161: Yeast Infections

Question 1

What are the common areas of involvement for Candida species in mucocutaneous candidiasis?

Answer 1

Common areas include: oral mucosa, lips, intertriginous zones, genital areas, skin and mucosal involvement.

Question 2

Which Candida species are most commonly implicated in localized mucocutaneous candidiasis?

Answer 2

The most commonly implicated species include Candida albicans, Candida glabrata, Candida tropicalis, Candida krusei, Candida parapsilosis, and Candida dubliniensis.

Question 3

What are the classic cutaneous findings associated with Candida infections?

Answer 3

Classic cutaneous findings include beefy-red patches and plaques with satellite papules and pustules, intertriginous areas, miliaria on occluded skin surfaces, pseudomembranous form in oropharyngeal mucosa, erythematous form in those with dentures, angular cheilitis, nipple candidiasis in breastfeeding women, and genital skin and mucosa involvement with itching and burning.

Question 4

What is the classic clinical triad of candidemia?

Answer 4

The classic clinical triad of candidemia includes myalgia, rash, and fever.

Question 5

What are the risk factors associated with onychomycosis caused by Candida?

Answer 5

Risk factors include moisture and occupational wet work, chronic exposure to water, use of the dominant hand, history of paronychia, and skin barrier breakdown due to dermatitis.

Question 6

What is the significance of chronic mucocutaneous candidiasis?

Answer 6

It presents with erythematous plaques with overlying scale reminiscent of plaque psoriasis.

Question 7

What is the role of Candida in chronic paronychia?

Answer 7

It can cause erythema of the proximal nailfold area with loss of the cuticle and skin breakdown.

Question 8

What percentage of candidemia patients may experience myalgia?

Answer 8

25% of patients with candidemia.

Question 9

What is the significance of myalgia, rash, and fever in a hospitalized patient with candidemia?

Answer 9

These findings suggest the classic clinical triad of candidemia. Empiric treatment should include echinocandins or fluconazole.

Question 10

What are the typical characteristics of skin lesions in candidemia?

Answer 10

Typical skin lesions range from erythematous papules with central pallor or necrosis to erythematous nodules or plaques.

Question 11

What are common sites of Candida colonization in healthy adults?

Answer 11

Common sites include skin, oropharyngeal, respiratory, gastrointestinal, and genital mucosa. Higher rates of carriage are observed in women and smokers.

Question 12

What are the classic cutaneous findings of localized Candida infections?

Answer 12

Localized Candida infections typically present as beefy-red patches and plaques with satellite papules and pustules at the periphery.

Question 13

Describe the clinical triad of candidemia and its implications for treatment.

Answer 13

The classic clinical triad includes myalgia, rash, and fever. Empiric treatment for presumptive invasive candidiasis is often initiated in hospitalized patients presenting with these symptoms.

Question 14

What are the common non-cutaneous findings associated with candidemia?

Answer 14

Common non-cutaneous findings include myalgia, chorioretinitis, vitreitis, and endophthalmitis.

Question 15

How does chronic mucocutaneous candidiasis present clinically?

Answer 15

It presents as erythematous plaques with an overlying scale, resembling plaque psoriasis.

Question 16

What are the implications of Candida species in invasive candidiasis and candidemia?

Answer 16

While Candida albicans is the most common species, non-albicans species collectively account for the majority of invasive candidiasis and candidemia.

Question 17

What are the common complications associated with candidemia?

Answer 17

Complications include multiorgan failure leading to septic shock, hematogenous dissemination to organs, and potential for painless retinal involvement resulting in permanent visual loss.

Question 18

What are the risk factors for localized or superficial Candida infections?

Answer 18

Risk factors include extremes of age, diabetes, obesity, pregnancy, HIV/AIDS, use of broad-spectrum antibiotics, corticosteroids, and immunosuppressive medications.

Question 19

What laboratory tests are used for the diagnosis of candidiasis?

Answer 19

Tests include swab culture from an intact pustule, tissue culture from biopsy specimens, and positive blood cultures.

Question 20

What is the first-line management for cutaneous candidiasis?

Answer 20

First-line management includes topical imidazoles and nystatin topical, with oral antifungals for severe cases.

Question 21

What are the clinical implications of the IL-17 pathway in Candida infections?

Answer 21

Defects in the IL-17 pathway can lead to increased susceptibility to chronic mucocutaneous candidiasis.

Question 22

What is the prognosis for candidemia?

Answer 22

Candidemia has significant mortality, with rates exceeding 35% over 12 weeks in some studies.

Question 23

What is the first-line treatment for oral candidiasis and its duration?

Answer 23

First-line treatment is Clotrimazole 10-mg troches taken 5 times daily or Miconazole 50-mg buccal tablets for 1 to 2 weeks.

Question 24

What is the recommended treatment for Candida onychomycosis?

Answer 24

First-line treatment is Itraconazole given orally for a total minimum duration of 4 weeks for fingernails and 12 weeks for toenails.

Question 25

What is the first-line treatment for Candida vulvovaginitis?

Answer 25

First-line treatment is topical Miconazole and Clotrimazole, with an alternative being oral Fluconazole.

Question 26

What is the first-line treatment for chronic mucocutaneous candidiasis?

Answer 26

First-line treatment involves prolonged courses of oral imidazoles or triazoles.

Question 27

What should be done for patients with disseminated candidiasis?

Answer 27

Patients should be managed with the assistance of an infectious disease specialist.

Question 28

What are the diseases associated with Malassezia species?

Answer 28

Malassezia species are associated with diseases such as pityriasis versicolor and Malassezia folliculitis.

Question 29

What is the first line treatment for oral candidiasis?

Answer 29

Clotrimazole 10-mg troches 5 times daily or miconazole 50-mg buccal tablets. ## Footnote Duration is 1 to 2 weeks.

Question 30

What is an alternative treatment for refractory oral candidiasis?

Answer 30

Itraconazole, posaconazole, voriconazole, and amphotericin B solutions and suspensions.

Question 31

What is the recommended treatment for Candida onychomycosis?

Answer 31

Itraconazole given orally, with a total minimum duration of 4 weeks for fingernails and 12 weeks for toenails.

Question 32

What adjunctive treatment can help prevent reinfection in oral candidiasis?

Answer 32

Denture disinfection using effervescent denture tablets or dilute bleach concentration of 1:32 or higher.

Question 33

What is the first line treatment for chronic mucocutaneous candidiasis?

Answer 33

Prolonged courses of oral imidazoles or triazoles (voriconazole and posaconazole).

Question 34

What should be done for patients with disseminated candidiasis?

Answer 34

They should be managed with the assistance of an infectious disease specialist.

Question 35

What is the first line treatment for Candida vulvovaginitis?

Answer 35

Topical miconazole and clotrimazole.

Question 36

What is the role of topical corticosteroids in chronic paronychia?

Answer 36

They help yield a higher cure rate than systemic antifungals.

Question 37

What is the significance of Malassezia in skin infections?

Answer 37

Malassezia species can cause a variety of clinical presentations including pityriasis (tinea) versicolor and Malassezia folliculitis.

Question 38

What is the recommended chronic suppressive therapy for recurrent oral candidiasis in a patient with HIV?

Answer 38

Chronic suppressive therapy involves fluconazole 150 mg orally three times weekly.

Question 39

What additional diagnostic steps are recommended for a patient with candidemia and a positive blood culture?

Answer 39

Follow-up blood cultures and an ophthalmologic examination are recommended to monitor for complications such as endophthalmitis.

Question 40

What is the primary insult leading to chronic paronychia, and what topical treatment has shown higher cure rates?

Answer 40

The primary insult is skin barrier breakdown from wet work and possible contact dermatitis. Topical corticosteroids have shown higher cure rates than systemic antifungals.

Question 41

What alternative treatment can be considered for a patient with disseminated candidiasis resistant to azoles and echinocandins?

Answer 41

Lipid formulation amphotericin B.

Question 42

What is the recommended duration of treatment with itraconazole for Candida onychomycosis?

Answer 42

A minimum of 4 weeks for fingernails and 12 weeks for toenails.

Question 43

What alternative treatments might be required for a patient with chronic mucocutaneous candidiasis who develops resistance to triazoles?

Answer 43

Alternative treatments include echinocandins, liposomal amphotericin, or flucytosine.

Question 44

What is the dosing regimen for severe or recurrent cases of Candida vulvovaginitis treated with oral fluconazole?

Answer 44

150 mg in 2-3 doses, 72 hours apart, and even longer for recurrent cases.

Question 45

What is the first-line treatment for hemodynamically stable candidemia?

Answer 45

An echinocandin or fluconazole.

Question 46

What is the rationale for using topical treatment as first-line therapy for Candida vulvovaginitis?

Answer 46

Topical treatment effectively targets localized infection with minimal systemic absorption.

Question 47

What is the recommended initial treatment for a neutropenic patient with candidemia, and when can it be switched?

Answer 47

An empiric echinocandin, which can be switched to fluconazole once the patient is stable.

Question 48

What is the mechanism of action of topical tacrolimus in chronic paronychia?

Answer 48

It acts as an immunomodulator, reducing inflammation.

Question 49

What is the first-line treatment for Candida vulvovaginitis?

Answer 49

Topical miconazole and clotrimazole, with an alternative being oral fluconazole, usually 150 mg in a single dose.

Question 50

What is the significance of resistance in the treatment of disseminated candidiasis?

Answer 50

Resistance to azoles and echinocandins is significant in non-Candida albicans species and in patients with prior exposure, necessitating alternative treatments.

Question 51

What are the diseases associated with Malassezia species?

Answer 51

Pityriasis (tinea) versicolor and Malassezia folliculitis.

Question 52

What are the common skin infections associated with Malassezia species in tropical climates?

Answer 52

Pityriasis versicolor and Malassezia folliculitis.

Question 53

What role do Malassezia species play in internal infections?

Answer 53

They are frequently isolated from sinuses, urinary tract infections, meningitis, pneumonia, and nosocomial bloodstream infections.

Question 54

What are the risk factors associated with Malassezia folliculitis and pityriasis versicolor?

Answer 54

Tropical climates, heavy sweating, immunosuppression, oral antibiotics, and corticosteroids.

Question 55

How is pityriasis versicolor diagnosed?

Answer 55

Using dermoscopy, Wood lamp examination, KOH preparation, and staining.

Question 56

What is the etiology of Malassezia infections?

Answer 56

Malassezia is normal flora of human skin, relying on hydrolysis of human host sebum triglycerides.

Question 57

What are the cutaneous findings of pityriasis versicolor?

Answer 57

Asymptomatic to mildly pruritic patches and thin plaques with fine scale.

Question 58

What distinguishes Malassezia folliculitis from acne vulgaris?

Answer 58

Malassezia folliculitis lacks comedones and tends to spare the centrofacial areas.

Question 59

What are the common species of Malassezia associated with pityriasis versicolor?

Answer 59

Malassezia globosa.

Question 60

What is the characteristic finding on KOH preparation for Malassezia folliculitis?

Answer 60

The 'ziti and meatballs' sign, showing short hyphae and yeast forms.

Question 61

What is the role of Malassezia in seborrheic dermatitis?

Answer 61

Malassezia acts as an exacerbating factor rather than a true infection.

Question 62

What is the expected finding under a Wood lamp for pityriasis versicolor?

Answer 62

Yellow-green fluorescence.

Question 63

What is the mechanism behind hyperpigmentation in pityriasis versicolor?

Answer 63

Increased melanosomes and thickening of the stratum corneum.

Question 64

What is the significance of azelaic acid in the context of Malassezia infections?

Answer 64

Azelaic acid inhibits tyrosinase, affecting melanin synthesis and can lead to hypopigmentation.

Question 65

What organism is most likely responsible for a bloodstream infection in a preterm neonate receiving parenteral lipid infusions?

Answer 65

Malassezia pachydermatis.

Question 66

What clinical feature can help differentiate Malassezia folliculitis from acne vulgaris?

Answer 66

Malassezia folliculitis lacks comedones.

Question 67

What are the most frequently isolated species from the sinuses in chronic rhinosinusitis?

Answer 67

Malassezia restricta and Malassezia globosa.

Question 68

What sample collection method is used for KOH preparation in Malassezia folliculitis?

Answer 68

A comedone extractor or needle is used to puncture an intact pustule.

Question 69

What is the characteristic microscopic finding in KOH preparation for pityriasis versicolor?

Answer 69

The 'ziti and meatballs' sign.

Question 70

What distinguishes Malassezia folliculitis from acne vulgaris?

Answer 70

It is characterized by follicularly based erythematous papules and pustules without comedones.

Question 71

How does the colonization of Malassezia occur in infants?

Answer 71

By the age of 3 to 6 months, with earlier colonization associated with the length of NICU stays.

Question 72

What are the clinical manifestations of pityriasis versicolor?

Answer 72

Asymptomatic to mildly pruritic patches and thin plaques with fine scale.

Question 73

What diagnostic tools are used for pityriasis versicolor?

Answer 73

Diagnostic tools include **dermoscopy** to highlight fine scaling, **Wood lamp** examination showing yellow-green fluorescence, and **KOH preparation** revealing the 'ziti and meatballs' sign with short hyphae and yeast forms.

Question 74

What is the significance of azelaic acid in the pathogenesis of pityriasis versicolor?

Answer 74

Azelaic acid, produced during the transition of Malassezia to its pathogenic mycelial form, inhibits **tyrosinase**, the enzyme responsible for melanin synthesis, leading to **hypopigmentation** especially in darker-skinned individuals.

Question 75

What laboratory testing challenges are associated with culturing Malassezia species?

Answer 75

Culturing Malassezia is challenging due to its **lipid requirement**, necessitating the addition of a layer of olive oil and the use of special growth media such as **modified Dixon**. Culture is not typically used to confirm Malassezia infections.

Question 76

What histopathological findings are associated with pityriasis versicolor and Malassezia folliculitis?

Answer 76

Histopathological findings include **Malassezia yeast forms** within the stratum corneum for pityriasis versicolor, and within dilated infundibula of plugged follicles in Malassezia folliculitis, often accompanied by **perivascular lymphocytes, histiocytes, and neutrophils**.

Question 77

What is the first line of treatment for Pityriasis versicolor?

Answer 77

The first line of treatment for Pityriasis versicolor includes: 1. **Topical shampoos** (pyrithione zinc or selenium sulfide) 2. **Propylene glycol** in aqueous solution 3. **Azole antifungal creams** (ketoconazole is the most studied).

Question 78

What are the recommended treatments for Malassezia folliculitis?

Answer 78

For Malassezia folliculitis, the treatment options include: - **Monotherapy with topical antifungals** (less reliable efficacy) - **Addition of keratolytics** like propylene glycol may improve efficacy - **Systemic treatment** may be required, with itraconazole 200 mg daily for 1 to 3 weeks being the best studied.

Question 79

What are the risk factors for recurrence of superficial Malassezia infections?

Answer 79

Risk factors for recurrence of superficial Malassezia infections include: - **Strong risk factors** such as preterm neonates and immunosuppressed patients - **Parenteral lipid infusions**, which increase the risk of disseminated infection.

Question 80

Why is ketoconazole not recommended for the treatment of Malassezia infections?

Answer 80

Ketoconazole is not recommended for the treatment of Malassezia infections due to the **risk of liver damage** and **adrenal dysfunction**.

Question 81

What is the prognosis for superficial Malassezia infections?

Answer 81

The prognosis for superficial Malassezia infections is generally good, as most will respond readily to antifungal treatment. However, recurrence is common, particularly in patients with strong risk factors.

Question 82

What is the recommended treatment for extensive or refractory Pityriasis versicolor?

Answer 82

Oral antifungal treatment with fluconazole or itraconazole.

Question 83

What is the role of propylene glycol in the treatment of Malassezia folliculitis?

Answer 83

Propylene glycol acts as a keratolytic, improving the efficacy of antifungal treatment in Malassezia folliculitis.

Question 84

What is the best-studied systemic treatment for Malassezia folliculitis?

Answer 84

Itraconazole 200 mg daily for 1 to 3 weeks.

Question 85

What is the typical duration of itraconazole treatment for Malassezia folliculitis?

Answer 85

The typical duration of itraconazole treatment for Malassezia folliculitis is 1 to 3 weeks.

Question 86

What is the recommended prophylactic dosing regimen for itraconazole?

Answer 86

The recommended prophylactic dosing regimen for itraconazole is 200 mg BID for 1 day per month for 6 months.

Question 87

What are the first-line treatments for Pityriasis versicolor and their formulations?

Answer 87

The first-line treatments for Pityriasis versicolor include: 1. **Topical shampoos**: - Pyrithione zinc - Selenium sulfide 2. **Topical antifungal creams**: - Azole antifungal creams (ketoconazole is the most studied) 3. **Propylene glycol** in aqueous solution.

Question 88

What are the long-term management strategies for preventing recurrence of Pityriasis versicolor?

Answer 88

Long-term management strategies for preventing recurrence of Pityriasis versicolor include: - **Prophylactic long-term treatment** in some patients: - Periodic topical selenium sulfide shampoo - Ketoconazole 2% shampoo - Itraconazole 200 mg BID, 1 day/month for 6 months.

Question 89

What factors increase the risk of disseminated Malassezia infection in patients?

Answer 89

Factors that increase the risk of disseminated Malassezia infection include: - **Preterm neonates** - **Immunosuppressed patients** - **Parenteral lipid infusions**

Question 90

What is the efficacy of monotherapy with topical antifungals for Malassezia folliculitis?

Answer 90

Monotherapy with topical antifungals for Malassezia folliculitis has less reliable efficacy. To improve treatment outcomes, the addition of a **keratolytic agent** like **propylene glycol** may enhance the efficacy of the antifungal treatment.