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.