Neonatal Evaluation

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Maternal Candida vulvovaginitis may result in colonization of the newborn or mucocutaneous, invasive candidiasis or congenital candidiasis. Congenital candidiasis can present in infants as CCC or invasive disease (6,12,17,21). CCC is a severe cutaneous candidiasis that is far less common.

Mucocutaneous candidiasis consists of oral thrush or diaper dermatitis or both. Oral thrush typically presents on the days 7-10 of life as whitish patches (resembling milk curds) anywhere on the oral mucosa. The lesions can extend to the posterior pharynx but most often are located on the buccal mucosa, tongue, and palate. Scraping of these lesions results in a denuded erythematous base. Microscopic examination of these scrapings placed in 10% KOH suspension on a glass slide reveals blastospores or oval-round yeast cells and pseudohyphae. The diagnosis of oral thrush is based on clinical findings. Even though this is a presumptive diagnosis, routine culturing or microscopic examination of the scrapings is not necessary unless the thrush is persistent or atypical.

Candida dermatitis appears as 1- to 3-mm vesicular or pustular lesions on an erythematous base in the perineum, axillae, and neck folds. These discrete lesions can coalesce to form large patches of inflamed, denuded skin, especially in the perineal area. Again, the diagnosis is a clinical one unless the lesions are atypical or persistent or there is evidence of systemic disease.

Invasive candidiasis in the newborn infant presents as acute respiratory distress usually after the first 2 weeks of life. This may be accompanied by apnea, bradycardia, temperature instability, metabolic acidosis, coagulopathy, and other focal signs. It may lead to meningitis, endocarditis, brain abscesses, pneumonia, endophthalmitis, renal and hepatic abscesses, and other organ involvement. Infants with C. albicans fungemia (compared to C. parapsilosis) are more likely to present early with hypoxemia, respira-

tory distress requiring intubation, shock, and bradycardia and thrombocytopenia. They were also more likely (46 vs 2%) to have positive cultures from sites other than the bloodstream, including abscess fluid, cerebrospinal fluid, ascitic fluid, and sputum (2). Therefore, in any low birth weight infant with respiratory distress and history of prolonged antibiotic therapy, parenteral nutrition, intralipid infusions, or with indwelling intravascular catheters, fungal sepsis should be suspected.

Infants with CCC typically present on the first day of life with a generalized rash consisting of erythematous macules, papules, or pustules on a 5- to 10-mm erythematous base. Generalized erythema can be seen initially, which then can evolve into a severe skin eruption with discrete papules or vesicles and sometimes bullae. The eruption occurs predominantly on the back, extensor surfaces, skin folds, palms, and soles, but the perineum area is spared. The rash in very low birth weight infants can rapidly progress to bullae, erosion, and desquamation resembling burns or scalded skin. This is associated with an extreme leukemoid reaction. The nails may also be involved and appear opaque, raised, and rough. With the loss of the skin barrier, the preterm infant is at risk for dehydration and secondary bacterial infections. The differential includes staphylococcal pustulosis, bullous impetigo, syphilis, neonatal pustular melanosis, toxic epidermolysis bullosa, incontinentia pigmenti, neonatal listeriosis, herpes simplex, or varicella-zoster. CCC may also involve multiple organ systems, leading to hemorrhage and necrosis of the heart, lungs, kidneys, spleen, and other organs.

A definitive diagnosis of Candida infection in the newborn is made by isolation of the organism from culture of a sterile site or demonstration of the organism in tissue specimens. A sepsis workup should be performed in any infant suspected of having congenital candidiasis or Candida sepsis. This includes a blood culture, urinalysis, urine culture, complete blood count, lumbar puncture, and chest x-ray. A buffy coat culture can also be done to isolate Candida. Urine samples should be obtained for culture by suprapubic aspiration if possible. Straight bladder catheterization is an alternative method for obtaining the urine but may be contaminated with normal or colonizing flora. The cerebrospinal fluid evaluation should include cell count, Gram stain, culture, protein, glucose, and KOH preparation. Demonstration of spores and pseudohyphae in tissue, urine, and skin scrapings should be attempted.

It is recommended that daily blood cultures be done until sterilization of the blood has been achieved, which may take several days. In one study, as many as 60% of infants with neonatal candidemia had persistently positive cultures (>72 hours after initiation of antifungal therapy) (22). These infants were more likely to have focal complications. Therefore, if Candida cannot be eliminated from the blood stream after 48-72 hours or if clinically indicated, an evaluation for focal sites of infection is recommended. An electrocardiogram and echocardiogram should be done to rule out fungal endocarditis. Magnetic resonance imaging or computeed axial tomography scan of the brain should be obtained to rule out brain abscesses. An abdominal or renal ultrasound should be performed to look for abscesses in the kidney, spleen, and liver. A computed tomographic scan of the abdomen and pelvis may provide further delineation of intra-abdominal or renal involvement or may be indicated for the purpose of localization for biopsy or drainage of an abscess. An ophthalmological examination should be performed to rule out retinitis or endophthalmitis. Diagnostic procedures such as bronchoscopy; biopsies of liver, lung, or bone; aspiration or incision and drain age of abscesses; and bone marrow aspiration should be performed if clinically indicated to obtain specimens for culture, Gram stain, KOH prep, and histological examination with special stains (periodic acid-Schiff, Gomori methenamine silver, toluidine blue). Indwelling vascular devices should be removed.

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