… is a very common dimorphic yeast, its yeast form is … and its hyphal form is …
candida albicans
comensural
pathogen
when candidiasis develops and the severity of the disease itself appears to depend on these 3 factors
host immune status
oral mucosal environment
virulence of the strain
3 ways oral candidiasis can present
pseudomembranous
erythematous
hyperplastic
… candidiasis is the most well recognized and is also known as “thrush”. It is white, curdled milk or cottage cheese- like plaques that can be wiped off .
pseudomembranous
common sites for pseudomembranous candidiasis
buccal mucosa, palate or tongue
pseudomembranous may be asymptomatic but … or … is usually noted
burning
unpleasant taste
most common type of canidiasis?
erythematous
… is diffuse atrophy of dorsal tongue papillae (“bald tongue”), particularly after broad-spectrum antibiotics. Acute onset and typically associated with “burning” sensation.
acute atrophic candidiasis aka “antibiotic sore mouth”
what is the most common type of erythematous candidiasis?
central papillary atrophy
… presents as a well defined area of redness in the mid-posterior tongue, usually asymptomatic and most are due to chronic candidiasis. Probably referred to as “median rhomboid glossitis” in the past
central papillary atrophy
… is when there is erythema of the palatal denture bearing area, typically asymptomatic. Often referred to as “chronic atrophic candidiasis” but not much evidence to support this concept because usually only the denture is contaminated and there is no invasion of the mucosa (not a true infection)
denture stomatitis
… presents as redness and cracking of corners of the mouth usually related to candidiasis but may have other cutaneous bacterial microflora admixed. often waxes and wanes and typically responds well to topical antifungal therapy
angular chelitis
… is often associated with lip-licking or chronic use of petroleum-based materials. usually related to candidiasis but may have other bacterial microflora admixed. responds well to topical antifungal
perioral candidiasis
…. is when a patient presents with at least 2 of the following: angular cheilitis, central papillary atrophy, “kissing lesion” of the posterior hard palate
chronic multifocal candidiasis
…. is also known as candidal leukoplakia” and presents with a white patch that CANNOT be rubbed off. It is uncommon and usually found on the anterior buccal mucosa. It may be problematic because a true leukoplakia may have candidiasis superimposed on it (should resolve with antifungal if it doesnt)
hyperplastic candidiasis
…. is a rare candidal infection associated with specific immunologic defects related to how the body interacts with candida albicans
chronic mucocutaneous candidiasis
… is a rare candidal infection seen in situations of severe uncontrolled DM or immune suppression
invasive candidiasis
histopath. features of candidiasis (3)
- variable response from host
- acanthosis usually present
- in almost all cases, the candidal hyphae never penetrate deeper than keratin layer
life threatening infections of candidiasis usually require
IV ampho B
…. is an imidazole antifungal agent with no significant systemic absorption or side effects and comes in pleasant tasting lozenges. disadvantage is that dosing should be 5x per day for 10 days
Clotrimazole (mycelex)
… is a med that was developed in the 1950s and is most commonly used today. It is NOT absorbed systemically and must be in contacct with organism to work. Distadvantage- multiple dosing schedule and tastes bitter
Nystatin (mycostatin)
Soak dentures in …. and soak RPDs in …
mild bleach solution
Nystatin (100k u/ml)
…. is a triazole antifungal agents that is readily absorbed systemically with no significant side effects but it does have drug interactions with antihyperlipidemics like lipitor. daily dosing is convenient but it is expensive
Fluconazole (diflucan)
2 creams used for the treatment of angular chelitis or perioral candidiasis
Mycolog II cream
Vytone cream
Mycolog cream is a combo of … and …
Nystatin
Triamcinolone (corticosteroid)
Vytone cream is a combo of …. and …
Iodoquinol (antifungal and antibacterial)
Hydrocortisone
drawback of vytone cream?
iodine allergy
…. is endemic to Ohio and Miss. River valleys, it is spread by spores in bird or bat droppings
Histoplasmosis
histoplasmosis- most cases are …
…. lymph nodes are seen coincidentally
asymptomatic
calcified hilar
clinical presentation of acute histoplasmosis?
flu-like
clinical presentation of chronic histoplasmosis
cavitary pulm. lesions
clinical presentation of oral lesions due to histoplasmosis
- chronic painful ulcer OR granular erythematous plaque
- usually seen in disseminated form
- affects tongue,palate or buccal mucosa
- may be identical to malignancy
histoplasmosis presents as a … inflammation with or without …
best visualized by …
granulomatous
necrosis
silver stain (GMS) or PAS
DX of Histoplas.
ID small yeasts in tissue sections
culture H. capsulatum from lesion
Sero. testing for antibodies or yeast related antigens
tx for mild cases of histoplasmosis?
ketoconazole or itraconazole
prognosis for actue histoplasmosis?
chronic histoplasmosis?
disseminated?
good
fair
poor (90% mortality with no tx, 7-23% with tx)
…. is endemic to desert SW U.S., is termed “valley fever” and represents a hypersensitivity rxn
Coccidioidomycosis
clinical features of Coccidioidomycosis?
- skin of central face may be affected (oral lesions are rarely described)
- inhalation of spores
- flu-like in 40% of patients
- dissemination in less than 1%
Coccidioisomycosis histopathologically shows …. that contain ….
large spherules (20-60 micron) endospores
tx for Coccidioidomycosis
ampho B for disseminated cases
fluconazole or itraconazole for mild cases
generally good prognosis if patient is not immunocompromised
Coccidioidomycosis may be more aggressive in
persons of color
…. is an organism that lives in pigeon droppings and is transmitted by air-borne spores. affects immunocompromised patients almost exclusively
cryptococcus
clinical presentation of crypto.
flu like with initial pulm. infection
disseminates to meninges resulting in headache, vomiting and neck stiffness
cutaneous lesions may develop in 10-20%
oral lesions are rare
histoplath of crypto
4-6 micron yeasts with a clear halo representing a mucopolysaccharide capsule
tx of severe cases of crypto
ampho B and flucytosine
tx for less severe cases of crypto
fluconazole
prognosis for crypto
poor because most are immunocompromised
… is also known as … and there are several genera of molds including …., … and …
zygomycosis
mucormycosis
Mucor, rhizopus and absidia
zygomycosis affects … and present with …
severe diabetic or immunocompromised patient
rhinocerebral form in oral region
clinical presentation of …. is nasal obstruction, bloody nasal discharge, facial pain, swelling, palatal perforation, black/necrotic lesions, blindess is progresses superiorly and seizures and death occur with intrcranial invasion
zygomycosis
Dx of zygomycosis is usually based on the … because … is too slow
histopath
culture
what is seen in the histopath of zygomycosis
large, branching, nonseptae hyphae with extensive tissue necrosis
hyphae are usually seen plugging small blood vessels
tx of zygomycosis
radical surgical debridement
IV ampho B
control of diabetes
poor prognosis
…. is common and second in frequency to candidiasis, spectrum of disease that included allergy, localized infection or invasive infection. Found in spores in soil, water, decaying organic debris. May be “nosocomial” infection
aspergillosis
4 ways aspergillosis can present
allergic fungal sinusitis
“aspergilloma” (maxillary sinus fungus ball)
tissue damage- locally invasive
disseminated (immunocomp pt.)
biopsy of aspergillosis shows … which contrasts with …
branching septae hyphae
mucormycosis/zygomycosis which doesnt have septae
… is significant with standard ampho B but newer liposomal preparations are relatively non-toxic
nephrotoxicity
… is the first oral antifungral agent that could be absorbed systemically but it requires an acidic stomach environment. single dose is convenient. there are some problems with drug interactions and idiosyncratic hepatotoxicity
ketoconazole (nizoral)
… is approved for treating histoplasmosis and is well absorbed. daily dosing, minimal side effects but expensive
itraconazole (sporanox)
… is the first line of therapy for invasive asperogillosis
voriconazole
voriconazole is approved for treating …
candida, aspergillus and several other species
side effects of voriconazole
photosensitivity
voriconazole- expensive?
yes