Candida/Candidiasis

Candida is a genus of dimorphic, opportunistic fungi Fungi Fungi belong to the eukaryote domain and, like plants, have cell walls and vacuoles, exhibit cytoplasmic streaming, and are immobile. Almost all fungi, however, have cell walls composed of chitin and not cellulose. Fungi do not carry out photosynthesis but obtain their substrates for metabolism as saprophytes (obtain their food from dead matter). Mycosis is an infection caused by fungi. Mycology: Overview. Candida albicans is part of the normal human flora and is the most common cause of candidiasis. Risk factors for infection include conditions or agents that may lead to an immunocompromised state, disruption of the normal flora, and/or disturbance of the mucosal barrier. The clinical presentation varies and can include localized mucocutaneous infections (e.g., oropharyngeal, esophageal, intertriginous, and vulvovaginal candidiasis) and invasive disease (e.g., candidemia, intraabdominal abscess, pericarditis Pericarditis Pericarditis is an inflammation of the pericardium, often with fluid accumulation. It can be caused by infection (often viral), myocardial infarction, drugs, malignancies, metabolic disorders, autoimmune disorders, or trauma. Acute, subacute, and chronic forms exist. Pericarditis, and meningitis Meningitis Meningitis is inflammation of the meninges, the protective membranes of the brain, and spinal cord. The causes of meningitis are varied, with the most common being bacterial or viral infection. The classic presentation of meningitis is a triad of fever, altered mental status, and nuchal rigidity. Meningitis). The diagnosis is made by identifying Candida on KOH preparation, cultures, or tissue biopsy. Treatment depends on the extent and site of infection, and includes topical or systemic antifungal medications

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General Characteristics

Basic features of Candida

  • Genus within the Saccharomycetaceae family
  • Dimorphic:
    • Yeast
      • Small
      • Oval
      • Unicellular
      • Reproduce by budding
    • Pseudohyphal and hyphal forms
  • Gross colony appearance:
    • Round
    • White or cream-colored
  • Characteristics:
    • Ferments: 
      • Glucose
      • Maltose
      • Sucrose
    • C. albicans does not ferment lactose.

Clinically relevant species

The most clinically relevant Candida species include:

  • C. albicans (most common)
  • C. glabrata
  • C. parapsilosis
  • C. tropicalis
  • C. krusei
  • C. auris (emerging, multidrug-resistant species)

Pathogenesis

Reservoir

Candida albicans is part of the normal human flora, particularly:

  • Oropharynx
  • GI tract
  • Genitourinary tract
  • Skin

Transmission

  • Candida is usually transmitted to newborns during childbirth and becomes part of the normal flora.
  • Endogenous spread from colonized sites can occur through:
    • Mucosal disruptions (often in oropharynx of GI tract)
    • Indwelling catheters (e.g., central venous catheters, urinary catheters

Host risk factors

Candidiasis is the most common opportunistic fungal infection. 

General risk factors for candidiasis:

  • Hot weather
  • Restrictive clothing
  • Infrequent undergarment or diaper changes
  • Antibiotic therapy
  • Skin conditions (particularly affecting skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin folds)
  • Xerostomia
  • Pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care
  • Immunosuppression 
    • HIV/AIDS
    • Hematologic malignancies
    • Individuals who have undergone transplantation
    • Immunosuppressive therapy
    • Diabetes

Additional risk factors for invasive disease:

  • ICU hospital stay
  • Central venous catheters
  • Total parenteral nutrition
  • Renal failure requiring dialysis Dialysis Renal replacement therapy refers to dialysis and/or kidney transplantation. Dialysis is a procedure by which toxins and excess water are removed from the circulation. Hemodialysis and peritoneal dialysis (PD) are the two types of dialysis, and their primary difference is the location of the filtration process (external to the body in hemodialysis versus inside the body for PD). Overview and Types of Dialysis
  • Abdominal surgery
  • GI tract perforation or anastomotic leak

Virulence factors

  • Cell-surface adhesins: facilitates adherence to host cells
  • Biofilm formation: provides protection from host defenses and antimicrobials
  • Extracellular hydrolytic enzymes Enzymes Enzymes are complex protein biocatalysts that accelerate chemical reactions without being consumed by them. Due to the body's constant metabolic needs, the absence of enzymes would make life unsustainable, as reactions would occur too slowly without these molecules. Basics of Enzymes: facilitate invasion into host tissue
  • Hyphae: facilitate tissue invasion

Pathophysiology

  • Host defense against Candida infection: 
    • Epithelial barrier
    • T-cell–mediated immunity
    • Macrophages and neutrophils
  • Superficial infection:
    • Disruption of normal flora or host immunity → overgrowth of Candida
    • Epithelial desquamation → buildup of keratin and necrotic tissue → pseudomembrane forms on mucosa
    • Underlying edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema and ulceration can develop.
  • Invasive infection:
    • Disruption of mucosal barrier and immune evasion → tissue penetration 
    • Vascular invasion can occur → dissemination to other host tissues

Clinical Presentation

Oropharyngeal candidiasis

This infection, commonly known as “thrush,” may present with:

  • “Cottony” feeling in the mouth
  • Adherent plaques on mucous membranes
    • Thick, white
    • Scraping may:
      • Reveal erythematous, inflamed areas
      • Cause slight bleeding
  • Pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain and difficulty swallowing
  • Erythema and cracking at the corners of the mouth

Esophageal candidiasis

Esophageal candidiasis is an AIDS-defining illness that occurs in individuals with a CD4 count < 100 cells/µL.

  • Dysphagia Dysphagia Dysphagia is the subjective sensation of difficulty swallowing. Symptoms can range from a complete inability to swallow, to the sensation of solids or liquids becoming "stuck." Dysphagia is classified as either oropharyngeal or esophageal, with esophageal dysphagia having 2 sub-types: functional and mechanical. Dysphagia (difficulty swallowing)
  • Odynophagia (pain with swallowing)
  • Retrosternal chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain
  • Heartburn
  • May or may not present with concurrent oropharyngeal candidiasis
  • EGD will show adherent whitish plaques and exudates
Epigastric distress caused by esophageal candidiasis

EGD illustrates diffuse white lesions in the esophagus Esophagus The esophagus is a muscular tube-shaped organ of around 25 centimeters in length that connects the pharynx to the stomach. The organ extends from approximately the 6th cervical vertebra to the 11th thoracic vertebra and can be divided grossly into 3 parts: the cervical part, the thoracic part, and the abdominal part. Esophagus characteristic of Candida esophagitis Esophagitis Esophagitis is the inflammation or irritation of the esophagus. The major types of esophagitis are medication-induced, infectious, eosinophilic, corrosive, and acid reflux. Patients typically present with odynophagia, dysphagia, and retrosternal chest pain. Esophagitis.

Image: “Epigastric Distress Caused by Esophageal Candidiasis” by Chen KH, Weng MT, Chou YH, Lu YF, Hsieh CH. License: CC BY 4.0

Intertriginous candidiasis

  • An inflammatory dermatosis
  • Well-demarcated, erythematous rash
  • Located in warm, moist areas of skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin (e.g., groin, under breasts Breasts The breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts)
  • Causes pain and pruritus
Erythematous rash under the breasts due to candidiasis

A well-demarcated, erythematous rash under the breasts Breasts The breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts due to candidiasis

Image: “Caption of candidiasis caused by Candida Albicans” by Center for Disease Control and Prevention / Dr. Martin. License: Public Domain

Vulvovaginal candidiasis

  • Vulvar pruritus, burning, and irritation
  • Erythema and edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema
  • Vaginal discharge
    • Thick
    • White
    • Cottage cheese–like
    • Minimal or no odor
  • Dyspareunia
Speculum examination of a patient presenting with vaginal candidiasis

Speculum examination of a woman presenting with vaginal candidiasis:
Note the thick, white discharge surrounding the cervix and the cervical os.

Image: “Interior view of the vaginal canal of a female patient, who had presented to a clinical setting with a vaginal infection involving the cervix” by Center for Disease Control and Prevention / Dr. N.J. Fiumara; Dr. Gavin Hart. License: Public Domain

Invasive candidiasis

Invasive Candida infections can have a variety of presentations, including (but not limited to):

  • Candidemia
  • Urinary tract Urinary tract The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. Urinary Tract infection
  • Peritonitis
  • Intraabdominal abscess
  • Endocarditis Endocarditis Endocarditis is an inflammatory disease involving the inner lining (endometrium) of the heart, most commonly affecting the cardiac valves. Both infectious and noninfectious etiologies lead to vegetations on the valve leaflets. Patients may present with nonspecific symptoms such as fever and fatigue. Endocarditis
  • Pericarditis
  • Mediastinitis Mediastinitis Mediastinitis refers to an infection or inflammation involving the mediastinum (a region in the thoracic cavity containing the heart, thymus gland, portions of the esophagus, and trachea). Acute mediastinitis can be caused by bacterial infection due to direct contamination, hematogenous or lymphatic spread, or extension of infection from nearby structures. Mediastinitis
  • Endophthalmitis Endophthalmitis Endophthalmitis is an inflammatory process of the inner layers of the eye, which may be either infectious or sterile. Infectious endophthalmitis can lead to irreversible vision loss if not treated quickly. Based on the entry mode of the infectious source, endophthalmitis is divided into endogenous and exogenous types. Endophthalmitis
  • Chorioretinitis Chorioretinitis Chorioretinitis is the inflammation of the posterior segment of the eye, including the choroid and the retina. The condition is usually caused by infections, the most common of which is toxoplasmosis. Some of these infections can affect the fetus in utero and present as congenital abnormalities. Chorioretinitis
  • Meningitis
  • Osteomyelitis Osteomyelitis Osteomyelitis is an infection of the bone that results from the spread of microorganisms from the blood (hematogenous), nearby infected tissue, or open wounds (non-hematogenous). Infections are most commonly caused by Staphylococcus aureus. Osteomyelitis
  • Septic arthritis Septic arthritis Septic arthritis is an infection of the joint due to direct inoculation, contiguous extension, or hematogenous spread of infectious organisms into the joint space. This process causes an acute, inflammatory, monoarticular arthritis. Septic Arthritis

Diagnosis and Management

Diagnosis

Identification of Candida organisms can be made with:

  • Wet mount with 10% KOH of sample scrapings
    • Budding yeast
    • Pseudohyphae or hyphae
  • Fungal cultures
  • Tissue biopsy

Management

Localized mucocutaneous infections:

  • Topical antifungals :
    • Miconazole
    • Nystatin
  • Systemic antifungals (fluconazole, itraconazole) can be used for:
    • Extensive disease
    • Esophageal candidiasis

Invasive infection:

  • Requires treatment with IV antifungals
  • Options include:
    • Fluconazole
    • Voriconazole
    • Caspofungin
    • Amphotericin B

Differential Diagnosis

  • Lichen planus Lichen planus Lichen planus (LP) is an idiopathic, cell-mediated inflammatory skin disease. It is characterized by pruritic, flat-topped, papular, purple skin lesions commonly found on the flexural surfaces of the extremities. Other areas affected include genitalia, nails, scalp, and mucous membranes. Lichen Planus: idiopathic, cell-mediated inflammatory skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin disease. Lichen planus Lichen planus Lichen planus (LP) is an idiopathic, cell-mediated inflammatory skin disease. It is characterized by pruritic, flat-topped, papular, purple skin lesions commonly found on the flexural surfaces of the extremities. Other areas affected include genitalia, nails, scalp, and mucous membranes. Lichen Planus is characterized by pruritic, flat-topped, papular, purple skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin lesions commonly found on the flexural surfaces of the extremities. Lacy web-like lesions and painful erosions can occur in the oral and genital regions. Biopsy of the most prominent lesion is used for confirmation of the diagnosis. Topical corticosteroids are the preferred treatment.
  • Leukoplakia Leukoplakia Leukoplakia is a potentially malignant lesion affecting the squamous epithelium usually within the oral cavity. Leukoplakia can be associated with a history of chronic tobacco and alcohol use, both of which can synergistically damage the epithelium. Leukoplakia: potentially malignant lesion affecting squamous epithelium Epithelium The epithelium is a complex of specialized cellular organizations arranged into sheets and lining cavities and covering the surfaces of the body. The cells exhibit polarity, having an apical and a basal pole. Structures important for the epithelial integrity and function involve the basement membrane, the semipermeable sheet on which the cells rest, and interdigitations, as well as cellular junctions. Surface Epithelium, usually within the oral cavity. Leukoplakia Leukoplakia Leukoplakia is a potentially malignant lesion affecting the squamous epithelium usually within the oral cavity. Leukoplakia can be associated with a history of chronic tobacco and alcohol use, both of which can synergistically damage the epithelium. Leukoplakia can be associated with a history of chronic tobacco and alcohol use, both of which can synergistically damage the epithelium Epithelium The epithelium is a complex of specialized cellular organizations arranged into sheets and lining cavities and covering the surfaces of the body. The cells exhibit polarity, having an apical and a basal pole. Structures important for the epithelial integrity and function involve the basement membrane, the semipermeable sheet on which the cells rest, and interdigitations, as well as cellular junctions. Surface Epithelium. Leukoplakia Leukoplakia Leukoplakia is a potentially malignant lesion affecting the squamous epithelium usually within the oral cavity. Leukoplakia can be associated with a history of chronic tobacco and alcohol use, both of which can synergistically damage the epithelium. Leukoplakia presents as a white plaque that cannot be scraped off. Diagnosis is confirmed with biopsy. The lesion can be surgically treated, but close observation is always recommended owing to the risk for malignant transformation.
  • Tinea infections Tinea Infections Tinea infections are a group of diseases caused by fungi infecting keratinized tissue (hair, nails, and skin). These infections are termed dermatomycoses and are caused by the dermatophyte fungi. There are approximately 40 dermatophyte fungi that are part of 3 genera, including Trichophyton, Epidermophyton, and Microsporum. These infections can affect any part of the body but occur most often in warm, moist regions like the groin and the feet. Dermatophytes/Tinea Infections: group of diseases caused by dermatophyte fungi Fungi Fungi belong to the eukaryote domain and, like plants, have cell walls and vacuoles, exhibit cytoplasmic streaming, and are immobile. Almost all fungi, however, have cell walls composed of chitin and not cellulose. Fungi do not carry out photosynthesis but obtain their substrates for metabolism as saprophytes (obtain their food from dead matter). Mycosis is an infection caused by fungi. Mycology: Overview infecting keratinized tissue. These infections can affect any part of the body but occur most often in warm, moist region, such as the groin and the feet. The diagnosis is clinical with characteristic skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin findings, but it can be confirmed with microscopy of skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin scrapings. Treatment depends on the site and magnitude of infection but typically begins with topical antifungals and may progress to oral medications if topical treatment fails.
  • Aspergillosis Aspergillosis Aspergillosis is an opportunistic fungal infection caused by Aspergillus species, which are common spore-forming molds found in our environment. As Aspergillus species are opportunistic, they cause disease primarily in patients who are immunocompromised. The organs that are most commonly involved are the lungs and sinuses. Aspergillus/Aspergillosis: opportunistic fungal infection caused by Aspergillus species. Organs that are most commonly involved are the lungs Lungs Lungs are the main organs of the respiratory system. Lungs are paired viscera located in the thoracic cavity and are composed of spongy tissue. The primary function of the lungs is to oxygenate blood and eliminate CO2. Lungs and sinuses. Invasive aspergillosis can spread hematogenously and may involve the brain, heart, and skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin. The diagnosis is made based on imaging, fungal cultures, and serologic or respiratory sample studies. Management depends on the presentation, but it can include antifungal therapy and surgical resection in severe disease.
  • Cryptococcosis Cryptococcosis Cryptococcosis is an opportunistic, fungal infection caused by the Cryptococcus species. The principal pathogens in humans are C. neoformans (primary) and C. gattii. The majority of affected patients are immunocompromised. Patients with AIDS, chronic steroid use, and organ transplant are particularly affected. Cryptococcosis is an AIDS-defining illness and typically associated with CD4 count < 100 cells/μL. Cryptococcus/Cryptococcosis: opportunistic infection caused by the yeast Cryptococcus Cryptococcus Cryptococcosis is an opportunistic, fungal infection caused by the Cryptococcus species. The principal pathogens in humans are C. neoformans (primary) and C. gattii. Cryptococcus neoformans is typically found in pigeon droppings and acquired by inhaling dust from contaminated soil. The majority of affected patients are immunocompromised. Cryptococcus/Cryptococcosis neoformans or C. gattii. Individuals may develop pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia, meningitis Meningitis Meningitis is inflammation of the meninges, the protective membranes of the brain, and spinal cord. The causes of meningitis are varied, with the most common being bacterial or viral infection. The classic presentation of meningitis is a triad of fever, altered mental status, and nuchal rigidity. Meningitis, or cutaneous disease.  Fungal cultures and cryptococcal antigen testing can provide the diagnosis. Management depends on the presentation, but it can include fluconazole and amphotericin B (for meningitis Meningitis Meningitis is inflammation of the meninges, the protective membranes of the brain, and spinal cord. The causes of meningitis are varied, with the most common being bacterial or viral infection. The classic presentation of meningitis is a triad of fever, altered mental status, and nuchal rigidity. Meningitis).
  • Mucormycosis Mucormycosis Mucormycosis is an angioinvasive fungal infection caused by multiple fungi within the order, Mucorales. The fungi are ubiquitous in the environment, but mucormycosis is very rare and almost always occurs in patients who are immunocompromised. Inhalation of fungal spores can cause rhinocerebral or pulmonary mucormycosis, direct inoculation can cause cutaneous mucormycosis, and ingestion can cause gastrointestinal mucormycosis. Mucorales/Mucormycosis: angioinvasive fungal infection caused by multiple fungi Fungi Fungi belong to the eukaryote domain and, like plants, have cell walls and vacuoles, exhibit cytoplasmic streaming, and are immobile. Almost all fungi, however, have cell walls composed of chitin and not cellulose. Fungi do not carry out photosynthesis but obtain their substrates for metabolism as saprophytes (obtain their food from dead matter). Mycosis is an infection caused by fungi. Mycology: Overview within the order Mucorales Mucorales Mucormycosis is an angioinvasive fungal infection caused by multiple fungi within the order, Mucorales. The fungi are ubiquitous in the environment, but mucormycosis is very rare and almost always occurs in patients who are immunocompromised. Inhalation of fungal spores can cause rhinocerebral or pulmonary mucormycosis, direct inoculation can cause cutaneous mucormycosis, and ingestion can cause gastrointestinal mucormycosis. Mucorales/Mucormycosis. Inhalation of fungal spores can cause rhinocerebral mucormycosis or pulmonary mucormycosis. Direct inoculation can cause cutaneous mucormycosis, and ingestion can result in GI mucormycosis. Symptoms result from fungal hyphae invading the blood vessels, causing thrombosis and, ultimately, necrosis of tissues. Diagnosis is confirmed with biopsy. Mucormycosis Mucormycosis Mucormycosis is an angioinvasive fungal infection caused by multiple fungi within the order, Mucorales. The fungi are ubiquitous in the environment, but mucormycosis is very rare and almost always occurs in patients who are immunocompromised. Inhalation of fungal spores can cause rhinocerebral or pulmonary mucormycosis, direct inoculation can cause cutaneous mucormycosis, and ingestion can cause gastrointestinal mucormycosis. Mucorales/Mucormycosis must be treated aggressively with surgical resection and antifungals.

References

  1. Richardson, J. P., Moyes, D. L. (2015). Adaptive immune responses to Candida albicans infection. Virulence 6:327–337. https://doi.org/10.1080/21505594.2015.1004977.
  2. Qin, Y., Zhang, L., Xu, Z., Zhang, J., Jiang, Y. Y., Cao, Y., Yan, T. (2016). Innate immune cell response upon Candida albicans infection. Virulence 7:512–526. https://doi.org/10.1080/21505594.2016.1138201.
  3. Centers for Disease Control and Prevention (2020). Candidiasis. Retrieved October 13, 2021, from https://www.cdc.gov/fungal/diseases/candidiasis/index.html.
  4. Kauffman, C.A (2021). Overview of Candida infections. UpToDate. Retrieved October 13, 2021, from https://www.uptodate.com/contents/overview-of-candida-infections.
  5. Schell, W.A. (2021). Biology of Candida infections. UpToDate. Retrieved October 14, 2021, from https://www.uptodate.com/contents/biology-of-candida-infections.
  6. Arya, N.R., Rafiq, N.B. (2021). Candidiasis. StatPearls. Retrieved October 13, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK560624/.
  7. Aaron, D.M. (2020). Candidiasis (mucocutaneous). MSD Manual Professional Version. Retrieved October 13, 2021, from https://www.msdmanuals.com/professional/dermatologic-disorders/fungal-skin-infections/candidiasis-mucocutaneous.
  8. Revankar, S.G. (2021). Candidiasis (invasive). MSD Manual Professional Version. Retrieved October 13, 2021, from https://www.msdmanuals.com/professional/infectious-diseases/fungi/candidiasis-invasiv.e
  9. The University of Adelaide (n.d.). Candida. Mycology Online. Retrieved October 13, 2021, from https://mycology.adelaide.edu.au/descriptions/yeasts/candida/.
  10. Mycoses Study Group Education and Research Consortium (n.d.). Candida species. Doctor Fungus. Retrieved October 13, 2021, from https://drfungus.org/knowledge-base/candida-species/.

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