Candida

Candida

What is Candida?

There are a number of different kinds of fungi existing and residing in our bodies at any given time, one of these kinds of fungus is known as Candida. This is a kind of yeast that typically exists in small amounts and is found in places like the stomach, skin and mouth and does not cause any issues. However, in some cases if the environment allows for it, this fungus is able to grow and multiply at a rapid pace, resulting in a fungal infection known as candidiasis, pronounced “kan-di-dahy-uh-sis”.

There are a number of different types of this fungal infection, most of these can be treated with OTC (over-the-counter) or prescription forms of treatment, however, in the case of more severe candidiasis, the treatment and diagnosis is far more complex and intricate, as are the severity of the symptoms the patient experiences.  

In its natural state Candida is a fungus that aids in the absorption of nutrients and digestion if it is found in the right levels in the body. When there is an over production of the fungus, this results in candidiasis.

When this happens in the intestinal tract, it is able to break down the intestinal lining and enter the blood stream, this is known as systemic candidiasis. When Candida multiplies unchecked resulting in overgrowth, this is referred to as Candida Overgrowth Syndrome (COS), otherwise known as invasive candidiasis.

To explain candidiasis further and in more detail, it is a fungal infection that is caused by the yeasts that are from the genus (family or group) of the fungi Candida. With more than 20 different species of this genus, Candida yeasts are able to cause infections in humans, with the most common one being Candida albicans.

As stated, these yeasts typically reside in one’s mucous membranes on the skin and in the gastrointestinal tract. When the fungus lives in these places, it does not normally result in infection. It is only when Candida multiplies and grows more than it should, this results in infection (candidiasis) with symptoms varying depending on the part of the body that has been infected.

When candidiasis forms in the mouth, this is known as oropharyngeal candidiasis, or more commonly “oral thrush”. This is often seen in those whose immune system function is reduced or in those who have been taking specific antibiotics.

If candidiasis develops in a woman’s vagina, this is known as a vaginal yeast infection, which is a common infection in women.

If candidiasis becomes systemic, meaning that it enters the blood stream and in doing so, spreads throughout the body, this is known as invasive candidiasis.

Recently, patients’ susceptibility to candidiasis has been increased due to the overuse of antibiotics, rising AIDS infections, the use of catheters, endoscopes and other invasive devices and the increase in organ transplants.  In cases where candidiasis develops as a result of surgery, the instruments used in these procedures may form the point of entry for Candida to enter the blood stream (as it resides on the skin or the instrument is infected) and cause an infection in those suffering from immunosuppression.

Causes of candidiasis

The following are the typical causes of candidiasis (these will be explained further in the article that follows):

  • Broad-spectrum antibiotics – Antibiotics are great when a bacterial infection in the body needs to be targeted and destroyed. However, broad-spectrum antibiotics do not target one kind of bacteria specifically, they target a wide range of invading bacteria, this can result in the good bacteria responsible for maintaining healthy levels of Candida within the body also being killed off. After a long course of antibiotics, this can create an environment suitable for the overgrowth of Candida.
  • Birth control pills – A Candida infection can stem from birth control pills, although they are not a direct cause, they can lead to yeast infections as they can upset the natural fungal balance of the vagina. If birth control pills are also taken after a course of antibiotics and the woman in question also consumes a diet high in refined sugars, this can significantly increase her risk of the infection developing.
  • Oral corticosteroids – These are used in inhalers for those with asthma and can lead to the systemic overgrowth of Candida.
  • Cancer treatments – Radiation and chemotherapy work by killing off cancer cells but also tend to destroy other healthy cells of the body which can adversely impact the patient’s immune system.
  • Diabetes – Those who have Type 1 or Type 2 diabetes tend to have higher sugar levels in the mouth as well as other mucous membranes. Seeing as Candida is a kind of yeast, and sugar is known to support the growth of yeast, this makes diabetics more susceptible to candidiasis.
  • Weakened immune system – Those who suffer from autoimmune diseases, are young or elderly or who have HIV/AIDS are at higher risk of candidiasis developing as their immune systems cannot always fight off the infection and control the levels of Candida effectively.

Signs and symptoms of candidiasis

The following are the typical signs and symptoms of candidiasis (these will be explained further in the article that follows):

  • Chronic fatigue – Feeling constantly exhausted is a characteristic of the infection, if this lasts for at least six months the patient may be diagnosed with chronic fatigue syndrome (CFS). This condition is often experienced with joint pain, headaches, memory issues and a sore throat.
  • Mood disorders – Patients who suffer from candidiasis will often go through major mood swings that are characterised by irritability, anxiety, depression and in some cases, panic attacks.
  • Recurring UTI (urinary tract infections) and vaginal infections – Infections that are recurring are often a result of candidiasis. Wearing loose and breathable underwear can help prevent Candida from growing as a moist environment is often optimal for fungal growth and infection.
  • Oral thrush – This is in actual fact a yeast infection and is a result of the Candida strain (Candida albicans) that also infects the mucous membranes of the vagina. This is often caused by medications such as oral corticosteroids. If this is left untreated it is able to spread throughout the body invading the lungs, liver, digestive tract and heart valves, this is known as invasive candidiasis.
  • Sinus infections – It can be difficult for the exact cause of a sinus infection to be pinpointed as there are a number of possible causes. If the symptoms of a sinus infection are persistent and include post-nasal drip, congestion and a persistent cough, then the patient should have their levels of Candida checked.
  • Intestinal distress – Burping, bloating, diarrhoea, constipation or flatulence that is persistent may be a result of unhealthy gut bacteria. If Candida yeast overgrows in the intestine, the healthy bacteria may become unbalanced and are therefore not strong enough to fight off the infection.
  • Brain fog – Brain fog is a result of the Candida overgrowth causing a lack of focus, poor memory and even poor coordination physically.
  • Nail and skin fungal infections – Fungus in the toenails and Athlete’s foot are extremely common yeast infections and can stem from Candida albicans. If these infections are experienced continuously, then this may be a sign that the individual has a systemic Candida infection (an infection that is affecting the body as a whole).
  • Hormonal imbalance – A Candida infection can cause a hormonal imbalance which can lead to migraines, water retentions, mood swings, endometriosis, water retention, a low sex drive and even early menopause. During a Candida overgrowth, the body may become inflamed and result in the yeast growing and spreading throughout the body, a by-product of this is that Candida is able to mimic oestrogen which can lead to a severe hormonal imbalance.

What are the different types of Candida?

The three main types of candidiasis, as previously mentioned, are:

  • Oropharyngeal / oesophageal candidiasis
  • Genital / vulvovaginal candidiasis
  • Invasive candidiasis

Oropharyngeal / oesophageal candidiasis (also known as oral thrush)

Candidiasis that involves the oesophagus and mouth is often an infection in those with AIDS. Mucocutaneous candidiasis, also known as chronic mucocutaneous candidiasis (CMC), is a candidiasis infection of the skin, nails and mucous membranes caused by Candida albicans (the fungus that causes most yeast infections).

If candidiasis forms in the throat or mouth it is called oropharyngeal candidiasis or thrush. This is the overgrowth of Candida which normally lives in small amounts. If the environment of the throat or mouth becomes imbalanced for some reason, this may allow for the yeast to multiply which results in various symptoms. The overgrowth of Candida can also occur in the oesophagus, this is known as oesophageal candidiasis or Candida oesophagitis.

Oral Thrush

Symptoms

When Candida infects the throat and mouth (candidiasis is an infection with Candida) the symptoms can develop in a number of ways. The symptom seen most commonly in oral thrush is plaques or white patches on the oral mucous membranes or the tongue.

Other symptoms may include:

  • Soreness or redness in the areas affected
  • Difficulty in swallowing
  • Painful sores on the sides of the mouth that result in the corners cracking due to the build-up of microorganisms (this is known as angular cheilitis) – these sores often cause a burning sensation in the affected area
  • Nausea
  • Vomiting
  • Weight loss

If you are experiencing any of these symptoms, it is advised that you see your doctor for treatment.

Symptom of oral thrush

Who is at risk of oral candidiasis?

When candidiasis occurs in the throat and mouth, those who have the highest risk are young babies being less than four weeks old, elderly people and people who suffer from a weakened immune system. These infections are uncommon in healthy adults. Thrush in newborns and infants can be common, however, contact your doctor should this thrush last longer than a few weeks.

There are other factors that are associated with oesophageal and oral candidiasis, these include:

  • Cancer treatments – These include radiation and chemotherapy as these treatment methods have an adverse impact on the immune system
  • HIV/AIDS infection
  • Diabetes that is poorly managed
  • Poorly fitted dentures
  • Organ transplantation
  • Broad-spectrum antibiotic use – these are antibiotics that work against a large range of bacteria.
  • Corticosteroid use

Can oral candidiasis be prevented?

Practising good oral hygiene helps to prevent oral thrush from occurring in those who have a weakened immune system. The development of oral thrush depends on the strength of one’s immune system.

There have been some studies conducted that note that mouthwash containing chlorhexidine (CHX), is able to aid in preventing oral thrush in those who are undergoing the treatment of cancer. Those who use an inhaler for the administration of corticosteroids (asthma medication), can benefit from washing their mouth out with mouthwash or even water after using their inhaler.

Causes of oral thrush

Candida species are natural residents of the mouth, throat and GI (gastrointestinal) tract. Normally, the Candida yeasts (fungi) reside in the body in small amounts without causing any damage or infection. However, when certain medications are taken or the immune system is weakened, this can result in the Candida multiplying which can cause an infection and lead to the various symptoms associated with oral thrush.  

Diagnosis of oral thrush

An oral thrush infection will be diagnosed based on the visible symptoms that the doctor can detect. The doctor will also scrape off some of the affected area in order for it to be examined. This procedure is quick and painless and allows for the doctor to examine the sample of the infected area for fungal infections.

A culture test using a cotton swab can also be performed, however, due to the Candida organisms being natural residents of the mouth, if the culture test is positive, this is not enough evidence to make an accurate diagnosis of infection.

Treatment for oral thrush and outcome

Antifungal medication is typically prescribed for oral thrush. The duration and type of the treatment will be dependent on the infection’s severity, as well as various factors regarding the patient such as their age and immune system status. If infections are left untreated, they can develop into more severe forms of candidiasis, this is known as invasive candidiasis (more on this later).

Topical treatments including nystatin suspension and clotrimazole troches are often used in the treatment of oral thrush. Antifungal medication that is systemic (drugs that act through the entire body), such as itraconazole or fluconazole, are sometimes necessary when oropharyngeal infections do not respond to other medications.

Itraconazole or intravenous fluconazole are common treatments for Candida esophagitis. In more severe cases of oesophageal candidiasis that do not respond to antifungal medications, then a treatment containing amphotericin B is used. This form of treatment will injure the membranes of the fungal cell, making it more permeable for other medications to treat and eliminate.

Genital / vulvovaginal candidiasis (VVC) / Candidal vulvovaginitis

Also known as a vaginal yeast infection, genital candidiasis is a common occurrence when the imbalance of fungus occurs, for example, when the normal levels of acidity in the vagina change or when there is a hormonal imbalance. This causes Candida to multiply which can lead to candidiasis and the symptoms associated with the infection. This kind of Candida infection is caused by Candida albicans.

Symptoms

Women who have a yeast infection will commonly suffer from:

  • Genital burning and itching
  • Increase in vaginal discharge that, in some cases looks similar to cottage cheese
  • Pain or burning when urinating
  • Discomfort during sexual intercourse
  • Swelling and redness of the vulva and vagina

Men can also get genital candidiasis, this often results in an itchy rash forming on the penis. The symptoms of genital candidiasis are very similar to a variety of other infections of the genitals. It is therefore vital that you make an appointment with your doctor should you have any of the above symptoms.

Yeast infections are not typically spread or caused by sex, however, less than 15% of men may suffer from an itchy and burning rash on the tip of their penis if they have had unprotected intercourse with an infected woman. Yeast infections can also increase one’s risk of contracting an STD (sexually transmitted diseases). Bear in mind, a yeast infection is NOT an STD, although they do share similar characteristics such as burning and vaginal discharge.

Diaper rashes and yeast infections

In infants, regardless of their sex, if they have an untreated diaper rash, they can develop a yeast infection. Mothers who are breastfeeding and taking antibiotics can also increase their child’s risk of developing a yeast infection. If babies are given antibiotics, their risks are also increased. Diaper/ nappy rashes are normally caused by a wet diaper creating a moist environment. When the baby’s skin is irritated from the rash, then an infection can occur.

If the baby’s rash is not going away, then check if their bottom is sensitive and red. If you can see sores with a red border that is slightly raised, then it is best that you speak to your paediatrician and have the baby checked for candidiasis. 

Who is at risk of genital candidiasis?

Roughly 75% of adult women around the globe have suffered from a yeast infection at least once in their lives. On some more rare occasions, men are also able to develop genital candidiasis. The condition tends to affect those who have a weakened immune system. There are a number of other factors in which women may have a higher risk of genital candidiasis developing.

The following are risk factors for genital candidiasis for women and in more rare cases, men:

  • Having poorly managed diabetes
  • Using broad-spectrum antibiotics for a long period of time
  • Using corticosteroids
  • Wearing tight underwear that is not cotton
  • Having a weakened immune system
  • Undergoing cancer treatments
  • Wearing wet clothing on the genital region for a prolonged period of time
  • Having sexual intercourse with an infected person (this is rare)

Female only risk factors include:

  • Being pregnant as this changes hormone levels in the body which alters bacterial balance in the vagina
  • Taking birth control pills
  • Using feminine hygiene sprays or douches
  • Scratches occurring in the vagina from tampon insertion or other objects

Can genital candidiasis be prevented?

Wearing underwear that is made of more breathable materials such as cotton and avoiding highly scented soaps and bath products can often aid in reducing one’s risk of a vaginal yeast infection developing.

If a woman suffers from yeast infections that are recurrent, meaning they occur more than three times a year, then there is some evidence that suggests that the use of intravaginal (applied to the inside of the vagina) or oral probiotics may prevent the infection from recurring.

What causes genital candidiasis?

The majority of Candida infections are a result of an imbalance in the individual’s own organisms. The Candida yeasts tend to reside in the GI (gastrointestinal tract), mouth and the vagina without resulting in any symptoms. In the case of an imbalance occurring, the organisms will multiply and grow. Any change to the environment that can disrupt this balance is a culprit in the development of candidiasis.

Diagnosis of genital candidiasis

With the symptoms of genital candidiasis being very similar to the symptoms of a number of different genital infections, the process of diagnosing a patient can often be difficult when only done through a physical examination. Therefore, the diagnosis will normally entail the doctor obtaining a sample of vaginal discharge by means of a pap smear and examining this under a microscope (this is often done in a lab as the doctor will send the sample for testing). This enables the doctor to find out if there is an abnormal amount of the fungus present. This will also enable the doctor to rule out any other causes of the infection.

Treatment and outcome of genital candidiasis

There are a number of different treatment options available in the form of antifungal creams or vaginal suppositories. These are able to range from a one-day form of treatment to a week of treatment. If the infection is mild or moderate it can be treated through the use antifungal medication in a single dose. These types of medications have a high success rate, however, short-course treatment is not always effective in those who have more resistant or recurrent infections.

There are also a few OTC (over-the-counter) options available. Always ensure that you have an accurate diagnosis from a doctor before treating yourself for the infection. Overusing OTC drugs can result in the infection becoming resistant to treatment. OTC options include:

  • Miconazole (Micatin, Monistat)
  • Clotrimazole (Gyne-Lotrimin, Mycelex)
  • Terconazole (Terzol)

Vaginal Thursh

Invasive candidiasis

Invasive candidiasis, also known as systemic candidiasis, candidemia or deep organ candidiasis, is an infection that is caused by the Candida fungus.

There are two main types of invasive Candida infections (candidiasis):

  • Candidemia – This is the most common kind of invasive Candida and involves Candida infecting the bloodstream which can lead to issues with a number of body parts and internal problems
  • Deep-seated tissue candidiasis – also known as deep-tissue(organ) candidiasis. This involves Candida infecting internal organs and is also known as a deep organ infection.

In some situations, the terms are used interchangeably as most cases of deep-tissue candidiasis coexist or are a result of a previous candidemia infection.

In order to get a thorough understanding of invasive candidiasis, we will first look at what the condition is as a whole and then go into further detail on the two main types of infection.

The difference between the previously mentioned Candida infections and invasive candidiasis, is that the oral and genital infections are viewed as surface level or superficial conditions and are also the most common infections of the Candida yeast, whereas invasive candidiasis, which comprises of both candidemia and deep-organ candidiasis, are far more severe infections with high mortality rates.

Candidemia has previously been associated with increased hospital stays for patients previously admitted for other underlying conditions (these patients are often infected during their stay in hospital due to their immune systems being compromised) and higher mortality rates and is the most widespread kind of invasive candidiasis. Deep-seated candidiasis is often associated with or secondary to candidemia and despite its severity, little is known about the condition.

Candidemia occurs when Candida enters a patient’s bloodstream, normally via medical equipment during surgery. However, unlike the previously mentioned Candida infections of the throat and mouth (oral thrush) or genital infections (vaginal yeast infections), this form of Candida is a severe infection that is systemic as it may affect the blood, brain, heart, bones, eyes and a number of other body parts of the patient. Candidemia is an infection of the bloodstream with Candida that usually occurs in hospitalised patients.

This is also the case for those who have recently been in hospital or in a healthcare facility like that of a nursing or old-age home. As with other yeast infections, an individual’s risk of this infection developing is increased if they have a weakened immune system, are diabetic, suffer from kidney failure or are taking antibiotics.

Typically, the person who has the infection is already sick with another condition, making the diagnosis more difficult as the symptoms can be misleading. The condition is normally treated orally or intravenously through the use of antifungal medications.

Invasive candidiasis infections encompass a number of different types of severe infections. As stated, there is normally an underlying problem or risk factor such as:

  • The immune system being compromised (immunocompromise)
  • Abdominal surgery
  • Critical illness

Candidiasis that is invasive is often life-threating with a mortality rate as high as 40%.

Diagnosis of invasive candidiasis

It is important that the condition is diagnosed in the initial stages as patients who suffer from the infection over a longer period of time can suffer from further risks and complications.

Antifungal therapy should typically be started if a patient who is at risk has a persistent fever lasting or more than four days despite the use of antibiotics.

The following tests are used in the diagnosis of invasive candidiasis:

Culture tests

  • Blood culture tests can be conducted to detect the presence of Candida overgrowth, however, the results from these tests can often take some time. Fungus can take as long as 30 days to show up. In some cases, the results will be available within a few days. Blood tests are the most common form of diagnosis regarding invasive candidiasis.
  • Culture tests can also be done of the infected tissues or bodily fluids. Here a sample is taken to be examined for fungal infection.
  • A number of rapid tests can also be performed. These are known as rapid diagnostic tests (RDT) that are easy and quick to perform as they are able to detect the antigens associated with candida overgrowth that are present in the blood.

Blood test

Screening tests

  • A CT (computed tomography) scan or an ultrasound can be conducted to detect any abdominal or renal infections.
  • An echocardiography (also known as a cardiac echo) can be conducted to create images of the heart. This is used when cardiac involvement in the infection is suspected.

Other tests

  • An endoscopy can also be conducted to check for intestinal infections (this will be done by means of a biopsy).

Treatment of invasive candidiasis

The type and the dose of the antifungal medication that is used as treatment for invasive candidiasis will depend on the age and immune status of the patient, as well as the severity and location of the infection. Antifungal medication will be the drug of choice in most cases. The most well-known antifungal drug is echinocandin which includes the following brands:

  • Micafungin
  • Anidulafungin
  • Caspofungin
  • Fluconazole

Duration of treatment for invasive candidiasis

In the case of candidemia, the treatment will typically continue for a duration of two weeks and the symptoms have been resolved, with the Candida yeasts no longer being detected in the blood stream. Deep organ candidiasis will normally be treated for a much longer period. 

Types of invasive candidiasis

Candidemia

As previously stated, Candida typically lives on the skin or in the GI (gastrointestinal tract) and does not cause any issues in most people. However, in some cases Candida is able to enter one’s bloodstream and result in a severe infection.

Candida in the bloodstream is the most common kind of invasive candidiasis and is known as candidemia. This condition often results in the patient undergoing lengthy hospital stays with high doctor and medical costs. The prognosis of this infection is often poor as the options of treatment are lacking in their abilities to yield effective treatment.  

The bloodstream infection is often the result of:

  • Major surgery
  • Central venous catheters
  • Broad-spectrum antibiotics
  • IV hyperalimentation – nutrients are administered via a drip
Who is at risk of candidemia?

Healthy individuals very rarely get candidemia. It is commonly found in those who have a current health issue that leads to the suppression of the immune system as this predisposes them to the development of this severe and dangerous infection.

Candidemia is known as one of the most common kinds of infection in people who are currently undergoing hospitalisation for an intestinal surgery or organ transplant. Seeing as the Candida yeast naturally resides on the surface of the skin in the majority of people, if the skin is punctured in some way, this provides the fungus with a direct entry point into the bloodstream. In the case of patients undergoing a central venous catheter, the risk of this infection developing is heightened. A central venous catheter is a tube that is inserted into a main blood vessel for it to deliver certain medications, nutrients or chemotherapy directly to the patient, this creates a route for the fungus as it enters the bloodstream from the skin.

Candidemia may also infect patients who suffer from a weakened immune system that can be due to a number of causes such as ongoing chemotherapy or an organ transplant. Those who have undergone a high dosage of prophylactic broad-spectrum antibiotics in order to rid their body of a certain bacterial antigen are also at risk as this provides Candida with an environment in which to multiply and infect the body. As well as this, those who have received mass doses of corticosteroids (often used to treat asthma) are vulnerable to infection. Finally, candidemia may occur in those who suffer from severe diabetes or have an HIV infection.

Treatment for candidemia

The treatment of candidemia can be complicated as the infection progresses and begins to infect some of the organs such as the eyes, brain, heart and kidneys. The most common kind of Candida species, Candida albicans were originally linked to the development of candidemia. However, recently Candida parapsilosis and Candida glabrata have been causing more infections, some of which have also been noted to be resistant to a number of the most widely used antifungal medications like the Azole drugs.  

The popular antifungal drugs that are usually used for candidemia treatment are:

  • Azoles
  • Echinocandin
  • Polyenes

The medication chosen will depend on the health and age of the patient and the species of Candida causing the infection.

Symptoms for candidemia

An issue with diagnosing candidemia comes in with the lack of exclusive or specific symptoms. However, a few of the symptoms such as chills and fever, as well as general weakness and fatigue are generally associated with the majority of systemic infections.

Patients with candidemia can also suffer from the following:

  • Skin rashes
  • Abdominal pain
  • Muscle aches
  • Vision changes
  • Loss of vision
  • Sustained headaches
  • Other neurological issues

Deep-seated tissue candidiasis

Please note that deep-seated tissue candidiasis is also known as deep-seated candidiasis and deep-organ candidiasis, the terms will be used interchangeably in the information that follows.

Invasive candidiasis is comprised of both candidemia and deep-seated tissue candidiasis. Deep-seated candidiasis is a result of either hematogenous dissemination (spread by the bloodstream) or the direct inoculation of the Candida species to a sterile site, for example, the peritoneal cavity (the space between the abdominal wall and the adjacent abdominal organs).

This kind of candidiasis also infects those who are predisposed through the means of an underlying condition, the immune system being compromised in some way is a leading cause.

Deep-seated tissue candidiasis is something that is being seen more and more in ICUs where patients are severely ill and are therefore predisposed to the condition. It is vital that more research is done on this type of invasive candidiasis as many patients are being misdiagnosed and are often left untreated which can result in the fungal infection progressing, which can, in some cases, end the patient’s life due to the severity of the infection.

Patients in ICU

What is known, and what helps to put this condition into perspective, is that all known episodes of deep-seated candidiasis coexist with or are preceded by candidemia. Bear in mind that as more research is done and more cases are accurately diagnosed and reported, the more information there will be available with more accurate findings.

In both types of invasive candidiasis, the Candida species is seen as an opportunistic pathogen that results in severe infections. As previously mentioned, vaginal and oropharyngeal candidiasis are viewed as ‘superficial’ kinds and do not compromise the survival of the patient. Whereas invasive candidiasis can be life-threatening.

Regardless of the severity of deep-seated candidiasis, apart from the fact that the occurrence of the condition is similar to that of candidemia, very few sources describe deep-seated candidiasis in detail, what is known, however, is that it can be present in any organ, sterile tissue or organ space.

Due to the diagnosis being difficult (diagnosis entail biopsies of the infected areas or blood tests), the estimates regarding the prevalence of the infections are lacking in reliability. Because of this, deep-seated candidiasis can be a condition that is severely underestimated in ICUs (where patients are critically ill and have their immune systems compromised).

Who is at risk of deep-seated tissue candidiasis?

Seeing as the majority of the cases of deep-seated tissue candidiasis have a co-existing or previous candidemia infection, the risk profile for a patient is very similar to that of candidemia. Since candidemia is not a specific clinical entity, the risk probability of a patient is vital for identifying their chance of developing the condition. If a patient undergoes a prolonged stay in ICU, being between seven to ten days, this is one of the highest and most vital risk factors for diagnosis as the condition is seen predominantly in those who are recovering from surgery or another condition in ICU.

The below is a list of risk factors:

  • Previous administration of broad-spectrum antibiotics
  • Abdominal surgery
  • Corticosteroid therapy
  • Previous Candida infection (colonisation) in multiple sites on the body
  • Multiple lumen catheters
  • Peritonitis (inflammation of the lining between the abdominal wall and the covering of the abdominal organs)
  • Use of corticoids or parenteral nutrition
  • Chemotherapy
  • Neutropenia (abnormally low white blood cell count – these form a part of the functioning of the immune system in being able to fight off infections)
Treatment for deep-seated tissue candidiasis

The treatment for deep-seated tissue candidiasis will require an individualised approach for each case. Therefore, the site of infection or the manifestation of the condition will involve antifungal therapy, with the dose and duration of it depending on the type of infection present. These drugs are likely to be administered intravenously or orally and can include brands in one of the following classes of drugs:

  • Azoles
  • Echinocandins
  • Polyenes – The medication known as amphotericin B is a common kind of polyene drug.

There are a number of side effects of the majority of the above systemic antifungal drugs. These can include nausea, vomiting, hepatitis, headaches, kidney- toxicity and even lupus-like symptoms (this is an autoimmune, inflammatory condition wherein the immune system will attack its own tissues resulting in joint pain, fatigue and sometimes brain fog).

Removal of the infection source such as a device (i.e. a catheter) or a drug that is compromising the immune system should also be stopped.

In some cases, surgical debridement (wherein the site of infection is removed) may also be required.

Symptoms of deep-seated tissue candidiasis

The symptoms of deep-seated tissue candidiasis are dependent on the site infected, with the treatment protocols following from this. Thus, each case is different with different symptoms, and the site of infection dictates the physical symptoms.  Some of the symptoms can include:

  • Dysphagia – This is a condition that involves drooling, having a hoarse voice, suffering from heartburn, having pain or difficulty swallowing or regurgitating food.
  • Mucosal and skin lesions
  • Fever
  • Renal shutdown
  • Brain fog – This is also known brain fatigue and may involve moderate to severe episodes of the patient suffering from mental confusion occurring without warning. This often results in a lack of focus, reduced mental ability and poor memory. This condition is often linked to the treatment of Candida with antifungal medications and is also associated with the lupus-like symptoms. Brain fog is typically linked to Candida albicans and Candida die-off during treatment.
Diagnosis for deep-seated tissue candidiasis

It is often difficult for deep-seated candidiasis to be accurately diagnosed, this is due to the blood cultures having a low sensitivity, meaning the results are not always accurate or able to detect the fungus, therefore not all the cases of invasive candidemia are detected.

The issue with deep-seated tissue candidiasis comes in with colonisation (the organisms have spread without causing an infection yet) as patients are often heavily colonised, particularly when they have been treated with broad-spectrum antibiotics. This means that it is difficult to differentiate between infection and colonisation. The infection of Candida, known as candidiasis, is normally secondary to colonisation.

Antifungal treatment is normally the chosen route in combatting the condition, with early diagnosis and accurate treatment associated with a more positive prognosis. Therefore, the diagnosis is dependent on the lab findings from blood and culture tests, however, at present, there is a vital need for more specific markers to be developed in order to make a more accurate diagnosis.

Infection sites of deep-seated tissue candidiasis

Due to deep-seated tissue candidiasis coexisting with or evolving from candidemia, roughly 80% of candidemia cases arise from the fungi having vascular access which often involves the use of central venous catheters. The primary source of entry of candidemia in patients who are non-neutropenic (i.e. who have a normal amount of white blood cells) and develop deep-seated tissue candidiasis may be that of an infected intravenous catheter or infusion fluid being contaminated. However, the peritoneal cavity being infected can also occur after abdominal surgery or trauma.

**My Med Memo – An intravenous catheter is a small, flexible tube that is inserted into a peripheral vein in order for fluids or medication to be administered. A central venous catheter, also known as a central line, is a thin, long and flexible tube that is used over a longer period of time to give fluids, nutrients and blood to the patient, usually when hospitalised.

It is believed that an infected organ is linked to the site that the haematogenous dissemination took place (i.e. the place from which the fungus entered the blood stream and spread) and whether the patient has adequate bone marrow functioning. The bone marrow is responsible for producing the body’s blood cells. White blood cells are involved in the ability of the immune system to protect the body.

Patients who are non-neurotropic and develop deep-seated tissue candidiasis after having abdominal surgery or have had IV catheter-induced phlebitis (trauma to the vein), tend to have myocardial (heart), renal, cerebral (brain), ocular (eyes) and pulmonary (lungs) involvement. Infections of spleen and liver are unusual in these types of patients. Any organ can be contaminated, colonised (where the fungus will spread without causing infection as yet) or infected by Candida.

Some of the most commonly seen infections in ICUs are briefly described below:

  • Gastrointestinal tract, spleen, liver and peritoneum

These infection sites can originate from the Candida fungus moving across the bowel wall, this movement is often facilitated by the decreased functioning ability of the mucosal barrier which is often the case in patients in the ICU.

The GI (gastrointestinal tract) infection of candidemia is often seen in patients who have leukaemia (cancer of the blood).  Candida peritonitis (inflammation of the lining between the abdominal wall and the covering of the abdominal organs), is often seen as a result of a bowel perforation from surgery or trauma.

  • Lung and trachea

Some patients may suffer from fungal pneumonia, although this is very rare. Therefore, Candida pneumonia is not seen very often and is mainly caused by the infection being carried by the blood to the organs (i.e. via haematogenous dissemination). It is often difficult for trachea and lung infections to be diagnosed as screening tests such as CT (computerised tomography) scans cannot be conducted in an ICU and require the patient to be moved.

  • Urinary tract

In as many as 20% of patients in the ICU, Candida has been seen to be isolated in the urinary tract mainly due to bladder catheterisation. Candida infecting the bladder and kidneys is known as Candida pyelonephritis. 

  • Cardiovascular candidiasis

This kind of infection infects the cardiovascular system. If Candida infects the heart, known as Candida myocarditis, it may be compromised by very subtle alterations in the muscle’s functioning, this makes it difficult to detect Candida in the heart. Candida infecting the heart valve, known as Candida endocarditis, has become a real threat to patients who have recently undergone cardiac surgery, specifically when prosthetic valves have been inserted. Endocarditis is the swelling of the heart valve.

  • Central nervous system

Candida meningitis has been seen to affect those who have HIV, neonates (infants) or those who have had neurosurgery (surgery involving the nervous system which includes the brain, nerves and spinal cord). This has a high mortality rate and is often only detected in a post-mortem.

  • Eye

If deep-seated candidiasis infects the eye is can present itself as endophthalmitis and chorioretinitis (inflammatory conditions of the eye). An ophthalmoscopy will need to be conducted that allows the doctor to take a look into the structures of the eye through the use of an ophthalmoscope which is a viewing device with various lenses and a light attached 

On a final note

Deep-seated candidiasis can manifest in a number of different infection sites. Due to the diagnosis being difficult, it is often misdiagnosed or underdiagnosed. On the one end of the scale, this finding presents a threat due to delayed diagnosis and treatment with the appropriate kind of antifungal therapy. On the opposite end, due to the condition being seen in more clinical settings, this can also lead to the over-prescription of antifungal drugs.

What is Candida die-off?

Once the condition has been diagnosed and accurately treated, large amounts of fungal and yeast cells are killed off rapidly and a die-off phase can occur, this is known as an Herxheimer reaction. This is basically a short-term (from a few days to a couple of weeks) reaction in the body as it detoxifies. It is also called the HERX reaction or healing crisis.

Herxing was first seen during the 15th century in patients who were undergoing the treatment of acute infections such as syphilis and were receiving mercury treatment (which is a weak antibiotic). It is an immune system response to the recovery and detoxification process and is known as the immune cascade. 

In the cases of candida die-off, the symptoms experienced are often those associated with the candidiasis infection, but are intensified. Patients often feel as though they are not improving in their health but that the infection is actually spreading and worsening.

The regular process of cell elimination of candida cells (the process that occurs naturally in the body when there is no infection or overgrowth) is vastly different to the pace of cell elimination associated with the treatment of infection.

When the candida yeast cells die, they will release a noxious (harmful) substance that contains roughly 79 different toxins. When these toxins are released (whenever a large number of micro-organisms that are parthenogenic are killed off over a short amount of time, they will release toxins as they die), the kidneys and liver work overtime to try and remove them. These toxins result in the symptoms within the body being intensified.

Some of these toxins include:

  • Uric acid
  • Ethanol
  • Acetaldehyde

The neurotoxin acetaldehyde has a wide range of detrimental effects on the health of the patient. The toxin is able to kill brain cells and therefore impair the functioning of the brain. The endocrine, respiratory and immune systems may all be affected. As well as this, the red blood cells can also be damaged as their ability to transport oxygen through the body can be reduced as the toxin attacks the membranes of the cells. It is easy to see how the consequences of this toxin can lead to symptoms such as fatigue and brain fog.

These toxins are also able to create allergic reactions which can lead to inflammation as the body’s ability to recognise non-threatening organisms is impaired resulting in certain substances or foods being identified as antigens. The immune system will, in turn, create antibodies as a means of fighting off the invaders, which leads to inflammation.

Th symptoms of Candida die-off will vary between individuals and each person will have their own unique degree of the symptoms depending on the area of the candida infection. It is best to always keep a professional doctor informed on the progress of the recovery.

Doctors may suggest the use of liver supplements such as milk thistle which aid in the liver’s ability to rid the body of toxins or that the patient decreases their doses of antifungals and probiotics should the Herxing symptoms be too severe.

Candida die-off symptoms

It is often the case where the symptoms of Herxing are compared to the symptoms of seasonal allergies or a common cold, these tend to differ from person to person and can be more severe (i.e. mood swings and psychological issues).

The by-products of the toxins involved will often cause inflammation which can lead to blocked sinuses and other sinus infections. Toxins such as acetaldehyde can lead to headaches, brain fog, nausea and fatigue. The liver will also be working at max capacity to filter the toxins out of the body which can result in a painful abdominal area.

The below is a list of the most common symptoms experienced with a Herxheimer reaction:

  • Psychological issues such as anxiety, depression and mood swings
  • Muscle and joint pain
  • Increased heart beat
  • Fever
  • Flatulence, bloating, gas, diarrhoea and/or constipation
  • Skin rash
  • Swollen lymph nodes or glands
  • Moderate to more severe headaches
  • Dry mouth and oral thrush
  • Sweating
  • Chronic fatigue
  • Inflammation
  • Brain fog
  • Sleep issues
  • Sore or itchy throat

In addition to these symptoms, the pre-existing symptoms of the current candida infection may progress, this is known as the healing reaction. As well as this, the symptoms caused by toxins can be exacerbated due to the body having to use more energy to replace the damaged cells and defective tissue that the toxins and Candida have caused during the infection.

Coping with the Herxheimer reaction

The exact amount of time a patient will suffer from Herxing is based on their infection and reaction to treatment. If Candida albicans occurs in the colon and intestines, the infection can lead to other issues such as leaky gut syndrome (this is where candidiasis breaks through the intestinal lining and this results in the contents of the intestines leaking into the bloodstream). This will often result in the patient experiencing a different reaction to the treatment.

There are a few things that can be done to help ease the symptoms(please note that the supplements listed should first be approved by a doctor before being taken):

  • Liver-support supplements – Mill thistle or molybdenum helps the liver to expel the toxins from the body. Molybdenum is especially helpful in those who are suffering from Candida die-off. This aids in helping the body to produce the enzymes needed to convert acetaldehyde into the acid known as acetic acid, this can then be converted into either helpful enzymes needed for digestion or be easily expelled from the body.
  • Drink enough water to help flush out toxins – Drinking water may help your body in eliminating toxins a bit faster as urine helps in transporting toxins out of the body. Hot showers, saunas and skin brushes (help to increase the circulation of lymphatic system) can also aid in detoxing the body.
  • Decrease stress levels – Stress can often weaken the body’s ability to recover and fight off the fungal infections. Stressing also increases levels of the hormone cortisol which can impact the immune system’s ability to function at full capacity.

What is the Candida diet?

There are some practitioners of CAM (complementary and alternative medicine) that recommend a diet known as the candida-cleanse diet to help in eliminating the symptoms of headaches, fatigue and memory issues associated with brain fog.

The diet is still a controversial topic, yet some people believe that this cleanse is able to cure the syndrome, however, this theory is not yet proven.

The basic idea behind the diet is that the patient should eliminate the following foods entirely from their diet:

  • Yeast
  • Cheese
  • Sugar
  • White flour

As these are said to promote candidiasis. Because there is still a large amount of research needed to be conducted on the more invasive types of this infection, some practitioners do not endorse the use of the candida-cleanse diet and there are currently no clinical trials documenting the validity and effect of the diet for the treatment of the recognised medical condition.

However, the majority of sufferers have noticed improvements in a number of their symptoms when they follow this diet strictly. The thinking behind this is that through cutting out these foods, you will effectively be eliminating sugar from your diet which in turn will starve Candida of the substance it needs to grow and spread.

In addition, by eliminating the majority of processed foods, this means that the person following the diet will be looking for more nutritive alternatives which are normally healthier. By replacing junk food with healthy food, the individual is likely to feel as though they have more energy and feel generally healthier.

What is the outlook for candidiasis?

The more superficial kinds of candidiasis tend to have a more positive prognosis, such as cases of oral or vaginal thrush. These kinds of infections are seen often, and when diagnosed correctly, can be treated effectively with the individual suffering from only mild discomfort or pain, depending on the severity of the condition.

However, it is clear that more extensive research regarding invasive candidiasis is vital for ensuring early diagnosis and effective treatment. At present, there is little information regarding the condition and the sites of infection are so vast, with each one having its own unique symptoms. One hopes that with the advances in technology and recent medical breakthroughs, we will be able to learn more about the condition in the near future.

Until then, it is not something to be taken lightly and recurrent cases of Candidiasis should be treated as such and brought to the attention of a medical doctor to ensure appropriate treatment.

Disclaimer - MyMed.com is for informational purposes only. It is not intended to diagnose or treat any condition or illness or act as a substitute for professional medical advice.