Diagnostic Considerations

A 2019 retrospective review of data in Spain Emergency departments showed that of patients who came through the emergency department and were diagnosed with candidemia, all patients had several risk factors for candida infection. The authors concluded that it is important for emergency departments to evaluate risk factors and underlying conditions when deciding to treat non-hospitalized patients empirically for candidemia.^[24]

Due to diagnosis requiring cultures or other lab work that requires time that generally extends beyond pratical emergency department stays, the diagnosis is probably not made until after the patient has left the emergency department, particularly with invasive candidiasis. Emergency physicians ought to maintain a high index of suspicion whenever encountering patients with risk factors for candidal infections.

Risk Factors for candidiasis include "immunocompromised status (neutropenia, chemotherapy, transplant, diabetes mellitus, chronic liver failure, chronic renal failure), prolonged invasive vascular devices (hemodialysis catheters, central venous catheters), total parenteral nutrition, necrotizing pancreatitis, recent major surgery (particularly abdominal), prolonged administration of broad-spectrum antibiotics, prolonged hospital/ICU admission, recent fungal infection, and multisite colonization", per surviving sepsis guidelines. ^[25]

A 2017 meta-analysis and systematic review of nineteen trials containing over 2,500 patients concluded that in immunocompetent adults in the ICU, antifungal prophylaxis for systemic candidiasis did not reduce mortality.^[26] Although this was a study conducted in the ICU setting, there does not appear to be strong data or guidelines supporting starting empiric treatment for candidiasis unless there are risk factors present.

Differential Diagnoses

Workup

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Media Gallery

Candidiasis. Image courtesy of Hon Pak, MD.
Candidiasis. A moist, erosive, pruritic patch of the perianal skin and perineum (with satellite pustule formation) is demonstrated in this woman with extensive candidosis. Image courtesy of Matthew C Lambiase, DO.
Candidiasis. Discrete superficial pustules developed within hours of birth on the hand of an otherwise healthy newborn. A potassium hydroxide preparation revealed spores and pseudomycelium, and culture demonstrated the presence of Candida albicans. Image courtesy of Matthew C Lambiase, DO.
Candidiasis. Dry, red, superficially scaly, pruritic macules and patches on the penis represent candidal balanitis. Image courtesy of Matthew C Lambiase, DO.
Candidiasis. White plaques are present on the buccal mucosa and the undersurface of the tongue and represent thrush. When wiped off, the plaques leave red erosive areas. Image courtesy of Matthew C Lambiase, DO.
Candidiasis. Erythema, maceration, and satellite pustules in the axilla, accompanied by soreness and pruritus, result in a form of intertrigo. Image courtesy of Matthew C Lambiase, DO.
Candidiasis. A nailfold with candidal infection becomes erythematous, swollen, and tender with an occasional discharge. Image courtesy of Matthew C Lambiase, DO.
Candidiasis. Soreness and cracks at the lateral angles of the mouth (angular cheilitis) is a frequent expression of candidosis in elderly individuals. Image courtesy of Matthew C Lambiase, DO.
Candidiasis. Fine superficial pustules on an erythematous patchy base are suggestive of candidosis. Image courtesy of Matthew C Lambiase, DO.
Candidiasis. Candida infection should be in the differential diagnosis when one or more nails become discolored, has subungual discoloration, nailplate separation from the nailbed, and lack evidence of a dermatophyte. Image courtesy of Matthew C Lambiase, DO.

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Author

Ivan L Yue, MD Resident Physician, Department of Emergency Medicine, Naval Medical Center San Diego

Ivan L Yue, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Wilderness Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

William D Goldenberg, MD Assistant Professor, Department of Emergency Medicine, Uniformed Services University of the Health Sciences; Staff Emergency Physician, Naval Medical Center San Diego

William D Goldenberg, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Emergency Medicine Residents' Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Barry J Sheridan, DO Chief Warrior in Transition Services, Brooke Army Medical Center

Barry J Sheridan, DO is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician / Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Prisma Health Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Columbia Medical Society, Society for Academic Emergency Medicine, South Carolina College of Emergency Physicians, South Carolina Medical Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Employed contractor - Chief Editor for Medscape.

Additional Contributors

Sukhveer (Sukhi) Bains, MD, MA Assistant Professor of Clinical Emergency Medicine and Clinical Internal Medicine, University of Illinois at Chicago

Sukhveer (Sukhi) Bains, MD, MA is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Acknowledgements

Tarlan Hedayati, MD Assistant Professor of Emergency Medicine, Rush Medical College, John H Stroger Hospital of Cook County

Tarlan Hedayati, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Emily Anne Carpenter Rose, MD, Fellow in Pediatric Emergency Medicine, Loma Linda University School of Medicine

Disclosure: Nothing to disclose. Ghazal Shafiei, MD Resident Physician, Department of Emergency Medicine, John H Stroger Jr Hospital

Ghazal Shafiei, MD is a member of the following medical societies: American Medical Association and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.