**4. Other neonatal fungal infections**

Despite *C. albicans* is known to be primarily responsible for most neonatal fungal diseases, the prevalence of infections caused by other fungi in neonates and young infants is not significant, except for *Malassezia* species, which may occur in epidemic outbreaks [44–46].

Since 1980, this genus has been recognized in sepsis and systemic infections involving neonates receiving lipidic parenteral nutrition using a central venous catheter. It is believed that lipid supplementation facilitates the colonization of the catheter that used to infuse the nutrients. In newborns, colonization by *Malassezia* can progress to fungemia. The removal of the infected catheter is sufficient to limit infection in most cases [46, 47].

The vast majority of cases of fungemia occur in children less than 12 months old. In this population, this *Malassezia* infection rarely remains asymptomatic. Interstitial pneumonia and thrombocytopenia are common clinical manifestations in this group of patients, and the most frequent symptoms in systemic infections are fever and respiratory dysfunction with or without apnea [46, 48].

Other less common symptoms include lethargy, malnutrition, bradycardia and hepatosplenomegaly. However, no signs of erythema, swelling or purulence appear at the catheter entry site. Signs of skin rash are also not evident in children with systemic infections. Interstitial bronchopneumonia can be found in 40% of children [44–46].

The diagnosis of fungal infection by *Malassezia* is made by isolating the microorganism from blood collected through the catheter or by culturing the catheter tip after its removal. In suspected sepsis by *Malassezia*, the tip of the catheter should be cultured in broth enriched with lipids [45, 46].

The standard therapeutic management for systemic infections by *Malassezia* is still not well defined, since the fungemia by this microorganism is relatively unusual. However, some authors recommend the use of amphotericin B to treat these infections [45, 46, 49]. Morrison and Weisdorf [50] found that all patients enrolled in their study were cured without the administration of systemic antifungal therapy.

Studies have indicated that the most important factor for therapeutic success against systemic infection is the removal of the infected catheter and the interruption of lipid infusion, with or without antifungals [18, 45, 46].
