DISCUSSION
CCC is a rare invasive fungal infection of the epidermis and dermis
caused by ascending intrauterine infection from Candida spp. CCC has
been estimated to occur in 0.1% of NICU admissions1-3. Common risk factors include preterm neonates,
gestational age less than 27 weeks, and weight < 1000g4. In addition, further risk factors are the presence
of intrauterine devices, maternal history of cervical cerclage, and
invasive maneuvers during delivery 5. Less common risk
factors that may participate CCC are the time of membrane rupture and
the mother’s diagnosis of fungal vaginosis previously4-6. Furthermore, this condition may occur either from
vaginal or abdominal delivery 4-6. Regarding
mucocutaneous compromise, manifestations are the result of the
aspiration of infected amniotic fluid 6. In our case,
our patient was a preterm neonate with a maternal history of fungal
vaginosis.
Clinically, CCC develops within the first week of life, usually within a
few hours of birth. It has a heterogeneous presentation that varies
according to the following factors: host immune response, number of
microorganisms, and time of exposure 1-6. It typically
initiates with diffuse maculopapular exanthema, with scaly patches
localized in the face, scalp, extensor surfaces of extremities, and
umbilical region 2. Diaper area, palms, and soles are
usually spared 5. Primarily, it begins with
erythematous patches that evolve to generalized diffuse papules and
pustules, which resolve with desquamation8. Other
clinical manifestations are paronychia, onychia, and funisitis. In
addition, in the context of chorioamnionitis, yellow-white plaques in
the proximal umbilical cord could be present 10. Also,
some cases present with skin compromise resembling burning-like
dermatitis 6. Additional clinical features may include
pustules in the palmar and plantar region 5.
Every CCC approach should begin with clinical suspicion. However, a
definite diagnosis, including microscopic evaluation, and the culture of
Sabouraud dextrose agar from the mucocutaneous lesions, placenta, or
umbilical cord, should be assessed 5-8. The clinical
course is benign and auto-limited. Generally, skin lesions resolve
within 5-20 days. However, this condition might lead to systemic
involvement, the former embrace candida septicemia, meningitis,
bronchopneumonia, arthritis, and endocarditis, associated with high
mortality rates 5. Therefore, it is essential to
evaluate complications 8. However, extensive
evaluation should be warranted when respiratory distress, positive
cultures from blood, urine, and cerebrospinal fluid, leukocytosis with
left shift and burning-like dermatitis 9-10.
Regarding the treatment for CCC, topical Nystatin is the most common
treatment, followed by topical Clotrimazole 1. On the
other hand, systemic antifungal therapy has efficacy in neonatal sepsis,
weight <1500 g, previous treatment with broad-spectrum
antibiotics, respiratory distress, positive cultures, and
immunodeficiency 5-9. Management includes non-azole
antifungal Amphotericin B, 1mg/kg for Amphotericin B deoxycholate, and 5
mg/kg for lipid-associated Amphotericin B preparations.3-9. In addition, 6-12 mg/kg fluconazole is also
recommended 10.
In this case, clinical examination revealed multiple erythematous
diffuse maculopapular and scaly patches resembling a burn. CCC was
confirmed with KOH, direct microscopy, culture of the skin, and
gastrointestinal fluid culture. Although risk factors for a systemic
compromise like respiratory distress, leukocytosis with left shift, and
burning-like dermatitis appearance, the patient had an excellent
response to treatment with topical and systemic therapy within the first
week.