Table 6.4. Clinical findings in candidiasis, as summarized by Rippon

I. Infectious form

A. Mucocutaneous involvement

1. Oral: glossitis, stomatitis, cheilitis, perleche
(fissures at angle of mouth)
2. Vaginitis: balanitis
3. Bronchial and pulmonary lesions
4. Alimentary: esophagitis, enteric and perianal infec
tions
5. Chronic mucocutaneous candidiasis

B. Cutaneous involvement

1. Intertriginous and generalizd candidiasis
2. Paronychia, onychomycosis
3. "Diaper" disease (napkin candidiasis)
4. Candidal granuloma

C. Systemic involvement

1. Urinary tract infections
2. Endocarditis
3. Meningitis
4. Septicemia
5. Iatrogenic candidemia

II. Allergic form

A. Candidids
B. Eczema
C. Asthma
D. Gastritis

Imaging Diagnosis

Only the pulmonary and disseminated infections, such as those of the alimentary tract, are of importance to imaging. Except in the esophagus, it is difficult if not impossible to make a firm imaging diagnosis of candidiasis by any imaging technique.

Pulmonary Candidiasis

Patients who are only moderately immunosuppressed may have candidal bronchitis, with bronchial wall thickening and hyperemia of the mucosa, indistinguishable from bronchial or viral bronchitis. The secretions may cause transient atelectasis.

More commonly, there is pneumonia - either scattered bronchopneumonia with ill-defined nodular shadows throughout both lungs, or, much less commonly, lobar penumonia, which suggests that the candidiasis complicates bacterial pneumonia. There may be fleeting changes in the radiographic appearances of the chest when the plugs of thickened mucus are coughed up, resembling bronchial casts. Miliary dissemination also occurs, causing soft and faint miliary nodulation throughout the lungs.

Pleural effusions and lymphadenopathy are uncommon: fibrosis and calcification are rarely seen.

In some patients with septicemia, the chest remains normal.

Candidiasis of the Alimentary Tract

The earliest sign of esophageal candidiasis is abnormal motility, with decreased peristalsis, aperistalsis, and some areas of spasm. The esophagus may widen and if the deeper muscularis layers are involved, remain distended. Because the mucosa is ulcerated, with contrast the esophagus appears rough and shaggy (like a carpet) (Fig. 6.64). The ulcers caused by the pseudohyphae trap the barium and retain it for a long period, unlike the normal rapid mucosal clearing. The fungal granulomas in the mucosa produce multiple small "negative" defects, which might be mistaken for small esophageal varices, but the ulcers of candidiasis are most numerous in the upper part of the esophagus and decrease towards the cardia, which is the converse of esophageal varices (Fig. 6.64 C).

The mucosal reaction can produce small polyps, diverticula, and even larger polyps resembling carcinoma. When patients have achalasia, e. g. from Chagas' disease or scleroderma, the obstruction at the cardia increases the likelihood of esophageal candidiasis, and the appearance may resemble retained food. Some of the fungus can be dislodged, and fungus balls in the esophagus have been described.

Candidiasis of the stomach is not common: it causes decreased peristalsis (Fig. 6.65). The larger mucosal folds are partially preserved but the minor folds are effaced and there is prolonged retention of barium in the shaggy carpet-like membrane which covers the mucosal lining. Discrete polypoid nodules may develop, and ulcerate centrally. The appearance can be mistaken for Kaposi sarcoma or lymphoma. If the patient is successfully treated, the stomach may return to an almost normal state.
There are no specific images.in the small intestine: in the large bowel the appearances resemble those of an irritable colon or even early ulcerative colitis.