Does a skin outbreak in a patient with myeloperoxidase (MPO) deficiency and a confirmed Candida glabrata vaginal culture raise concern for systemic infection?

Does Skin Outbreak After Confirmed Candida Glabrata Vaginal Culture Raise Concern for Systemic Infection in MPO Deficient Patient?

Yes, a skin outbreak in an MPO-deficient patient with confirmed C. glabrata vaginal colonization should raise significant concern for disseminated candidiasis and warrants immediate aggressive diagnostic evaluation including skin biopsy with culture, blood cultures, and consideration of systemic antifungal therapy. 1

Why This Is High Risk

MPO deficiency creates a critical vulnerability to invasive Candida infections that can be rapidly fatal:

• MPO deficiency combined with any physiologic stress dramatically increases susceptibility to severe candidiasis, as demonstrated by a fatal case where MPO deficiency with pre-eclampsia led to lethal disseminated candidiasis within 2 days 2
• The combination of C. glabrata vaginal colonization and new skin lesions in an MPO-deficient patient represents a high-risk scenario for hematogenous dissemination 1
• Up to 13% of patients with invasive disseminated candidiasis develop cutaneous manifestations, presenting as discrete pink to red papules (0.5-1.0 cm) typically on the trunk and extremities 3, 1

Immediate Diagnostic Algorithm

Step 1: Skin Biopsy (Most Critical)

• Obtain skin biopsy with culture immediately - recovery of fungi from skin or soft tissue aspiration/biopsy almost always warrants aggressive systemic antifungal therapy 3, 1
• Look for yeasts, pseudohyphae, or true hyphae on histopathology 1
• Send tissue for both culture and histological examination 3

Step 2: Blood Cultures

• Obtain blood cultures immediately, though recognize they may be negative in 50-75% of systemic candidiasis cases 1
• Blood culture positivity is uncommon with Candida but when present indicates high mortality risk 3

Step 3: Clinical Assessment

• Evaluate for high fever and poor general condition - characteristic of systemic candidiasis 1
• Assess for myalgias and persistent fever despite any antimicrobial therapy 3
• Examine for signs of deep tissue involvement or other organ manifestations 1

Treatment Approach

If Disseminated Candidiasis Is Confirmed or Highly Suspected:

Initiate echinocandin therapy immediately - this is the preferred first-line treatment for invasive C. glabrata due to its inherent azole resistance 1:

• Micafungin 100 mg IV daily 4
• Caspofungin 70 mg loading dose, then 50 mg IV daily 4
• Anidulafungin (alternative echinocandin) 1

Alternative Options:

• Amphotericin B formulations remain effective alternatives for invasive C. glabrata 1
• Voriconazole or posaconazole have variable efficacy against C. glabrata and should not be first-line 1

If Only Vaginal Disease Without Systemic Involvement:

Only if skin biopsy is negative and blood cultures are negative, treat the vaginal infection with:

• Topical boric acid 600 mg intravaginally daily for 14 days (preferred for C. glabrata) 1
• Alternative: 17% flucytosine cream alone or combined with 3% amphotericin B cream for 14 days 1
• Azole therapy is unreliable for C. glabrata due to innate resistance 3, 5

Critical Pitfalls to Avoid

Do Not Delay Biopsy

• The single most important diagnostic error is failing to biopsy suspicious skin lesions in immunocompromised patients 3
• Skin lesions may be the only clinical manifestation of disseminated disease 3

Do Not Assume Localized Infection

• C. glabrata vaginal colonization does not mean the skin outbreak is unrelated - disseminated candidiasis can present with both mucosal colonization and cutaneous manifestations 1
• Superficial cutaneous candidiasis rarely causes dissemination in immunocompetent hosts, but MPO deficiency changes this risk profile dramatically 3, 2

Do Not Use Azoles Empirically

• C. glabrata has innate resistance to azole antifungals - fluconazole and other azoles are unreliable 3, 1, 5
• The widespread use of azole prophylaxis has increased the incidence of azole-resistant C. glabrata infections 3

Do Not Wait for Blood Culture Results

• Negative blood cultures do not rule out disseminated candidiasis - blood cultures are positive in only 25-50% of cases 1
• Dissemination is commonly detected only at autopsy in fatal cases 3

Prognosis Considerations

• Mortality from disseminated C. glabrata infection remains high, especially in immunocompromised hosts 3, 5
• The prognosis depends heavily on the host's immune status - MPO deficiency represents a significant risk factor 6, 2
• Early aggressive antifungal therapy improves outcomes 1