Pediatric emergency medicine trisk 321

Candida is a yeast that commonly superinfects inflamed, warm, moist skin.
The typical clinical appearance is erythema in skin folds with pustules and
peeling in the periphery (satellite pustules) ( Fig. 66.14 ). Candidal
infection of the oropharynx (“thrush”) presents with white papules and
plaques that cannot be easily wiped off. Feeding may be painful. Thrush is
common in young infants or after use of systemic antibiotics or steroids. In
older children with no steroid or antibiotic exposure, thrush may be a
marker of immunosuppression. Diagnosis is usually clinical but the white
discharge can be cultured to prove the diagnosis. Therapy is with topical
nystatin or clotrimazole troches (in older children) or oral fluconazole if
severe.
Neonatal candida infections can be mild or severe depending on the age
and weight of the child and the mode of infection. If there is premature
rupture of membranes and an ascending candida infection, the child is
surrounded by candida in the amniotic fluid. Infants may be born with
broad redness that looks like a sunburn and then often develops
superimposed pustules and then peels within a few days. This type of
candida infection is severe and can be life threatening, especially in
children under 1,000 g. All children with congenital candidiasis should be
evaluated for clinical signs of systemic infection and treated under the
guidance of an infectious disease specialist. Those under 1,000 g should be
treated systemically and evaluated for more widespread infection.


FIGURE 66.14 Candida infection. Note the intense confluent area of inflammation
surrounded by discrete satellite lesions. (Reprinted with permission from Sauer GC,
Hall JC. Manual of Skin Diseases . 7th ed. Philadelphia, PA: Lippincott-Raven; 1996.)

Localized candidal infections in healthy full-term infants often present in
diaper, axillary, or other warm moist environments. In addition to therapy
with topical antifungal agents, allowing the folds to dry is important to

prevent reinfection.
Opportunistic Fungal Infections
There are some fungi and yeasts that should not grow in patients with
normal immunity under normal circumstances. Therefore, infection with
these opportunistic pathogens should warrant a workup for
immunosuppression.
Fungi such as Aspergillus species, and molds such as mucormycosis
(including Rhizopus species), Fusarium species, alternaria , and others can
either cause infection by direct inoculation of the skin or by dissemination
to the skin from a distant systemic infection in immunosuppressed patients.
Infection through direct cutaneous inoculation presents with an eschar or
deep purple nodule. The purple color is caused by vascular invasion or


infarction and can simulate a bruise. Infection is often at the site of trauma
(including IV or surgical site). Localized infection with opportunistic fungi
can also present as a pustular eruption if the fungus is present under
occlusion such as tape or an arm board. It is vital to identify localized
opportunistic fungal infections immediately to prevent dissemination. A
biopsy with histopathologic evaluation and tissue culture can establish the
diagnosis and fungal sensitivities. Since the cause of an erythematous or
necrotic skin lesion in an immunosuppressed patient can be bacterial, viral,
or fungal, a tissue Gram stain or frozen section from tissue biopsy can help
make a rapid diagnosis. Patients with suspected opportunistic fungal
infections should be treated with antifungals under the guidance of an
infectious disease specialist.
Deep Fungal Infections
Deep fungal infections are typically acquired as pulmonary infection
through inhalation of the spores when the soil is disrupted and the spores
are

aerosolized. Cryptococcosis,
histoplasmosis,
blastomycosis,
coccidioidomycosis, and paracoccidioidomycosis are common causes of
deep fungal pulmonary infection in normal hosts in North America. This
pulmonary infection can disseminate, or some of the spores can cause
primary infection around the mouth. Primary infection is uncommon but
presents with inflamed papules or nodules, often with crusting or erosion
typically perioral, perinasal, or involving the oral mucosa. There also can be
secondary reactive skin changes such as erythema nodosum (EN). EN is
characterized by red, painful subcutaneous nodules, most specifically on the
anterior shins. The nodules seem to be reactive and not truly infectious and
there are many other causes of EN.
Deep fungal infections can also manifest as nodules or verrucous plaques
when directly inoculated into the skin. Sporotrichosis often presents this
way after direct inoculation of the fungus into the skin. The fungus
Sporothrix schenckii lives on various plants and vegetation, including rose
thorns, sphagnum moss, and carnations. Once inoculated into the skin, the
fungus spreads along the lymphatic drainage (sporotrichoid pattern) up the
affected arm or leg.
Diagnosis of cutaneous deep fungal infections is best proven with biopsy
for histopathology and fungal culture. The specimen should also be sent for


bacterial and mycobacterial culture since these can mimic deep fungal
infections. Therapy is with systemic antifungals and should be guided by
culture and infectious disease consultation depending on the specific
fungus, extent of infection, and host factors such as immunosuppression.
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