​Kembara Xtra - Medicine-Mucocutaneous Candidiasis

​Kembara Xtra - Medicine-Mucocutaneous Candidiasis 
Introduction 
Heterogeneous group of commensal Candida species infections of the mucosa
characterized by an infection of the nails, mucous membranes, and skin on the surface
More than 20 different species of Candida infect people. Infections with fungi are the cause of 70% of infections globally.
The developing pathogen Candida auris has a high propensity to become drug-resistant.
● It has an impact on:
Airdigestive system
Esophageal candidiasis Gastritis and/or ulcers, linked with thrush; alimental or perianal Oropharyngeal candidiasis (thrush): mouth, throat Angular cheilitis: corner of the mouth Other systems
Candida vulvovaginitis affects the glans of the penis and/or the vaginal mucosa. Candidal balanitis affects the vulvar skin.
Candidal diaper dermatitis, intertrigo (between skin folds), and candidal paronychia are all examples of candidiasis. Other terms for it include monilia, thrush, yeast, and intertrigo.
ALERT
Condoms and diaphragms can get weakened by vaginal antifungal creams and suppositories.

pregnant women's issues
Pregnancy frequently results in vaginal candidiasis; continue therapy (usually a whole 7-day course).
Vaginal yeast infection before birth does not harm the infant in any way, but it raises the chance of newborn thrush.

Epidemiology (Prevalence and Incidence) Common in the US, especially in those with immunosuppression and/or uncontrolled diabetes Age factors Thrush and cutaneous infections (baby diaper rash) in infants and seniors
- Females (prepubescent to postmenopausal): incidence of yeast vaginitis
Unknown—in people with healthy immune systems, mucocutaneous candidiasis is prevalent. Low rates of complications exist.
Prevalence
More than 70% of Americans have the typical flora of the GI tract and oral cavity, which includes Candida species.

Pathophysiology and Etiology 

C. albicans (80-92% of vulvovaginal isolates and >80% of oral isolates). Increased vulnerability to infection results from altered cell-mediated immunity (either temporary or chronic) against Candida species.

Genetics A hereditary disease called chronic mucocutaneous candidiasis often first manifests in infancy.

Risk factors include: malignant disorders; corticosteroid usage; immunological suppression (including anti-neoplastic therapies, transplant recipients, cellular immune abnormalities, and HIV/AIDS); smoking; and drunkenness.
Hyposalivation (radiotherapy, drug-induced xerostomia, Sjögren illness)

Broad-spectrum antibiotic treatment, douching, chemical irritants, birth control pills, intrauterine devices, and concurrent vaginitides, poor oral hygiene, and endocrine changes (diabetes mellitus, pregnancy, renal failure, hypothyroidism) are all associated with an increased risk of balanitis in uncircumcised men.

Prevention 
Use antibiotics and steroids sparingly; after taking inhaled steroids, rinse your mouth.
Prevent douching.
Reduce perineal dampness by wearing cotton underwear and changing diapers frequently.
Clean your dentures frequently, wear well-fitting dentures, and take them out at night.
Improve diabetics' glucose control.
Preventive measures used by cancer patients, particularly those with hematologic malignancies

 HIV-positive patients should be treated with HAART; antifungal prophylaxis is not advised unless HIV-positive adults experience frequent or severe recurrences.

HIV, diabetes, cancer, and other immunosuppressive diseases that produce leukopenia are associated illnesses.


Introducing history to young children
- Oral: stubborn white patches on the tongue or oral mucosae that are difficult to remove with a wet cloth
- Angular cheilitis: painful fissures at mouth corners; perineal: erythematous rash with distinctive satellite lesions; severe if skin layer eroded

Adults may experience burning, itching, and whitish "curd-like" discharge from the vulvovagina.
- Erythema, erosions, and scaling in balanitis; dysuria
Immunocompromised hosts - Oral: red, slightly elevated patches/petechiae; white, raised, painless patches.
- GI symptoms: stomach discomfort - Esophagitis: dysphagia, odynophagia, and retrosternal pain; typically accompanied with thrush
- Follicular pustules: Folliculitis

clinical assessment 
Children and infants
- Oral: When wiped off, a crimson base is revealed beneath the white, elevated, and distinct patches in the mouth.
Erythematous maculopapular rash with satellite pustules or papules on the perineum
Adults: Vulvovaginal: thick, creamy discharge that resembles cottage cheese; vagina or perineum erythema; angular cheilitis: sore fissures in the corners of the mouth that are frequently cracked and bleeding
- Balanitis: scaling, erythema, and linear erosions
Immunocompromised hosts: Interdigital: redness, excoriation at the base and web gaps of fingers and/or toes, possibly maceration; Oral: thick, dark-brownish coating; deep fissures; white, raised, nontender, distinct patches; red, slightly elevated patches- Oral thrush is frequently noticeable with esophagitis.
- Follicular pustules: Folliculitis

Multiple Diagnoses 
Consider leukoplakia, lichen planus, geographic tongue, herpes simplex, erythema multiforme, pemphigus, burning mouth syndrome, and herpes simplex for oral candidiasis.
Breast milk or baby formula can imitate thrush; thrush is more difficult to treat.
Hairy leukoplakia on the tongue's dorsum and lateral edges that doesn't rub off
Angular cheilitis brought on by a staphylococcal infection, iron or vitamin B insufficiency, or edentulous overcrowding.
The odor, itching, and discharge of bacterial vaginosis and Trichomonas vaginalis are typically more intense.

Diagnostic tests and laboratory results 

Initial examinations (lab, imaging)
Mycelia (hyphae) or pseudomycelia (pseudohyphae) yeast forms are prepared for 10% KOH slides.
Associated with vaginal pH that is normal (4.5)

Other/Diagnostic Procedures
Esophagitis or hyperplastic candidiasis may require endoscopy with biopsy (if suspicious for malignancy) if first-line treatment is unsuccessful.
Interpretation of Tests
Epithelial parakeratosis and polymorphonuclear leukocytes are found after a biopsy, and candidal hyphae are seen after periodic acid-Schiff staining.


Administration General Therapy

(Diabetes, HIV, autoimmune illness) Perform an immune deficiency screening.

First Line of Medicine
Vaginal (choose 1).
Clotrimazole (Gyne-Lotrimin, Mycelex): intravaginal suppository (100 mg QHS for 7 days; 200 mg QHS for 3 days; 500 mg daily for 1 day) or 2% cream (one applicator QHS for 3 days). Miconazole (Monistat): one applicator or 200 mg (one suppository), intravaginally QHS for 7 days.
- One dose of 150 mg of fluconazole orally
Oropharyngeal - Minor illness
Nystatin suspension: 100,000 U/mL swish and swallow 400,000 to 600,000 U QID. Nystatin pastilles: 200,000 U each, QID daily for 7 to 14 days. Clotrimazole (Mycelex): oral 10-mg troche; 20 minutes 5 times per day for 7 to 14 days (3)
Wearers of dentures
 For 3 weeks, apply nystatin ointment to the corners of the mouth and under dentures if the condition is moderate to severe.
Fluconazole: 200 mg loading dose, followed by 100 to 200 mg (>14 days of age: 6 mg/kg 1 dose, followed by 3 mg/kg q24h 7 to 14 days [maximum 100 mg/day]).
Esophagitis - Fluconazole: IV 400 mg (6 mg/kg) daily or PO 400 mg load followed by 200 to 400 mg/day for 14 to 21 days - If fluconazole is not tolerated, other alternatives are available; systemic antifungal medication is always necessary (4).
pregnant women's issues
For simple candidiasis, apply 2% miconazole cream intravaginally for 7 days; for invasive candidiasis, administer systemic amphotericin B.

Next Line
Vaginal - Topical antifungals, no preferred drug is advised; fluconazole 150 mg in a single dose is an alternative.
- For instances that are recurring (4 symptomatic episodes in a year), induction therapy should include topical or oral azoles for 10 to 14 days, followed by fluconazole 150 mg once a week for 6 months. 
Concerns with this regimen in HIV patients include the development of medication resistance.
Miconazole oral gel (20 mg/mL) administered orally: QID, swish, and swallow.
- Itraconazole (Sporanox) suspension: 200 mg (20 mL) once a day for 7 to 14 days; swish and swallow.
- Oral suspension of posaconazole (Noxafil): 400 mg BID for 3 days, followed by 400 mg daily for up to 28 days.
- Amphotericin B (Fungizone) oral suspension: 1 mL QID daily, swish it around in your mouth, and swallow it. Use this between meals.
Patients with esophagitis who are unable to take oral medication should be treated with an echinocandin or Amphotericin B (variable dosage) IV dose of 0.3 to 0.7 mg/kg daily.
- In cases of refractory illness:
Amphotericin B, itraconazole, posaconazole, voriconazole, and isavuconazole are possible options.
Echinocandins (may be the first choice in patients with immunodeficiency who have severe disease) (3) Several novel agents are being researched.
Two days after the infection has cleared up, continue treatments:
- Inhibitory conditions
 Severe hepatotoxicity if ketoconazole, itraconazole, or nystatin are ingested
Amphotericin B: Nephrotoxicity is a risk.
- Safeguards
Fluconazole: renal excretion; infrequent; hepatotoxicity; resistance common. Miconazole: can increase the effects of warfarin but is preferred during pregnancy.
 Voriconazole: brief visual abnormalities; clinical hepatitis, cholestasis, and fulminant liver failure (rare) Posaconazole: may cause GI pain or QT prolongation

Potential interactions (rare with topical therapy)
— Fluconazole
Fluconazole concentrations are lowered by rifampin and tolbutamide.
Check levels of warfarin, phenytoin, and cyclosporine for altered metabolism.
Itraconazole is an effective CYP3A4 inhibitor. Examine each drug that is co-administered with care.

Sources of Referral 
Check for immunodeficiency in patients with recurrent superficial candidal infections.

GI Candidatism

Further Treatments 

For infants suffering from thrush: Boil bottle nipples and pacifiers, and check the mother's breasts and nipples for Candida infection.

 For candidiasis brought on by dentures: Put your dentures in at night. Dentures should be cleaned with a 0.1% hypochlorite solution, 2% chlorhexidine gluconate solution, or white vinegar soak solution before being treated orally.


Further Treatments 
Probiotics: Candida spp. may be inhibited by Lactobacillus and Bifidobacterium.

Education of Patients

good dental hygiene. Oral candidiasis is lessened by brushing, caring for dentures, and moisturizing the oral cavity protocols.


Immunocompromised individuals benefit from routine assessment and screening.


diet culture activity Live lactobacillus in yogurt or other foods may reduce colonization; uncertain evidence

Inform patients who are at risk for recurrence about the possibility of overgrowth after receiving antimicrobial medication.
In the first trimester, oral "azole" drugs should be avoided. After that, only provide orally when advantages outweigh dangers.

Prognosis 

Immunocompetent people have a benign prognosis; those who are immunosuppressed may experience substantial morbidity

Complications
Chronic candidiasis may be linked to mild immunosuppression in HIV patients (e.g., CD4 200 to 500 cells/mm3) (5)[A]. Esophagitis or systemic fungal infections are conceivable with more severe immunosuppression (for example, CD4 100 cells/mm3).

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