Candidiasis

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Classification according to ICD-10
B37 Candidosis
ICD-10 online (WHO version 2019)
Thrush in a child

Candidiasis or candidiasis is a collective name for infectious diseases caused by fungi (sprouts) of the genus Candida , with Candida albicans being the most common, and is also referred to as candidosis , candidiasis , candidamycosis , candidiasis or moniliosis . If only the skin and mucous membranes are affected, it is called thrush (also known as moniliasis out of date ).

Infectious fungal organisms ( yeasts / Candida , dermatophytes , molds ) are usually unable to completely overcome the defense mechanisms of the human skin and mucous membranes and the immune system . In healthy people, they only occur in the form of superficial colonization of the skin and mucous membranes (cf. mycosis ). Certain types of Candida also live in the throat, esophagus, stomach, and small and large intestines of most people as harmless saprophytes ; they have been found in around 70% of all healthy subjects . Candidiasis is a sexually transmitted disease . In the case of congenital or acquired immunodeficiency ( cancer , AIDS , sepsis , cytostatics , etc.), however, both these endogenous fungi and the fungi that are found everywhere in our environment can also attack internal organs and cause serious diseases, such as pneumonia or systemic mycoses ( infection of the entire body). Candida styles are the most common pathogens such serious fungal diseases. In addition to Candida albicans, there are also Candida tropicalis , Candida parapsilosis , Candida guilliermondi , Candida dubliniensis , Candida krusei , Candida glabrata and the like. a. in front. In addition, it is not uncommon for fungal infections of the skin and / or mucous membranes when the immune system z. B. is temporarily impaired, for example when using certain drugs such as antibiotics or cortisone- containing preparations (see below).

Candida albicans diseases

Candidiasis of the oral cavity

Candida albicans has the ability to grow in both yeast and hyphae forms , which allows it to invade previously damaged skin. Candida albicans can also secrete tissue-dissolving enzymes such as proteases and phospholipases .

Simple candidiasis are therefore commonplace; they are favored by various factors: contraceptives and other hormone preparations as well as pregnancies reduce the acidic vaginal environment ; Antibiotics damage the competing bacterial flora, glucocorticoids and cytostatics inhibit the immune system . Cosmetic mistakes can disturb the protective acid mantle of the skin.

Infection sites are the oral cavity (called thrush or stomatitis candidomycetica ), the oral mucosa under dentures, the genital mucosa, conjunctiva , moist skin folds and nail folds. On the skin you can see a strong reddening with itching. A whitish, wipeable coating appears on the reddened mucous membranes. For vaginal infections , see under vaginal fungal infections , these can affect the vagina as well as the vulva and are then referred to as vulvovaginitis candidomycetica . The infection of the glans with microorganisms such as Candida -Pilzen or bacteria is infectious balanitis called. Superficial Candida infections can be cured without any problems.

Organ candidates and generalized infections in people with a severely weakened immune system can affect the lungs, heart, stomach and intestines ( self-brewing syndrome ), liver, spleen and central nervous system , for example . Candida can cause abscesses and joint inflammation (arthritis). The prevalence in intensive care units is around 14% of all patients. Men and women are equally affected, older people more often than young people. (Systemic) candidiases affecting the whole organism are fatal in about 70% of cases. What is feared is candidasepsis , in which the pathogens can be found in large numbers in the blood.

In Germany around 40,000 people are affected by this invasive Candida infection every year . In terms of hospital infections, yeast is now number 4 on the list of the most dangerous pathogens.

Current threat from Candida auris

Candida auris is a rapidly spreading, multi-resistant yeast that can cause invasive infections and is associated with high mortality.

Candida auris was extracted from the ear secretion of a patient in Japan and described in 2009. Since then, infections of this pathogen, especially fungemia (i.e. fungal infestation of the blood system), have been reported in South Korea, India, South Africa and Kuwait. The pathogen has also been identified in Colombia, Venezuela, Pakistan and the United Kingdom. In the United Kingdom, there was a local cluster of cases in 2015/2016 in which 72 patients were infected. Sporadic cases are also reported in Norway, Germany and Spain.

diagnosis

The diagnosis of superficial candidiasis is easily made microscopically from the smear . Imaging tests such as gastroscopy , ultrasound , X-ray, and CT will indicate the presence of an internal organ infection. To rule out disseminated candidiasis, if yeast is detected in the blood culture, an ultrasound of the upper abdominal organs and kidneys should be performed. Systemic infections with Candida spec. can then only be detected from blood, liquor and urine cultures. False positive and - especially with sepsis - also false negative findings are not uncommon. The informative value of the detection of antibodies in venous blood is controversial, as antibodies are retained long after an infection.

treatment

A correct diagnosis requires the detection of the fungi in the native preparation and cultivation in the culture . If only the clinical impression is used, one arrives at dubious therapeutic attempts.

In the case of yeasts detected in blood cultures, antimycotic therapy is required in any case and this should then be checked with daily blood cultures.

First of all, receptive (disposing) factors are eliminated as far as possible. Lying central venous catheters and other foreign materials should be removed as far as possible. Candida of the mucous membranes and skin respond well to topical treatment with antifungal agents (such as econazole , nystatin , amphotericin B , miconazole or natamycin ), disinfecting dyes and special cleaning agents. The skin is kept as dry as possible. There are also effective drugs available for organ involvement, which are administered intravenously. Resistance to certain antifungal drugs has been found in a few cases .

The choice of antifungal drug depends on several factors. Fluconazole , voriconazole , anidulafungin , caspofungin , micafungin , itraconazole , posaconazole and flucytosine are among the most frequently used for candidiasis .

Before and after antifungal therapy if yeasts are present in the blood culture or other sterile materials, an ophthalmoscope should be performed to rule out endophthalmitis .

Prevention of candidiasis in the newborn

Candida albicans has estrogen receptors. This is one of the reasons why the growth of yeast in the vagina is favored during pregnancy, so that in women who have not been treated with antifungal agents the prevalence is around 35% in the 40th week of pregnancy. During vaginal birth, there is an approximately 80% probability that the yeast will be transferred to the skin of the newborn. From there, the oral cavity and intestinal tract of the newborn are colonized. Candida albicans is practically obligatorily pathogenic for the mature, healthy newborn. In the case of colonization during the first week of life, oral or anogenital candidosis results in at least 90% of cases within the first year of life. The dermatitis seborrhoica infantum and the erythrodermia desquamativa Leiner as well as seborrheic mycids of the scalp are considered to be the result of yeast infections. As part of preventive examinations from the 34th week of pregnancy, fungal cultures are created and, if necessary, an antifungal treatment is recommended regardless of the clinical symptoms.

Candida Hypersensitivity Syndrome

An alternative medical perspective is originally based on a publication by C. Orian Truss (an internist from Alabama ) from 1976 ( The Missing Diagnosis ) and several books by William Crook ( The Yeast Connection ). Scientific studies could not prove any of the alleged connections, so that Truss' thesis was abandoned by the specialist public as early as the 1980s.

In the meantime, further publications, including numerous layman's guides, have emerged, in which the hypothesis is represented that the intake of antibiotics , corticosteroids and ovulation inhibitors as well as an unbalanced diet ( food sugar, flour, alcohol ), stress and exposure to environmental pollutants (especially mercury ) lead to this that the different types of Candida are increasing. This could cause a "candida hypersensitivity syndrome". Symptoms such as digestive disorders (flatulence, diarrhea , constipation ), heart problems, shortness of breath, food cravings, chronic fatigue, skin diseases ( psoriasis , seborrheic eczema , neurodermatitis ), depression , asthma , allergic rhinitis as well as headache, joint pain and muscle pain are the result. The colonization of the lower 2/3 of the small intestine is mainly held responsible for the symptoms. It has not been clarified whether the presence of Candida, which can be detected in over 70% of all healthy people, is responsible for the symptoms or is just a secondary finding.

The cross-reaction to the skin fungus Malassezia furfur (formerly called Pityrosporum ovale ) seems to play a significant role in skin diseases . The microbiologist Wolfgang R. Heizmann has set up a model of the pathogenesis in this regard.

In a relatively new (2001) randomized, placebo-controlled double-blind study, the treatment concept with nystatin was confirmed for the first time. The study also provides evidence of the diet's effectiveness.

Supporters of the Candida hypersensitivity hypothesis usually use established Candida detection methods (stool sample (intestinal flora status), blood sample) for diagnosis, rarely just the symptoms that they assign to a Candida colonization or infection. Alternative medical diagnostic methods such as kinesiology , bioresonance , electro-acupuncture and even commuting can also be used.

Therapeutically, they almost always recommend a change in diet. The "anti-fungal diet" propagated for this purpose dispenses with sugar and white flour and sweet fruit, with the alleged intention of "depriving the yeasts of nutrition". Sour fruit is allowed in small quantities. In addition, there is usually a so-called " intestinal flora structure " with probiotics , which are on the German market under numerous trade names such as Enterobakt , Symbioflor , Bactisubtil , Mutaflor , Omniflora , Paidoflor . Antifungal drugs must always be used; Both pharmacy-only medicines and, in some cases, natural remedies are then used. Treatment usually lasts four to six weeks. Colon hydrotherapy is also often recommended.

criticism

As early as 1996, the gastroenterologist Wolfgang Rösch questioned the existence of the Candida hypersensitivity syndrome in a review article. He rated the stool examination as pointless because up to 80 percent of healthy people could see positive results. An anti-fungal diet would not eliminate the yeast.

The gastroenterologist Volker Eckardt answered the question of an insecure practitioner in the Medical Tribune in 1996 as follows:

“Alternative practitioners and doctors who work as alternative practitioners have discovered a new source of income, namely the 'microecology' of the intestine. The principle is simple: first stir up the population's concern about illness, then offer cost-intensive procedures for early diagnosis and finally promise a cure through dubious therapeutic methods. A prime example of this approach is the diagnosis and treatment of fungi in the intestine. A central Hessian institute for microecology suggests in glossy brochures that 30 to 40 million of all German citizens are infected with fungal infections without offering the slightest evidence for this grotesque statement. Obviously, fungal disease is being confused with fungal colonization. The fact that fungal infestation is responsible for unspecific symptoms such as meteorism and changing bowel habits is wild speculation and contradicts every proven concept of the pathophysiology of gastrointestinal symptoms. [...] "

In 2001, the German Nutrition Society assessed the thesis that the intestinal colonization with Candida albicans would be promoted by the consumption of refined carbohydrates, especially sugar, as "not proven" and "purely speculative". There is also little evidence that an “anti-fungal diet” could influence the Candida colonization. Candida albicans is a normal component of the intestinal flora in about 75 percent of all healthy Central Europeans, and this fungus occurs with about the same frequency on the mucous membrane of the mouth, throat and esophagus. The detection in the stool should not be equated with a Candida albicans infection of the intestine or even with an intestinal mycosis and does not require any therapeutic measures in immunocompetent persons. Actual fungal infections or diseases can only be treated with antifungal drugs. Fiber-rich foods and the daily consumption of sour milk products would have a beneficial effect on the intestinal flora.

In 2004, experts from the Robert Koch Institute (RKI) came to the following assessment in a detailed statement:

“Neither clinical-epidemiological investigations nor treatment studies have so far given any indications for the existence of the 'Candida hypersensitivity syndrome' or 'Candida syndrome' with the various symptoms and diseases associated with it by its proponents. […] However, it cannot be completely ruled out that under certain circumstances an allergic sensitization caused by Candida colonization occurs. […] Overall, it can be said that the ecology of the intestinal flora and the interaction of its components (including C. albicans with various strains) and the relationships between microorganisms and intestinal mucosa are still insufficiently understood. […] The low or carbohydrate-free so-called 'anti-fungal diet' already appears conceptually questionable, since mono-, di- and oligosaccharides are completely absorbed in the proximal sections of the small intestine and are used for Candida spp. are not available in the colon [...] "

However, if there is a disproportion between supply and catabolism (breakdown / digestion), e.g. B. with increased and one-sided constant consumption of starch and sugar, or with digestive insufficiency (e.g. fructose / lactose intolerance), certain amounts of undigested sugar can indeed get into the colon and thus trigger candidiasis. Especially after antibiosis (when 'healthy', competing microbes such as lactic acid bacteria etc. are largely suppressed).

Differential diagnoses

The following differential diagnoses do not relate to the easy-to-diagnose candidiasis, but to chronic, non-specific gastrointestinal complaints, which are diagnosed by alternative medicine as "intestinal fungi". Behind it can u. a. hide the following pathologies:

Chronic liver diseases (e.g. liver cirrhosis, chronic hepatitis , Wilson's disease , hemochromatosis, etc.), portal hypertension or right heart failure with congestion of blood in the abdominal intestines , chronic pancreatitis , chronic gastritis , lactose intolerance , milk protein allergy , intolerance to certain foods , chronic enteric celiac disease Intestinal diseases such as Crohn's disease or ulcerative colitis , chronic appendicitis , sigmoid diverticulosis , intestinal stenosis, infections ( Whipple's disease , worm diseases, intra-abdominal abscesses), mechanical irritation from e.g. B. Tumors such as uterine fibroids (uterine muscle tumors ), abdominal aortic aneurysms , internal hernias ( hiatal hernia , Treitz's hernia) or adhesions (adhesions), circulatory disorders (mesenteric artery stenosis), endometriosis , intestinal sluggishness ( constipation , pathology , causes, drug abuse , diabetes drugs , drug abuse ), Potassium deficiency, hypothyroidism , diabetic gastrointestinal paresis), coronary heart disease with atypical symptoms (upper abdominal pain).

Very often the causes of chronic, unspecific gastrointestinal complaints are of a psychosomatic nature ( irritable bowel syndrome ). Indications for this are the typical presentation of the complaints by the patient, the stable existence for a long time with free intervals, the dependence of the complaints on stress, predisposing factors (gastrointestinal infections, trauma in childhood, learned disease processing) and ultimately the absence explanatory organic findings despite repeated examinations.

literature

Web links

Commons : Candidiasis  - collection of images, videos and audio files

Remarks

  1. ↑ The word thrush , formerly also "Sohr", comes from the old German sohren , also soren , "wilt, wilt". Middle High German sōr referred to the death or rotting of a tree due to fungal attack. Cf. Max Höfler: German book of names of diseases. Piloty & Loehle, Munich 1899 (Reprographic reprint: Olms, Hildesheim and New York 1970 and 1979, ISBN 1-174-35859-9 , p. 657.)
  2. ↑ cdc.gov
  3. ↑ J: Rhodes, A. Abdolrasouli, RA Farrer, CA Cuomo, DM Aanensen, D. Armstrong-James, MC Fisher, S. Schelenz: Genomic epidemiology of the UK outbreak of the emerging human fungal pathogen Candida auris . In: Emerging Microbes & Infections . tape 7 , no. 1 , March 2018, p. 43 , doi : 10.1038 / s41426-018-0045-x , PMID 29593275 , PMC 5874254 (free full text).
  4. ↑ A. Jeffery-Smith, SK Taori, S. Schelenz, K. Jeffery, EM Johnson, A. Borman, R. Manuel, CS Brown: Candida auris: a Review of the Literature . In: Clinical Microbiology Reviews . tape 31 , no. January 1 , 2018, doi : 10.1128 / CMR.00029-17 , PMID 29142078 , PMC 5740969 (free full text). Fig. 1.
  5. ↑ Marianne Abele-Horn (2009), p. 272.
  6. ↑ Marianne Abele-Horn (2009), p. 273.
  7. ↑ Marianne Abele-Horn (2009), pp. 274–280.
  8. ↑ Marianne Abele-Horn (2009), p. 273.
  9. ↑ John A. Anderson, Hyman Chai, Henry N. Claman, Elliot F. Ellis, Jordan N. Fink, Allen P. Kaplan, Philip L. Lieberman, William E. Pierson, John E. Salvaggio, Albert L. Sheffer, Raymond G. Slavin: Candidiasis hypersensitivity syndrome: Approved by the executive committee of the American academy of allergy and immunology. In: Journal of Allergy and Clinical Immunology , Volume 78, No. 2, 1986, pp. 271-273, PMID 3734279 , doi: 10.1016 / S0091-6749 (86) 80073-2 .
  10. Jump up ↑ William E. Dismukes, J. Scott Wade, Jeannette Y. Lee, Bonita K. Dockery, Jack D. Hain: A randomized, double-blind trial of nystatin therapy for the candidiasis hypersensitivity syndrome. In: The New England Journal of Medicine , Volume 323, No. 25, 1990, pp. 1717-1723, PMID 2247104 , doi: 10.1056 / NEJM199012203232501 .
  11. ↑ Manfred Knoke: Fungi in the oro-intestinal tract and their scientifically founded status. In: Journal for Medical Training and Quality Assurance , Volume 92, No. 3, 1998, pp. 157–162, PMID 9606881 .
  12. Jump up ↑ Robert Krause, Egon Schwab, Daniela Bachhiesl, Florian Daxböck, Christoph Wenisch, Günter J. Krejs, Emil C. Reisinger: Role of Candida in antibiotic-associated diarrhea. In: The Journal of infectious diseases , Volume 184, No. 8, 2001, pp. 1065-1069, PMID 11574923 , doi: 10.1086 / 323550 .
  13. ^ H. Senff, C. Bothe, J. Busacker, D. Reinel: Studies on the yeast flora in patients suffering from psoriasis capillitii or seborrhoic dermatitis of the scalp. In: Mycoses , Vol. 33, No. 1, 1990, pp. 29-32, ISSN  0933-7407 , PMID 2140431 .
  14. ↑ Johannes Savolainen, Kaija Lammintausta, Kirsti Kalimo, Markku Viander: Candida albicans and atopic dermatitis. In: Clinical & experimental allergy. The official Journal of the British Society for Allergy and Clinical Immunology , Volume 23, No. 4, 1993, pp. 332-339, PMID 8319131 , doi: 10.1111 / j.1365-2222.1993.tb00331.x .
  15. ↑ K. Akiyama, T. Shida, H. Yasueda, H. Mita, T. Yamamoto, H. Yamaguchi: Atopic asthma caused by Candida albicans acid protease: case reports. In: Allergy. Volume 49, Number 9, October 1994, pp. 778-781, ISSN  0105-4538 . PMID 7695069 .
  16. ↑ A. Koivikko, K. Kalimo, E. Nieminen, M. Viander: Relationship of immediate and delayed hypersensitivity to nasopharyngeal and intestinal growth of Candida albicans in allergic subjects. In: Allergy. Volume 43, Number 3, April 1988, pp. 201-205, ISSN  0105-4538 . PMID 3287998 .
  17. ↑ G. Doekes, AG van Ieperen-van Dijk: Allergens of Pityrosporum ovale and Candida albicans. I. Cross-reactivity of IgE-binding components. In: Allergy. Volume 48, Number 6, August 1993, pp. 394-400, ISSN  0105-4538 . PMID 8238794 .
  18. ↑ J. Savolainen, A. Broberg: Crossreacting IgE antibodies to Pityrosporum ovale and Candida albicans in atopic children. In: Clinical and experimental allergy: journal of the British Society for Allergy and Clinical Immunology. Volume 22, Number 4, April 1992, pp. 469-474, ISSN  0954-7894 . PMID 1377092 .
  19. ↑ Wolfgang Heizmann: Candida albicans - a model of pathogenesis.
  20. ↑ H. Santelmann, E. Laerum, J. Roennevig, HE Fördertun: Effectiveness of nystatin in polysymptomatic patients. A randomized, double-blind trial with nystatin versus placebo in general practice. In: Family practice. Volume 18, Number 3, June 2001, pp. 258-265, ISSN  0263-2136 . PMID 11356731 .
  21. ↑ Wolfgang Rösch: Fungi in feces, fungi in the intestines - therapeutic consequences? In: Insurance Medicine . 1996 Dec 1; 48 (6): 215-7. PMID 9082647 .
  22. ↑ Ghost mushrooms in the intestines . In: Spiegel Special , July 1, 1996.
  23. ↑ Statement from Prof. Dr. Volker Eckardt (gastroenterologist in Wiesbaden) in the Medical Tribune No. 1/2 1996 (PDF; 18 kB) dr-moosburger.at
  24. ^ German Society for Nutrition: "Anti-Fungal Diet". In: Consulting Practice 08/2001.
  25. ↑ Commission "Methods and Quality Assurance in Environmental Medicine" of the Robert Koch Institute: Pathogenetic significance of the intestinal Candida colonization. In: Federal Health Gazette - Health Research - Health Protection 2004; 47: 587-600. doi: 10.1007 / s00103-004-0860-1 apug.de (PDF; 314 kB)