Snapshot A 58-year-old man presents to the emergency room for fevers. He reports having a persistent fever for the past 2-3 days. He denies having any respiratory symptoms or any skin infections. His past medical history includes diabetes, IV drug use, and a recent admission for pneumonia requiring broad-spectrum antibiotics. He is admitted to the hospital for further management and again started on broad-spectrum antibiotics as well as anti-fungal drugs. A bedside echo reveals vegetations on the tricuspid valve and blood cultures eventually grow Candida. Introduction Classification Candida albicans yeast with budding and pseudohyphae germ tube formation at 37°C (diagnostic) true hyphae sprout from yeast immunocompetent hosts usually present with skin and mucous membrane infections oral thrush inhaled corticosteroids HIV patients with CD4+ cell count < 500/mm3 candidal intertrigo yeast infection in the skin folds diaper rash vulvovaginitis perleche or angular cheilitis cracks at corner of the mouth associated with malnutrition immunocompromised hosts usually presents with systemic disease esophagitis HIV patients with CD4+ cell count < 100/mm3 endocarditis associated with IV drug users disseminated/invasive candidiasis chronic mucocutaneous candidiasis Epidemiology risk factors neutropenia immunocompromised status indwelling catheter hospital admission, especially in the ICU recent use of antibiotics recent use of corticosteroids ETIOLOGY Pathogenesis neutropenia in patients causes systemic Candida infections T-cell deficiency causes local infections antibiotic use may lead to overgrowth of Candida due to disruption of normal flora Presentation Oral thrush white plaque on tongue that can be scraped off Intertrigo well-demarcated, erythematous, and itchy patches in skin folds Esophagitis dysphagia throat pain Vulvovaginitis thick “cottage cheese” white discharge itchiness Endocarditis fevers heart failure new murmur Invasive candidiasis fever septic shock pain or swelling at site of initial infection Imaging Endoscopy indication esophagitis findings white plaques along esophagus Studies Labs blood or other tissue culture definitive diagnosis Wet mount of vaginal fluid yeast and pseudohyphae visualized with potassium hydroxide Biopsy yeast and pseudohyphae visualized Making the diagnosis based on clinical presentation and laboratory studies Differential Bacterial infection distinguishing factor cultures will often grow bacteria Treatment Medical nystatin indication local infections azoles indications local and systemic infections first-line if the fungus is not resistant echinocandins indications systemic infections often first-line due to increased resistance to azoles amphotericin B indications systemic infections second-line or in pregnant women Complications Disseminated disease Prognosis High mortality in invasive candidiasis