluconazole at 800 mg as the loading dose, followed by fluconazole at a dose of 400 mg/d for at least 2 weeks of therapy after a demonstrated negative blood culture result or clinical signs of improvement. This treatment regimen can be used for infections due to C albicans, C tropicalis, C parapsilosis, C kefyr, C dubliniensis, C lusitaniae, and C guilliermondi.

oA critical component in the management of candidemia and disseminated candidiasis is the removal of the focus of infection, such as intravenous and Foley catheters.

oAlternative options for candidemia include the following:

§ Amphotericin B can be administered at 0.7 mg/kg/d intravenously for a total dose of 1-2 g over a 4- to 6-week period

§ Liposomal preparations of amphotericin B also may be options if (1) a patient is refractory to fluconazole or at least 500 mg of standard amphotericin B, (2) a patient has severe infusion-related toxicity, or (3) a patient develops renal insufficiency while on amphotericin B (generally with an increase in creatinine level >2.5 mg/dL).

§ Caspofungin acetate (Cancidas) as a 70-mg loading dose is followed by 50 mg/d intravenously for a minimum of 2 weeks after improvement or after blood cultures have cleared. Caspofungin is a semisynthetic echinocandin also approved for Aspergillus infections. It is an effective alternative for severe mucosal infections and systemic infections due to Candida, especially those due to non-albicans Candida species.

§ Anidulafungin and micafungin also have comparable activity against Candida organisms and have been studied in clinical trials for invasive candidiasis and candidemia.

§ Voriconazole has been recently approved for use in candidemia in non-neutropenic patients based on the findings of a clinical trial.

· Chronic mucocutaneous candidiasis: Generally, chronic mucocutaneous candidiasis is treated with oral azoles, either fluconazole at a dose of 100-400 mg/d or itraconazole at a dose of 200-600 mg/d until the patient improves. Generally, the initial therapy is always followed by maintenance therapy with the same azoles for life.

· Hepatosplenic candidiasis: Induction therapy generally is started with amphotericin B for at least 2 weeks, followed by consolidation therapy with fluconazole at a dose of 400 mg/d for an additional 4-12 weeks, depending on the response.

· Respiratory tract candidiasis: If the diagnosis is established on the basis of biopsy findings, then the infection is treated as disseminated candidiasis.

· Disseminated candidiasis and organ infection: Disseminated candidiasis with end organ involvement requires an individualized approach. Thus, the manifestation of invasive candidiasis involving localized structures, such as in Candida osteomyelitis, arthritis, endocarditis, pericarditis, and meningitis, requires prolonged antifungal therapy for at least 4-6 weeks. The optimum dosage and duration of therapy for various types of deep candidal infection have not been definitively determined.

oThe standard recommended dose for most Candida infections is fluconazole at 800 mg as the loading dose, followed by fluconazole at a dose of 400 mg/d either intravenously or orally for at least 2 weeks of therapy after a demonstrated negative blood culture result or clinical signs of improvement.

oAmphotericin B has become an alternative to fluconazole, although, amphotericin B has been the criterion standard in systemic fungal infections for the past 30 years. The dose for amphotericin B is 0.7-1 mg/kg/d intravenously to achieve a minimum of 1- to 2-g total dose.

oLiposomal preparations of amphotericin B also may be options if (1) a patient is refractory to fluconazole or at least 500 mg of standard amphotericin B, (2) a patient has severe infusion-related toxicity, or (3) a patient develops renal insufficiency while on amphotericin B (generally with an increase in creatinine level >2.5 mg/dL).

oCaspofungin acetate (Cancidas) at a 70-mg loading dose is followed by 50 mg/d intravenously for a minimum of 2 weeks after clinical improvement or after blood culture results have cleared.

oThe role of the newer antifungals in the management of invasive candidiasis needs to be defined.

· Special situations involving antifungal resistance: Several of the Candida species require special mention because of their known intrinsic resistance to antifungals.

oBecause C glabrata has lower susceptibility to antifungals, these infections require (1) higher daily doses (800 mg/d) of fluconazole, (2) caspofungin at 70 mg intravenously as a loading dose followed by 50 mg/d, (3) conventional amphotericin B (1 mg/kg/d), and (4) lipid preparations of amphotericin B at 3-5 mg/kg/d.

oInfections due to C krusei necessitate the use an agent other than fluconazole because this organism is intrinsically resistant to fluconazole and less susceptible to itraconazole, ketoconazole, and amphotericin B. Thus, the preferred regimen includes (1) caspofungin at 70 mg intravenously as a loading dose or 50 mg/d intravenously, (2) voriconazole at 4 mg/kg intravenously twice daily or 200 mg orally twice daily, and (3) amphotericin B at 1 mg/kg/d. Infections due to C lusitaniae or C guilliermondi necessitate the use of fluconazole, voriconazole, or caspofungin because these isolates are frequently intrinsically resistant to amphotericin B or develop resistance to amphotericin B while the patient is on therapy.

· Alternative antifungal regimens:

oAlternative regimens may be considered if patients are either intolerant to the treatment regimens or the infection is refractory to the antifungal regimen. The combination of amphotericin B and flucytosine has been recommended in several special situations. For instance, this combination has been used in immunocompromised patients with Candida endophthalmitis and Candida meningitis. Flucytosine appears to interact synergistically with amphotericin B in animal models.

oThe role of other combinations of antifungals to treat complicated Candida infections needs to be evaluated.

oA human recombinant monoclonal antibody against heat shock protein 90 was recently reported to significantly improve outcomes in patients treated with lipid-associated amphotericin B for confirmed invasive candidiasis.

Surgical Care:

· Major organ infections associated with abscess formation may require surgical drainage procedures along with the appropriate antifungal therapy.

· Prosthetic joint infection with Candida species requires removal of the prosthesis.

· Surgical debridement generally is necessary for sternal infections and possibly for vertebral osteomyelitis.

· Splenic abscesses may mandate splenectomy.

· Valve replacement surgery is indicated in cases of endocarditis.

Consultations: In some forms of candidiasis, involving physicians of different specialties for some of the specific infections may be necessary. Some examples of these situations are endocarditis, endophthalmitis, peritonitis, osteomyelitis, and other forms of invasive candidiasis that may require surgical drainage and debridement.

· Ophthalmologist

· General surgeon

· Cardiothoracic surgeon

· Gastroenterologist

· Infectious disease specialist

· Orthopedic surgeon

MEDICATION

[This is the chemical category which I'm not particularly fond of. However, the category does include drug and alternative medicine interactions and should not be ignored. For viewing the category, go to the source.]

Disclaimer:

This is NOT my research or information, but I am very impressed. In my broad readings, I've read that there are 81 known types of candida, and so the above selection are just some examples. It is VERY INTERESTING that various types of infection are affected by specific types of bacteria. This makes a lot of sense based on my readings that different diseases are the result of different bacteria. (I've made this comment before.) More research on my part and others needs to be done to determine which bacteria are triggering which disease(s). This information would be very useful as preventative medicine; doctors could then state that certain bacteria are present and treat the patient for the bacteria ... before the person is diagnosed with a disease. This would destroy many jobs in the medical world as fewer patients would then be having operations, chemo perhaps, etc., but it would also create more jobs for testing, developing accurate tests and administrating the tests while teaching a more health-conscious lifestyle complementary to the preventative testing procedures. 

I am really baffled by our modern "medical world". I think it's a no-brainer that diseases are caused by infection (acknowledged by the medical world) and that infections are caused by bacteria (not talked about in the clinical setting - all conversations it seems seem to be centered around "treating the infection" but not addressing the fact that an infection is bacteria gone wild and needs to be tempered by a change in lifestyle too and not just a pill to pop. Original research located here.