Recurrent

Importance
of
Mary Ryan Miles, MD;

Vaginal Candidiasis
an

Intestinal Reservoir
Rogers,
PhD

Linda Olsen, MS; Alvin

To test the hypothesis that all cases of vaginal candidiasis are associated with a "reservoir" of this organism in the bowel, paired specimens of feces and vaginal material were cultured for Candida albicans simultaneously. Ninety-eight young women who complained of recurrent vaginitis were selected in sequence. The results showed that if C albicans was cultured from the vagina, it was always found in the stool. Conversely, if it was not isolated from the stool, it was never found in the vagina. These data are presented as an explanation for the recurrent nature of Candida vaginitis, and thus a cure of vaginitis would not be possible without prior eradication of C albicans from the gut. The gut-reservoir concept may well apply to other forms of candidiasis.

sented themselves for treatment of

rent

recur

vaginitis (three or more episodes) at Michigan State University Health Center

were chosen in sequence and on a volun teer basis. Cultures were obtained from

(JAMA 238:1836-1837, 1977)

CANDIDA ALBICANS is found
so

frequently in the gut (stools) of healthy individuals that its presence in this location is generally accepted
normal occurrence. In the follow paper, the term candidiasis will therefore be used only in connection with patients who exhibit manifesta tions of infection outside the gut, that is, in the vagina, perianal skin, and elsewhere. Vaginitis caused by C albicans has become one of the most troublesome forms of vaginitis because it is so fre quently a recurrent problem. The rea sons that some persons present with repeated episodes of vaginitis and other forms of mucocutaneous candi diasis are not known although precip itating events are known. Cellular and humoral immunological data are
as a

ing

This paper presents evidence that the intestine acts as a reservoir for C albicans, where it may live in har mony with the rest of the host's fecal flora. Minor alterations in the milieu of the host (ie, pregnancy and inges tion of broad-spectrum antibiotics) facilitate change from commensal to parasite in/on mucocutaneous sur faces. The most common sites of in fection are contiguous to the anus, ie, cutaneous candidiasis of the diaper or crural area and vaginitis. The results of this study demonstrate that vagi nal candidiasis does not occur natu rally46 without the concomitant pres ence of C albicans within the large bowel and that a "cure" is not likely as long as the vagina remains the

the vagina and feces of each participant and further processed in the Fee Medical Microbiology Laboratory of Michigan State University. Cultures.Raulin's medium was used for primary isolation of C albicans. This me dium was designated to inhibit the growth of most micro-organisms but to allow the growth of Candida species. Yeast growth is evident as early as 24 hours after inocu lation, but optimal growth may be ex pected between five and seven days when incubated at 24 C. Approximately 1 gm of fecal material and swabs containing vagi nal specimens were inoculated directly into the media. Chlamydospore formation on cornmeal plus polysorbate-80 agar was used for positive identification of C albi
cans.

RESULTS

only

treatment

target.

rapidly accumulating,13 but as yet, have contributed little knowledge in understanding the pathogenesis or
control of candidiasis.
From the Departments of Human Development (Dr Miles), Microbiology and Public Health (Dr Olsen), and Student Health Center (Dr Miles), Michigan State University (Dr Rogers), East Lansing, Mich. Reprint requests to Health Center, West Georgia College, Carrollton, GA 30117 (Dr

PATIENTS AND METHODS

Patients.-Healthy, nonpregnant, female patients, 18 to 20 years of age, who pre-

Ninety-eight patients were in volved in the study. Fifty-one (52%) were found to harbor C albicans in both vagina and fecal material; 46 (47%) were Candida free in both sites (Table 1). Thus, there was 100% corre lation between the presence or ab sence of C albicans in the feces and vagina of this population (Table 2). A review of the patient's clinical records supported the recurrent na ture of candidiasis. In approximately one third of the patients, there had been no prior laboratory confirmation
Stool

Table 1.Incidence of C Albicans Isolation From Stool and Vagina*

(%)_No. (%) _No. (52) Candida

Candida

Vagina

Total_98 (100)_98 (100)

'Samples
from 98 young
women

positive_52 (53)_51 negative_46 (47)_47 (48)

with recurrent vaginitis.

Miles).

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Table 2.Correlation Between Presence

C albicans

or

Absence of C Albicans'

Stool, positive Stool, negative

Vagina, Positive No. (%) 51 (98)

Vagina, Negative No. (%) 1(2) 46(100)

hope of accomplishing this. It has been our policy to use the least expen

'Candida albicans isolated from stool and vagina of 98 patients with recurrent vaginitis.

of clinical

impressions. However, in Candida previously iso lated from the vagina of those who subsequently proved to be yeast-free.
no case was

COMMENT

Candida albicans, unlike other Candida species, is rarely found out side of the natural animal host.57 However, it is isolated from many sites in healthy persons, especially from the stools.8,9 Finding Candida in the gut of persons with clinical candi diasis elsewhere is not new infor mation. In the late 1950s and 1960s, clinicians were well aware of this cor relation, but since a practical means of eradicating the organism from the intestinal tract of adults was not known, the subject was never thor

oughly pursued. The data presented

in this paper show 100% correlation between the presence of C albicans in the vagina and in the bowel (a level of correla tion that is rare in any biological sys tem). It would appear that permanent clinical cure of vaginal candidiasis is impossible no matter what drug is used to treat it topically. Transmission from one adult or child to another has not been sat isfactorily demonstrated. Many au thorities state that candidiasis is venereally transmitted,51012 and sex ual partners may present concomitantly with genital candidiasis. But active vaginitis rarely causes lesions in men. Preliminary data from our laboratory and extrapolation of the bowel-reservoir concept suggest that crural candidiasis may develop in those men who also harbor C albicans in the gut. The rare lesions of balanitis attributed to C albicans contain no organisms and may represent an allergic reaction to a water soluble antigen produced by C albicans in the

organism on mucus membrane skin depends on the organism's habitation within an intestinal reser voir may not be unique. A recent study by Badri et al14 suggests that the gastrointestinal tract may be the primary site of colonization in preg nant women who harbor the orga nism in the vagina. The authors can find no evidence that C albicans, once it becomes part of the fecal flora, ever leaves the host spontaneously during his or her life time. The reported incidence of C al bicans being isolated from unselected healthy populations over the years has varied widely, but roughly 35% to 50% of humans harbor this yeast in the gut. There is little variation in the constancy of this figure from infancy to the grave, which may imply a con tinuous relationship beginning at birth. Candida albicans has been cultured from both mouth and stool of newborns as early as 24 hours after birth.15 In 1960, Kozinn et al1G demon strated the passage of p-32 labeled C albicans from the vaginae of mice to their offspring thus verifying these workers' previous studies in humans in which maternal vaginal candidiasis appeared to be the primary source of neonatal thrush and diaper derma
of
an
or

sive medication for the shortest pe riod of time to suppress symptoms. Discussing the nature of the problem with the patient, eliminating contrib uting causes when possible, and giv ing her access to subsequent treat ment as she needs it, has been reassuring and comforting to her.

Extending the gut-reservoir con cept may help to explain other forms of candidiasis and the immunological phenomena found in some people.
References
1. Taschdjian CL, Seelig MS, Kozinn PJ: Serological diagnosis of candidal infections. CRC

titis.17

Many papers have appeared in the pdiatrie literature linking C albicans pathological conditions in infants

coital partner.13 A biological model in which support

with the presence of this yeast in the bowel.1819 The hiatus of years be tween the Candida problems of babies and those beginning at pu berty may simply reflect a milieu less favorable to Candida proliferation during the middle years. Of economic importance is the knowledge that Candida vaginitis cannot be cured by vigorously treat ing the vagina. Millions of consumer dollars are spent yearly in the vain

Crit Rev Clin Lab Sci 4:19-59, 1973. 2. Young RC, Bennett JE, Geelhoed GW, et al: Fungemia with compromised host resistance. Ann Intern Med 80:605-611, 1974. 3. Kozinn PJ, Galen RS, Taschdjian CL, et al: The precipitin test in systemic candidiasis. JAMA 235:628-629, 1976. 4. Hesseltine HC: Factors relating to mycotic and trichomonal infections. Ann NY Acad Sci83:245-252, 1959. 5. Monif GRG: Infectious Diseases in Obstetrics and Gynecology. Hagerstown, Md, Harper & Row, 1974, pp 242-267. 6. Meisels A, Toth B van O: Microbiology of the female reproductive tract as determined in the cytologic specimen: II. In the presence of diabetes mellitus. J Reprod Med 2:91-95, 1969. 7. Drake TE, Maiback HI: Candida and candidiasis. Postgrad Med 53:83-88, 120-126, 1973. 8. Epstein B: Studien zur soorkrankheit jahrb kinderheilk. 104:129-182, 1924. 9. Schnoor TG: The occurrence of Monilia in normal stools. Am J Trop Med 19:163-169, 1939. 10. DeCosta EJ: Infections of the vagina and vulva. Clin Obstet Gynecol 12:198-218, 1969. 11. Waisman M: Genital moniliasis as a conjugal infection. Arch Dermatol Syph 70:718-722, 1954. 12. Weech AA: Commencement address, College of Medicine, University of Florida. J Fla Med Assoc 63:995-999, 1976. 13. Rippon JW: Medical Mycology. Philadelphia, WB Saunders Co, 1974, p 183. 14. Badri MS, Zawaneh S, Cruz AC, et al: Rectal colonization with group B streptococcus: Relation to vaginal colonization of pregnant women. J Infect Dis 135:308-312, 1976. 15. Anderson NA, Sage DN, Spaulding EH: Oral moniliasis in newborn infant. Am J Dis Child 67:450-456, 1944. 16. Kozinn PJ, Taschdjian CL, Burchall JJ, et al: Transmission of P-32 labeled Candida albicans to newborn mice at birth. Am J Dis Child 99:31-34, 1960. 17. Kozinn PJ, Taschdjian CL, Wiener H: Incidence and pathogenesis of neonatal candidiasis. Pediatrics 21:421-429, 1958. 18. Taschdjian CL, Kozinn PJ: Laboratory and clinical studies on candidiasis in the newborn infant. J Pediatr 50:426-433, 1957. 19. Kozinn PJ, Taschdjian CL, Dragutsky D, et al: Cutaneous candidiasis in early infancy and childhood. Pediatrics 20:827-833, 1957.

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