Systemic and localized infection by Candida species in patients with rheumatic diseases receiving anti-TNF therapy / Infecção sistêmica e localizada por Candida spp. em pacientes reumatológicos em terapia anti-TNF

ABSTRACT Objective: To evaluate the prevalence of systemic and localized infection by Candida species and its possible association with demographic, clinical and laboratory manifestations and therapy in patients with rheumatic diseases taking TNF blockers. Methods: Consecutive patients with rheumatic diseases receiving anti-TNF agents were included. The following risk factors up to four weeks prior to the study were analyzed: use of antibiotics, immunosuppressant drugs, hospitalization and invasive procedures. All subjects were evaluated for clinical complaints; specific blood cultures were obtained for fungi and blood samples were collected for Candida spp. detection by polymerase chain reaction. Results: 194 patients [67 with rheumatoid arthritis (RA), 47 with ankylosing spondylitis (AS), 36 with juvenile idiopathic arthritis (JIA), 28 with psoriatic arthritis and 16 with other conditions] were included. The average age of patients was 42 ± 16 years, with 68 (35%) male and mean disease duration of 15 ± 10 years. Sixty-four (33%) patients were receiving adalimumab, 59 (30%) etanercept and 71 (36%) infliximab. Eighty-one percent of patients were concomitantly taking immunosuppressant drugs. At the time of the study, only one (0.5%) patient had localized fungal infection (vaginal candidiasis). None of the patients included had systemic candidiasis with positive blood cultures for fungi or PCR positive for Candida spp. in peripheral blood sample. Conclusions: This was the first study to assess the prevalence of invasive and localized fungal disease by Candida in a significant number of patients with rheumatic diseases on anti-TNF therapy, and demonstrated low risk of candidiasis, despite the high prevalence of immunosuppressive drug use.

RESUMO Objetivo: Avaliar a prevalência de infecção sistêmica e localizada por Candida spp. e sua possível associação com dados demográficos, manifestações clínicas e laboratoriais e terapêutica em pacientes com doenças reumatológicas em uso de anti-TNF. Métodos: Foram incluídos pacientes consecutivos com doenças reumatológicas em uso de agentes anti-TNF. Foram analisados os seguintes fatores de risco até quatro semanas antes do estudo: uso de antibioticoterapia, imunossupressores, hospitalização e procedimentos invasivos. Todos foram avaliados para queixas clinicas, coletaram hemocultura específica para fungos e amostras de sangue para pesquisa de Candida spp. por reação em cadeia de polimerase. Resultados: Foram incluídos 194 pacientes [67 com artrite reumatoide (AR), 47 espondilite anquilosante (EA), 36 artrite idiopática juvenil (AIJ), 28 artrite psoriásica e 16 outros]. A média de idade era de 42 ± 16 anos, com 68 (35%) do sexo masculino e média de duração de doença de 15 ± 10 anos; 64 (33%) pacientes usavam adalimumabe, 59 (36%) etanercepte e 71 (36%) infliximabe; 81% faziam uso concomitante de imunossupressores. No momento do estudo, apenas um (0,5%) paciente apresentou infecção fúngica localizada (candidíase vaginal). Nenhum dos pacientes incluídos apresentou candidíase sistêmica com hemocultura positiva para fungos ou PCR positiva para Candida spp. em amostra de sangue periférico. Conclusões: Este foi o primeiro estudo que avaliou prevalência de doença fúngica invasiva e localizada por Candida em um expressivo número de pacientes reumatológicos em terapia anti-TNF e demonstrou baixo risco de candidíase, apesar da alta prevalência de uso de imunossupressores.

Expresiones cutáneas de candidiasis sistémica en pacientes inmunosuprimidos / Cutaneous expression of systemic candidiasis in immunosuppressed patients

La candidiasis sistémica constituye una importante causa de morbimortalidad en pacientes internados en centros de alta complejidad. Las expresiones cutáneas de la infección son múltiples y se observan en un pequeño porcentaje de pacientes. Se presentan cinco casos de candidiasis sistémica con compromiso cutáneo en pacientes inmunosuprimidos: un paciente trasplantado de médula ósea, dos pacientes con leucemia mieloide aguda, un caso de sepsis bacteriana y un paciente con linfoma linfocítico. Todos los pacientes presentaron fiebre persistente y lesiones cutáneas que se biopsiaron para estudio histológico y cultivo. La histopatología mostró seudohifas en tres de los casos. En los cultivos de piel se identificó a Candida tropicalis, Candida Krusei y Candida albicans en dos pacientes. El incremento de cepas resistentes hace necesario el empleo de nuevos antifúngicos como las equinocandinas para el tratamiento de esta entidad.

Systemic candidiasis is a signifi cant cause of morbidity and mortality in immunosuppressed hospitalized patients. Skin signs of systemic candi-diasis are numerous although they can be observed in a small percent-age of patients. We report fi ve cases of systemic candidiasis with cutaneous manifestations in immunosuppressed patients: one case of bone- marrow transplantation, two patients with acute myeloid leukaemia, one with bacterial sepsis and one patient with lymphocitic lymphoma. The patients presented persistent fever and cutaneous lesions. Skin biopsy for histopathological study and cultures were carried out. The histological examination showed yeasts in three of the cases. Skin culture revealed: Candida tropicalis, Candida krusei and Candida albicansin two cases. Due to the increase of resistant species new drugs such as echinocandins are currently available for the treatment of this entity.

A Case of Disseminated Candidiasis Presenting with Subcutaneous Nodules / 대한의진균학회지

Systemic candidiasis is a fatal fungal infection and its diagnosis is often difficult because Candida organism may be cultured from blood specimens in only 25% of the patients. The triad of systemic candidiasis is fever, papular rash, and diffuse muscle tenderness. Therefore, the recognition of the characteristic cutaneous lesions of disseminated candidiasis allows earlier diagnosis and treatment. The cutaneous lesion usually consists of red or purpuric papules, some with pale centers, abscess, necrotic lesion, hemorrhage and skin lesion mimicking ecthyma gangrenosum. We report a rare case of disseminated candidiasis presented as multiple subcutaneous nodule-typed skin lesions.

A Clinical Characteristics of Systemic Candidiasis in Neonatal Intensive Care Unit: Comparison with Systemic Bacterial Infection

PURPOSE: Long term hospitalized infants in neonatal intensive care units(NICUs) are prone to systemic infection. It is important to differentiate systemic candidiasis from systemic bacterial infection early in the course. Thus, in this study, we have compared clinical characteristics of systemic candidiasis and systemic bacterial infection, in premature low birth weight infants. METHODS: Retrospective chart review of the medical records of 20 patients with systemic candidiasis and 23 patients with systemic bacterial infection was performed. RESULTS: Among the risk factors of systemic candidiasis, total parenteral nutrition(TPN), the use of broad spectrum antibiotics, central catheter insertion, endotracheal intubation and the use of H2 blockers were more frequent in neonates with systemic candidiasis than neonates with systemic bacterial infection. Apnea with bradycardia developed more frequently in neonates with systemic candidiasis compared with systemic bacterial infection(75% vs 39%). In laboratory findings at symptom onset, seven cases(35%) of systemic candidal infections and two cases(9%) of systemic bacterial infections showed leukopenia and thrombocytopenia(P=0.03). Blood was the most frequent isolation site of candida and bacteria. CONCLUSION: In neonates with systemic candidiasis, apnea with bradycardia, pneumonia and thrombocytopenia were prone to develop more frequently. The use of TPN, antibiotics and central catheters was strongly associated with systemic candidiasis. Empirical treatment with antifungal agent should be considered in critically ill neonates with above findings.

Three Cases of Systemic Candidiasis with Skin Manifestations in Patients with Hematologic Malignancies / 대한피부과학회지

Systemic or disseminated candidiasis is a not uncommon serious complication among patients with impaired host-defense mechanisms, particularly among those with hematologic malignancies. Although widespread organ involvement is characteristic of disseminated candidiasis, there is only a few reports of skin manifestation in Korea. The diagnosis is often difficult to establish, since Candida organisms can be cultured from blood specimens in only 25% of the patients. Unless treated, the disease is rapidly fatal. If there is any evidence of respiratory distress or signs of sepsis in hematologic malignancy patients the possibility of systemic candidiasis and the need for parenteral antifungal therapy must be considered by early pathologic diagnosis of heralding skin lesions. We describe three hematologic malignancy patients with systemic candidiasis with disseminated maculopapules and vesicular eruption and respiratory distress. Skin biopsies showed multiple spores and pseudohyphae in the dermis and subcutis. These patients did not respond to intravenous antifungal agents and had fatal course.

Systemic Candidiasis in Neonatal Intensive Care Unit : A 8-Year Experience

PURPOSE: Recently, Candida has become an increasingly significant neonatal pathogen, and may result in serious morbidity and mortality in the neonatal intensive care units. The purpose of this study was to describe and analyze our 8-year experiences with a review of the related literature, and to contribute to the improvement of the survival rate in the neonatal intensive care unit. METHODS: We retrospectively reviewed the medical records of 20 patients who were diagnosed as systemic candidiasis in the neonatal intensive care unit of Seoul National University Children's Hospital between January 1993 and December 2000. We then analyzed demographics, clinical presentations, diagnostic features, risk factors, antifungal therapy, and outcomes. RESULTS: Twenty-one systemic candidial infections occurred in 20 patients representing 0.85% of all NICU patients during the study period, among which 13 were very low birth weight (VLBW) infants (2.85% of total 456 VLBW infants). The mean gestational age and birth weight were 30.4 weeks and 1,430 gm, respectively. The common Candida species were C. albicans (61.9%), C. parapsilosis (38.1%), and the others such as C. glabrata (4.8%), C. tropicalis (4.8%), and C. famata (4.8%). The rates of culture positivity of blood, urine, and tracheal aspirates were 95.2%, 42.9%, and 9.5%, respectively. Each of candidial endocarditis, peritonitis, and renal fungus ball developed in a different patient. The most common presenting clinical signs were respiratory deterioration, abdominal distension, and apnea/bradycardia. All patients were treated with amphotericin B, alone in 9 cases or in combination with 5-flucytosine (7 cases) and with fluconazole (4 cases). Systemic candidiasis contributed to the deaths of 6 patients (30%). CONCLUSION: In the neonatal intensive care unit of Seoul National University Children's Hospital, systemic candidiasis was a serious infection associated with high mortality and the diverse clinical features. Early diagnosis and appropriate antifungal therapy, combined with the elimination of the risk factors, may guarantee lower morbidity and mortality in the neonatal systemic candidiasis.

Intraocular Candidiasis in Babies with Candida Sepsis

Systemic candidiasis is a life-threatening disease in premature infants and may result in several complications. Early recognition is essential, but it is delayed and treatment is difficult. Candida endophthalmitis develop with systemic infection and intraocular involvement is detected by fundus examination with an indirect ophthalmoscope. Improvement of intraocular lesion and therapeutic effect of systemic candidiasis are detected with careful retinal examination. Twenty five premature infants received indirect ophthalmoscopic examination and we investigated the prevalence of intraocular involvements and related factors for eye involvement. The ocular findings were classified chorioretinitis, endophthalmitis and nonspecific lesion, except premature vitreous haziness. Chorioretinitis in 4 infants and nonspecific lesion in 3 infants were detected but endophthalmitis was not found. There was slight difference in each group for gestational age, birth weight and ventilator etc, but no signifficant statistical difference was noted. Systemic candidiasis was treated with systemic antifungal agent, and the chorioretinitis is resolved with systemic antifungal agents. We propose that retinal examination be performed on all infants suspected of having systemic candidiasis for the diagnosis and early treatment. Funduscopy may be a helpful as an early diagnostic tool, and to monitor appropriate therapy of systemic candidiasis.

Two Cases of Systemic Candidiasis in Very Low Birth Weight Infants / 대한의진균학회지

Reports of systemic candidiasis in neonates have been noted with major advances in neonatal care permitting the frequent survival of low birth weight infants. We experienced 2 cases of systemic candidiasis associated with skin involvement in very low birth weight infants. One case presented with abdominal distension and an erythematous maculopapular eruption on trunk, buttock, and lower extremities. Culture of peritoneal fluid grew Candida of albicans. In another case, a diffuse erythematous patch was noted on the back and buttock. Culture of blood sample grew Candida of albicans. Despite the treatment with intravenous fluconazole, clinical status of the patients continued to remain unstable, and they died.

A Case of Systemic Candidiasis with Skin Manifestations / 대한의진균학회지

Candidiasis is the most common fungal infection complicating the course of the patients with hematologic malignancies. Although widespread organ involvement is characteristic of systemic candidiasis, report of skin involvement is rare. A 22-year-old man with acute lymphocytic leukemia showed fever and painful erythematous maculopapular eruptions on the whole body after combination chemotherapy of mitoxanthrone, cytosine arabinoside and etoposide. Histopathologic sections from the skin lesions showed sparse perivascular mononuclear cell infiltration in the dermis, and many blastospores and pseudohyphae within the dermis and subcutis. The patient died in spite of treatment with intravenous amphotericin B and oral flucytosine.

A Case of Systemic Candidiasis with Skin Manifestations Simulating Varicella

No abstract available.

A case of neonatal systemic candidiasis

No abstract available.