What are the clinical signs of persistent chronic mucocutaneous candidiasis in a 30‑year‑old woman?

Clinical Signs of Persistent Chronic Mucocutaneous Candidiasis in a 30-Year-Old Woman

Chronic mucocutaneous candidiasis (CMC) presents with persistent or recurrent candidal infections affecting the skin, nails, and mucous membranes, with characteristic long-standing whitish hyperplastic and nodule-like lesions that are irremovable and feature exaggerated deep fissures, particularly on the tongue and oral mucosa. 1

Oral and Mucosal Manifestations

The oral cavity is the most prominently affected site in CMC patients:

• Hyperplastic, nodule-like lesions with irremovable whitish patches and deep fissures are the most characteristic oral findings, distinguishing CMC from typical oral candidiasis 1
• The tongue is the most commonly affected site, showing long-standing whitish lesions that cannot be scraped off like typical thrush 1
• Three clinical patterns may be observed: pseudomembranous (creamy white plaques), erythematous (red patches), and angular cheilitis 2
• Oral lesions are persistent and recurrent despite standard antifungal therapy, a hallmark feature 2

Cutaneous and Nail Involvement

• Chronic onychomycosis (nail infections) that are persistent and difficult to treat 2
• Skin lesions affecting various body sites, particularly in intertriginous areas 2
• Response to antifungal therapy is often delayed when extensive skin or nail involvement is present 2

Esophageal Involvement

• Retrosternal burning pain, altered taste, and odynophagia (painful swallowing) suggest esophageal extension 2
• Endoscopic findings reveal whitish plaques progressing to superficial ulceration with central whitish exudates 2
• Recurrent intense pain contributing to weight loss due to poor nutrition is common 2

Genital Manifestations

• Recurrent vulvovaginal candidiasis characterized by white adherent vaginal discharge with burning and itching 2
• Episodes may be more severe and more frequently recurrent than in immunocompetent women 2
• However, vulvovaginal candidiasis alone in a 30-year-old woman should not be assumed to indicate CMC, as it is common in healthy women 2

Key Distinguishing Features from Typical Candidiasis

The critical distinction is persistence and refractoriness to standard therapy:

• Lesions are chronic and persistent rather than acute 1, 3
• Multiple and widespread candidal lesions across different body sites simultaneously 1
• Irremovable whitish patches that cannot be scraped off, unlike typical oral thrush 1
• Relapses almost invariably occur after treatment cessation, requiring long-term suppressive therapy 2
• Development of fluconazole-refractory infections is common in CMC patients 2

Associated Systemic Findings to Evaluate

When CMC is suspected, look for underlying immunological abnormalities:

• Abnormal T-lymphocyte subset proportions (found in 42.9% of CMC patients) 1
• Positive autoantibody titers (14.3% of cases) 1
• Decreased albumin and increased globulin levels (57.1% of cases) 1
• Elevated erythrocyte sedimentation rate (ESR) (42.9% of cases) 1
• Consider screening for autoimmune polyendocrinopathy syndrome type 1 or thymoma 2
• Genetic testing for IL-17 pathway defects (IL-17RA, IL-17RC, IL-17F, ACT1 deficiencies) should be considered in isolated CMC 4, 5, 6

Common Pitfalls to Avoid

• Do not dismiss recurrent vulvovaginal candidiasis alone as CMC in an otherwise healthy 30-year-old woman, as this is common and unrelated to immunodeficiency 2
• Do not assume typical oral thrush appearance—CMC lesions are hyperplastic, nodular, and irremovable, not the easily scrapable plaques of acute candidiasis 1
• Do not expect iron deficiency—this is not a typical finding in CMC patients 1
• Do not rely on histology alone—histological findings show no obvious distinction between CMC and other candidal infections; diagnosis requires clinical correlation 1

Microbiological Confirmation

• Candida albicans is the predominant organism isolated from CMC patients 1
• Species identification and susceptibility testing are essential in recurrent cases, as non-albicans species (particularly C. glabrata and C. krusei) with intrinsic azole resistance may emerge 2
• Culture from affected sites (oral scrapings, nail clippings, skin lesions) should be performed 1