Infectious diseaes Kumar Flashcards

Question

What are the medications used to treat Primary HSV?

Answer 1

**❏ OTC Magic Mouthwash Formulation:** helps the person to actually be able to eat bc they have so many ulcerations ○ 1 Part‐ Diphenhydramine/ Benadryl (anticholinergic) 12.5mg/5mL elixir ○ 1 Part‐ Lidocaine (topical anesthetic) ○ 1 Part‐ Magnesium hydroxide/ Maalox (mucosal coating agent) ○ Disp: 4 oz bottle ○ Label: Rinse with 5mL every 2 hours for 30 sec. then spit out **❏ Rx‐Topical Anesthetic** ○ Lidocaine 2% viscous solution\* (viscous lidocaine) ○ Disp: 100mL bottle ○ Label: Rinse with 10 mL for 2 minutes and spit out \*May diminish the gag reflex therefore better suited for older patients‐ shouldn’t be prescribed to kids. Remember serious sideeffects of seizures and methemoglobinemia in pediatric population. **❏ OTC Analgesic** ○ Acetaminophen (Tylenol) OR ibuprofen (NSAID) suspension/ tablets as directed for body weight ❏ **Rx Antivirals** ○ Generally only indicated for immunocompromised or dehydrated patients ○ Limited evidence for other cases‐ see Cochrane Oral Health Group Review\* (\*Amended recently) ○ Oral acyclovir suspension (Zovirax) is typically used ○ 15 mg/kg up to adult dose of 200mg ○ Rinse and swallow, 5 times a day for 5‐7 days

Answer 2

* §**Secondary herpes** * §Mild, self-limiting * §Vermilion border * §Intraorally on **fixed keratinized mucosa** * §7-10 days * **§Unilateral** * § Prevalence‐15‐45% * 90% of adults have the antibodies, but 15‐45% of them can get recurrent herpes. Most of us have the antibodies, but we never exhibited the primary infection or a recurrent infection***.** * **§ 1‐6 outbreaks a year**

Answer 3

**trigeminal ganglion**

Answer 4

Prodrome►papules►vesicles►ulcer►crust►heals►no scar

Answer 5

**recurrent Hsv-1/Recurrent herpes** It is raised (papule), so it’s in the middle stage

Answer 6

* Old age, Allergy * UV light ,Trauma * Physical / emotional stress, Dental treatment * Fatigue, Respiratory illnesses * Heat, Fever * Cold, Menstruation * Pregnancy, Systemic Diseases * Malignancy

Answer 7

Asymptomatic shedding can occur in seropositive patients ❏ More common after surgical procedures and in immunocompromised patients ❏ We need to take Universal precautions

Answer 8

Recurrent HSV-1 papule bc its raised

Answer 9

Recurrent HSV-1 crust → later crust comes off and then you'll have epithelialization underneath

Answer 10

Recurrent HSV-1 Vesicle stage (unilateral)

Answer 11

Recurrent HSV-1 **Bilateral** \> THIS IS KEY -differential diagnosis with a Staph infection that occurs periorally with kids -\> impetigo

Answer 12

Recurrent HSV-1 This is recurrent intraoral herpes. We have punctate (point‐like) ulcerations which sometimes have clusters of coalescing ulcers. That’s the words you wanna use Other features of the ulcers: ○ Erythematous border ○ Irregular shape ○ Fixed mucosa ○ Unilateral

Answer 13

Recurrent HSV-1 Punctuate ulceration erythematous border, irregular shape, fixed mucosa, unilateral

Answer 14

**Recurrent HSV-1** healing stage cause you might see this one day

Answer 15

**❏** **Clinical**‐ if you see punctate ulcers unilaterally on the palate, it is usually recurrent herpes simplex. ❏ Culture (may take 2 weeks) ‐ takes too long ❏ Tissue biopsy‐ if it wasn't typical **❏ Cytologic smear**‐ the ideal way if you want a definitive diagnosis

Answer 16

_❏ **Depends on severity/frequency**_ _❏ **Preventive/suppressive vs episodic/abortive strategies** Two types of treatment:_ **Preventive/Suppressive: taking antivirals everyday to prevent an outbreak** **Episodic: taking antivirals here and there to abort the process; episodic: abortive. _❏ Drugs used:_** ❏ *Antiviral agents* ❏ *Antiviral‐steroid combination agents* **_❏ Avoid precipitating factors, like use sunscreens – avoid any triggers_**

Answer 17

❏ the **prodrome**, prodrome treatment is abortive \*\*remember this!\*\*

Answer 18

Topical like Acyclovir or Acylovir + steroid combination There are many OTC topical medications

Answer 19

: taking antivirals everyday to prevent those 6 outbreak/year. There is modest evidence that systemic **acyclovir or valacyclovir** prevents recurrent herpes labialis these drugs tend to only affect virally‐altered cells. They don’t affect the mammalian cells; they’re very safe.

Answer 20

❏ Episodic‐Occurring, appearing, or changing at usually irregular intervals ❏ Abortive‐Tending to cut short the course of a disease ○ Medication has to be taken during Prodrome ○ When the patient feels a burning, itching, and tingling

Answer 21

❏ Rx: **Acyclovir cream 5% (Zovirax)** Disp: 5g tube Label: dab on lesion every 2 hours for 4 days ❏ Rx: **Penciclovir cream 1% (Denavir)** Disp: 5g tube Label: dab on lesion every 2 hours for 4 days ❏ Rx: **Docosanal cream (Abreva) OTC** Disp: 2g tube Label: dab on lesion five times per day for 4 days **Acyclovir and Penciclovir should be taken during the prodrome stage** ❏ Rx: Acyclovir 5%/ hydrocortisone 1% cream (Xerese) Disp: 5g tube Label: dab on lesion 5 times a day for 5 days ❏ Rx: Acyclovir buccal tablets (Sitavig) 50mg Disp: 2 dose pack Label: apply to canine fossa within 1 hour of symptoms (single dose)

Answer 22

**❏ Rx: Valacyclovir 1g tablets** Disp: 4 tabs Label: 2 tabs stat PO, then again in 12 hours (ie 2 doses) *Given during prodrome.* **❏ Rx: Famciclovir 500mg tablets** Disp: 3 tabs Label: 3 tabs stat PO

Answer 23

❏ Ice ❏ L‐lysine ❏ Bioflavonoids ❏ Evaporants ‐ Desiccants ❏ Emollients ❏ Bioadhesives (Zilactin‐benzyl alcohol, topical pain reliever) ❏ Wound‐healing modification/ occlusive agents

Answer 24

**Atypical recurrent HSV** **❏ Immunocompromised host** Atypical recurrent HSV can have this appearance on the movable mucosa too, not just fixed

Answer 25

**HSV Associated Erythema Multiforme** ❏ Skin immune reaction in response to infection ❏HSV implicated in trigger for erythema multiforme where you get target lesions and crusted ulcerations on the lip ❏ need to prescribe :antiviral prophylaxis

Answer 26

❏ Primary infection **○ Varicella/ Chicken pox** ❏ Secondary infection **○ Zoster/ Shingles** ○ May affect oral cavity/ face if reactivation along distribution of V1/2/3

Answer 27

HHV3 Varicella (chickenpox) It is caused by Varicella Zoster Virus Infection a typical macular, papular, vesicular rash – it’s bilateral

Answer 28

**Herpes Zoster/ Shingles** * It is affecting the intraoral region * and the maxillary branch. * Picture on the far right looks like recurrent HSV (cluster of coalescing ulcers) * Looking at the picture on the left you can determine it is NOT a recurrent intraoral herpes **because we have vesicles that opened up and crusted over on** **the skin.** **VZV histopathology is the same as HSV.** **VZV remains latent in the dorsal root ganglion** travels down the sensory nerves to skin upon reactivation. ❏ The reactivation presents as **a painful rash in one or two adjacent dermatomes that does not cross the midline.** ❏ The rash is **maculopapular** and **develops into vesicles.** ❏ One complication of zoster is **post‐herpetic neuralgia**: pain that persists in the area where the rash once was present.

Answer 29

**Epstein‐Barr Virus Infection** Latency in **lymphocytes** §Infectious mononucleosis §Oral hairy leukoplakia §Nasopharyngeal carcinoma §EBV mucocutaneous ulceration §Burkitt lymphoma §Other lymphomas (Hodgkin, post transplant)

Answer 30

**Infectious mononucleosis** **Epstein‐Barr Virus/EBV‐induced disease** The virus spreads through saliva, which is why it's sometimes called "kissing disease." Mono occurs most often in teens and young adults. However, you can get it at any age. Symptoms of mono include: **Fever** **Sore throat** **Swollen lymph glands** * when you have salivary transfer, your lymph nodes get swollen * people feel fatigue and fever * they have tonsilitis * can lead to the secretion of white or gray‐ green tonsillar exudate * they can get petechiae on the palate too.

Answer 31

**Oral hairy leukoplakia** Epstein‐Barr Virus induced disease ❏ Corrugated white keratotic lesion on the lateral tongue in HIV+ people

Answer 32

**Nasopharyngeal carcinoma** ❏ Associated w/ HHV‐4 (EBV) ❏ You might be one of the first people to detect this cancer – the first sign is the swelling of the lymph nodes In this case, these are late stages of the disease. *this photo from google*

Answer 33

**EBV mucocutaneous ulceration** Very rare *Photos from google*

Answer 34

**Burkitt Lymphoma** *caused by **EBV***

Answer 35

**Burkitt Lymphoma** Epstein‐Barr Virus Infection * Fast growing tumor discovered by Dr. Burkitt * **High grade lymphoma B** **cells**‐ Usually affects the jaws of children. * **It is the fastest growing tumor/cancer**. * There is _translocation of c‐myc_

Answer 36

**Cytomegalovirus Infection** ❏ Usually **asymptomatic** ❏ Symptomatic infections are nonspecific: **chills, fever, sore throat** ❏ What’s interesting here: ❏ When the cells are affected, they form these owl eyes – they are **nuclear inclusions and cytoplasmic inclusions.** ❏ Disease states found predominantly in: * **○ pregnancy/neonates** (congenital infection) * **immunocompromised patients,** particularly **transplant and HIV+** **patients** **** ❏ Latency in **myeloid cells, salivary gland cells and endothelium**

Answer 37

**HHV 5** **Cytomegalovirus Infection** Histopathology look like an owl eyes means the cells are affected- they are **nuclear inclusions and cytoplasmic inclusions.**

Answer 38

HHV 5 Cytomegalovirus Infection When a person is immunocompromised, particularly those who’ve had a transplant or HIV+ patients, only these people will present with ulcerations It's very hard to identify based on photo alone - it's very nonspecific

Answer 39

**Kaposi sarcoma--associated herpesvirus (KSHV)** **❏ Vascular neoplasm of endothelium** ❏ Associated with **immunosuppression** ❏ Usually evolves through 3 stages: **○ Patch►plaque►nodular** * **More commonly seen in patients with HIV infection.** * **Treated** with _topical agents and chemotherapy._

Answer 40

**Kaposi sarcoma** HHV 8 Kaposi sarcoma on the skin: \>1cm Different color, so this is called a **patch**. Erythematous patches present on multiple areas of the face.

Answer 41

Histopathology shows **malignant endothelial cells proliferating.** There are tiny spaces. Extravasation of RBCs can be seen

Answer 42

**Kaposi Sarcoma (HHV‐8)** Right photo: we see Patch, slightly raised plaque stage ○ This is different from **hemangioma** because if you press on it, it doesn’t blanch (where all the blood goes away, and it looks white) Left photo: Nodular is when it becomes very exophytic You need to do a biopsy for this because it looks irregular.

Answer 43

§Small, non-enveloped **icosahedral DNA virus** that infects **skin or mucosal cells of humans.** **§Circular DNA** §198 types established **§High and low risk types** ## Footnote **‐ HIGH risk = CANCER ‐ LOW risk = WARTS**

Answer 44

▪ **Benign**: neoplasms of squamous epithelium ▪ **Pre‐malignant**: epithelial dysplasia – can lead to cancer ▪ **Malignant**: squamous cell carcinoma – infiltration of epithelial cells

Answer 45

**6 & 11**

Answer 46

**6, 11, 16, 18** ***(condyloma – can be malignant)***

Answer 47

**16, 18**

Answer 48

▪ **Sexual/non‐sexual direct contact** ▪ **Salivary transfer** ▪ **Contaminated objects (fomite)** – not well established ▪ **Autoinoculation** – child puts finger into mouth ▪ **Perinatal/pre‐natal transmission**

Answer 49

Incubation period: **3 weeks – 2yrs** ▪ Basic Explanation: Basal epithelial cell infection ► Genome replicates ► DNA released into stratum corneum ▪ Detailed Explanation: 1. HPV accesses and infects cells of the epithelial basal layer through breaks in the skin or mucosa 2. The virus becomes incorporated in the genome of the infected cell 3. The site of HPV integration into the cellular genome is in the general region of known oncogenes 4. The virus replicates during keratinocyte differentiation in the spinous and granular cell layers 5. A portion of the HPV genome encodes proteins that are capable of inducing cell proliferation and transformation **(E6, E7)**

Answer 50

1. Completely have infection go away or 2 .Stays and forms wart or affects maturation (becomes cancer, depending on strain)

Answer 51

▪ LCR: long control region ▪ P97: promoter protein ▪ E1‐E7: early region genes ▪ L1,L2: late region genes

Answer 52

``` **E6 = degrades p53 E7 = inactivates pRb** ``` ## Footnote 1. E2 = attachment location of Integrated HPV 2. transcription of E6 + E7 3. Binding of the viral E7 protein to pRb ► release of E2F and other proteins ► signals for the cell cycle to progress ▪ **As long as the E7 protein stays attached to pRb, uncontrolled cell proliferation will continue** HPV E6 protein is: ‐ A ubiquitin ligase ‐ contributes to oncogenesis by attaching ubiquitin molecules to p53 ► making p53 inactive and subject to proteasomal degradation ▪ **Normal function of p53 = to stop cell division + repair damaged DNA so that damaged cells do not reproduce (apoptosis)** ▪ _When p53 is inactive_, cells with changes in the DNA, such as integrated viral DNA, are not repaired ► destabilizes the cell ► increases the risk of malignant transformation

Answer 53

▪ Low‐risk types: clear faster, less likely to become persistent ▪ High‐risk types: clear slowly, more likely to become persistent

Answer 54

Overall: 6.9% (CI 6.7‐8.3) ▪ Gender: **Men (10.1%) \> Women (3.6%) – women clear faster** ▪ Age: **bimodal distributio**n – 30‐34yo and 60‐64yo (she says 30‐34 but Dr. Kerr’s graph shows mid‐20s ▪ High Risk HPV (3.7%) \> Low risk HPV (3.1%) ▪ **HPV‐16 infection most prevalent** (1% or 2.13 million Americans) ▪ Based on NHANES study w/ oral rinse sampling and PCR

Answer 55

▪ Ever had sex (7.6%) vs never had sex (0.9%) ▪ Male ▪ Increased number of sexual partners (vaginal or oral sex) ▪ Tobacco smoking ▪ HIV infection

Answer 56

HPV 16 = most prevalent

Answer 57

**Ppl w/ HIV+ and low CD4 T‐cells lvl** = higher risk of HPV **HPV 16+ higher if CD4 \<200**

Answer 58

**▪ HPV associated SCCa** ‐ Wild type TP53 ‐ Low pRb _‐ Increased p16_ **▪ Tobacco and Alcohol associated SCCa** _‐ \*Mutated TP53_ – mutated by carcinogens in tobacco and alcohol► cancer ‐ pRB overexpression ‐ Decrease p16

Answer 59

§_Appear_ as **single or multiple exophytic papules, either sessile and flat or pedunculated and papillary.** §_Color_ depends upon degree of keratinization, ranging **from white to pink.** §_Size_ of papules **generally \<10mm in diameter.** §_Histologically_, lesions may have **koilocytes.**

Answer 60

▪ Squamous papilloma ▪ Verruca vulgaris ▪ Condyloma acuminatum ▪ Focal epithelial hyperplasia ▪ Oral florid papillomatosis

Answer 61

▪ **Benign proliferation of stratified squamous epithelium resulting** ► p*_apillary, verruciform, rugose (ridged or wrinkled) mass_* ▪ **HPV types 6 + 11** – Low risk ▪ **M = F** ▪ **Any age** (more common in 30‐50s) ▪ Any oral mucosal surface (palate most common) ▪ **Soft, painless, usually pedunculated, exophytic lesion w/ numerous finger‐like projections** ▪ **HPV DNA detected in only ~50%** ▪ \*\*should remove from mouth – but WOULD NOT submit for HPV typing

Answer 62

SQUAMOUS PAPILLOMA Benign Oral Low Risk HPV Lesion **HPV 6+11** “finger‐like projections

Answer 63

SQUAMOUS PAPILLOMA Benign Oral Low Risk HPV Lesion **HPV 6+11** “finger‐like projections - The projections are almost feathery - exophytic lesion

Answer 64

▪ HPV **2**, and others (1,**4,6**,7,11,26,27,29,41,57,65,75‐77) ▪ Benign, HPV‐induced focal hyperplasia of stratified squamous epithelium ▪ **Contagious** – transmitted by direct contact ▪ **Any age** – frequently seen in children ▪ More common **Anterior** \> Posterior part of mouth ▪ **Soft, painless, usually pedunculated, exophytic lesions w/ numerous fingerlike projections** (similar to squamous papilloma) ‐ _How to tell the difference? Under microscope_

Answer 65

***Oral Verruca Vulgaris*** HPV 2,4,6 Also “finger‐like projections” remember it's *contagious*

Answer 66

**HPV Types 6, 11** – _condyloma can turn cancerous_ ▪ Virually induced proliferation of stratified squamous epithelium – usually genital or anal mucosa ▪ **Contagious** – transmitted by direct contact ▪ Incubation period: 1‐3mo ▪ Considered **sexually transmitted disease** (if corroborated by history) ▪ **Oral lesions** – usually **anterior part of mouth** ▪ S**essile, pink, well‐demarcated, non‐tender exophytic mass ▪ Short, blunted surface projections ▪ Larger than papilloma or verruca vulgar** ## Footnote **▪ Characteristic clustering of multiple lesions**

Answer 67

**Condyloma Acuminatum** (Venereal Wart) HPV 6,11 – can be cancerous Genital warts “short, blunt, clusters” Characteristic clustering of multiple lesions

Answer 68

-Since this is a sexually transmitted disease, we need to suspect sexcual child abuse and investigate further!

Answer 69

▪ HPV Types **13, 32** and others (1,6,11,16,18,55) ▪ **HPV‐induced localized proliferation of oral squamous epithelium ▪ “Flat‐top papules”** ▪ Endemic in some **Inuit/Alaskan native + Native American** **communities**, **Puerto Rican communities** ▪ _Crowded situations, malnutrition_ ▪ Usually seen in children ▪ May be seen in HIV + individuals ▪ **M = F** ▪ Histology: **focal epithelial acanthos**

Answer 70

(Multifocal) Epithelial Hyperplasia/**Heck's Disease** HPV 13,32 **“Flat‐top papules”**

Answer 71

(Multifocal) Epithelial Hyperplasia/**Heck's Disease** HPV 13,32 **“Flat‐top papules”**

Answer 72

IIt's benign HPV disease ▪ HIV infection ‐ Increased prevalence since advent of HAART therapy ‐ Multiple HPV types ▪ Down syndrome Oral Florid Characteristics: ‐ **Diffuse, multiple locations ‐ Papillary ‐ Bumpy and tall**

Answer 73

**Oral Florid Papillomatosis** Very characteristic appearance - diffused, in multiple locations - papillary **"Multifocal, papillary lesions"** -if we biopsied these or had these removed for aesthetic regions, we’d see that the epithelium have become white, long, taller, and bumpy

Answer 74

**§Acanthosis §Koilocytosis §Binucleated***and***multinucleated keratinocytes §Dyskeratosis §Mitosoid figures §Basilar hyperplasia**

Answer 75

HPV is thought to cause **70%** of oropharyngeal cancers in the US That's why we want to know if high risk HPV– better prognosis

Answer 76

_▪ Pathologists order it_ ▪ Only do testing if pathologist sees cancer **No HPV testing on low‐risk HPV lesions (warts)** ▪ No medical indication for **low‐risk HPV testing** b/c ‐ infection **NOT** associated w/ disease progression ‐ no treatment or therapy change indicated when low‐risk HPV is ID’ed ▪ HPV testing using p16 surrogate on **oropharyngeal squamous cell carcinoma** **(SCC)**

Answer 77

‐ Usually appear exophytic and papillary ‐ Excision is warranted ‐ Consider possible recurrence

Answer 78

‐ Use high power evacuation to prevent transmission ‐ Treatment = controversial ‐ Excision/ablation vs Topical vs Intralesional therapy (or combo) ‐ Consider higher rate of recurrence

Answer 79

Excision/Ablation ▪ Scalpel ▪ Carbon dioxide laser – be cautious, don’t know what is burned away ▪ Electrosurgery

Answer 80

▪ Podophyllin resin ▪ Imiquimod (extra‐oral use only) ▪ Cidofovir ▪ Interferon

Answer 81

▪ Topical cytotoxic agent which arrests mitosis ▪ Genital warts and other papillomas ▪ Not FDA approved for oral warts ▪ Serious adverse reaction if absorbed systemically ▪ Pregnancy category X

Answer 82

▪ Induces cytokines + chemokines w/ resutlant anti‐virl (HPV) effects Not FDA approved for oral warts

Answer 83

**Newest is Gardsail 9** against many types for both men and women ▪ 2 doses recommended for boys/girls age 11‐12 and 6mo later ▪ Recommended for everyone \<26yo (MAX) ▪ NOT recommended for 26+yo unless risk for new infections (less benefit since most already exposed) ▪ Virus like particles (VLP) of L1 capsid protein present in vaccine Results of Vaccination ▪ Drops in infections w/ HPV types that cause most HPV cancers + genital warts in teen girls, young adult women ▪ Among vaccinated women – cervical precancers dropped by 40%

Answer 84

▪ 80% ppl will be infected in lifetime so better take the vaccine early!

Answer 85

▪ **Poxvirus** ▪ Presents as: ‐ pink, dome‐shaped, smooth‐surfaced or umbilicated (like belly‐button) papules ‐ with caseous plug involving skin, lips, buccal mucosa, and palate ▪ Florid cases seen in immunocompromised persons ▪ Children, young adults ▪ Histopathology characterized by: ‐ Large intracytoplasmic inclusion bodies – “Henderson‐Paterson bodies” ‐ Kids can have 6‐9mo and will go away

Answer 86

**Oral Molluscum Contagiosum** *multiple pink, dome‐shaped, smooth‐surfaced or umbilicated (like belly‐button) papules ‐ with caseous plug*

Answer 87

**▪ Paramyxovirus** ▪ Spread through _respiratory droplets_ ▪ **Symptoms**: runny nose, red/watery eyes, cough, fever, rash, desquamation of skin ▪ \***Characterized by Koplik’s spots** ‐ Pathognomonic for measles ‐ Discrete, bluish white punctate mucosal macules ‐ Surrounded by rim of erythema ‐ Represent foci of epithelial necrosis ‐ Often precedes skin manifestations **▪ Most common location for Koplok’s spots:** _Buccal mucosa_ ‐ Lesions may resemble _“grains of salt sprinkled on erythematous background”_

Answer 88

**Measles** **\*Characterized by Koplik’s spots** salts/grains

Answer 89

**-Herpangina**‐soft palate, red macules ► fragile vesicles (back of throat) ‐ **Hand, foot, and mouth disease** – oral lesions more in anterior regions (aphthous‐like), hand/foot (vesicles) ‐ **Acute lymphonodular pharyngitis** – nodules on the soft palate ▪ Usually seen in children ▪ Self‐limiting

Answer 90

**_Hand, foot, and mouth disease_** caused by **Coxsackie Virus** affect children contagious The condition is spread by direct contact with saliva or mucus.

Answer 91

**Herpangina** casued by **_Coxsackie Virus_** *red macules and vesciles on the soft palate* a sudden viral illness in children. It causes small blisterlike bumps or sores (ulcers) in the mouth

Answer 92

**Acute lymphonodular pharyngitis** Caused by **Coxsackie Virus** *Affects children* Nodules on the soft palate. -distinctive, raised, micronodular lesions occur primarily in the pharynx and related structures and regressed without ulceration.

Answer 93

**▪ Family: Togavirus; Genus: Rubivirus** **▪ Respiratory droplets** **Symptoms:** ‐ Fever, headache, malaise, coryza (runny nose), anorexia, pharyngitis, lymphadenopathy ▪ Rash – **maculopapular w/ desquamation** * *▪ Forchheimer sign** * *▪ Palatal petechiae** ▪ **Congenital rubella syndrome** – pandemics in past ▪ Vaccine: **MMR** – so we barely see this anymore ▪ Diagnosis**: by serology**

Answer 94

Rubella caused by Family: Togavirus; Genus: Rubivirus ``` Forchheimer sign (left) Palatal petechiae (right) ``` | (German Measles)

Answer 95

**Candida Species** ● Over 200 species exist ● At least 15 distinct Candida species cause human disease

Answer 96

**Candida albicans**

Answer 97

‐ C. albicans ‐ C. glabrata ‐ C. tropicalis ‐ C. parapsilosis ‐ C. krusei

Answer 98

● **Commensalism**: ‐ “long‐term biological interaction (symbiosis) in which members of one species gain benefits while those of the other species neither benefit nor are harmed” ● \>50% of humans carry candida without harmful effects

Answer 99

* Becomes an “infection” called **candidiasis** when environment changes and encourages growth * ● Defect in cell‐mediated immune response * ‐ Ranges from mild superficial mucosal infection ►(can be) fatal disseminated disease (usually with people with HIV and transplants)

Answer 100

● A disrupted balance of the normal mucosal flora ● Impaired barrier functions ● Immunosuppression such as: ‐ Use of broad‐spectrum antibiotic ‐ Leukemia ‐ HIV ‐ Cancer chemotherapy ‐ Diabetes ‐ Xerostomia (what we deal with, candidiasis can persist here)

Answer 101

Normally it is in the commensal state and once you reach a certain level where the fungal burden has increased, you increase the c‐FOS pathway ‐ This is when the organism forms **hyphae**; once these are formed, you see invasion into the **epithelial** cells.

Answer 102

**● Commensalism** * **Fungus is tolerated** (threshold not reached) * I**mmune cells are not activated** **● Pathogenicity** * _Fungal burden is increased_ and **hyphae** form * Immune cells are recruited by cytokines, chemokines * Neutrophils are recruited and kill fungus * Dendritic cells present antigen to T‐cells * T‐cells also decrease fungal burden (IL‐22, IL‐17) * Innate and acquired clear fungus to levels below threshold

Answer 103

1. **Dimorphism** (can be _spore_ and a _hyphae_‐ 2 forms) 2. **Phenotypic switching** (change shape) 3. **Adhesins/Invasins** (aid in attachment) 4. **Molecular mimicry of mammalian integrins** (helps to be avoided by the immune system) 5. **Secretion of hydrolytic enzymes** (aids in invasion) 6. **Phospholipase B contributes to degradation of host tissue** (aids in degradation to gain entry)

Answer 104

SPORES‐ when they are in this form, they do NOT invade HYPHAE‐ when they begin their invasion

Answer 105

Crosstalk: Candida **glycans** play an important role in the continuous interchange that regulates the balance between saprophytism and parasitism

Answer 106

**● Superficial and localized‐more common (mild disease)** ‐ Intertrigo §Paronychia/Onychomycosis ‐ “Diaper Rash” ‐ Vulvovaginitis ‐ Esophageal Candidiasis §Oral Candidiasis (Candidosis) **● Invasive, disseminated and deep infection‐rare (moderate‐severe)** ‐ Affects blood (candidemia‐hospitalized), heart, brain, eyes, bones)

Answer 107

**Intertrigo** a type of candidiasis

Answer 108

**“Diaper Rash”** a type of candidiasis

Answer 109

**Vulvovaginitis** a type of candidiasis

Answer 110

**Esophageal Candidiasis** a type of candidiasis

Answer 111

**Oral candidiasis** a type of candidiasis

Answer 112

**Onychomycosis** a type of candidiasis

Answer 113

**C. albicans** * **Candidal sepsis** means that you have the fungal moving around in your body * **Life‐threatening event** in individual with severely deficient cell * mediated immunity * Most commonly involves urinary tract infection (women/men 4:1) * _Very rare_

Answer 114

● 30‐50% of people carry organism without infection (called candida carriage) ● Rate of carriage increases with age and risk factors ● 70‐80% of oral isolates are Candida albicans

Answer 115

**Local** * denture wearing * smoking * atopic consitituion * steroid inhalation * hyperkeratosis * imblance of the oral microflora * quality and qunatity of saliva\ **General** * immunosupressive disease * impaired health status * immunosupressive drugs * endocrine disorders * hematinic deficiencies

Answer 116

● “**Thrush**” ● KEY FEATURE: **Wipeable** _white plaques that resemble curdled milk_ ● Underlying mucosa is **erythematous** ● Asymptomatic usually ● Mild symptoms: burning, dysgeusia ● Seen in patients with: **HIV, broad‐spectrum antibiotics, leukemia, infants**

Answer 117

**PSEUDOMEMBRANOUS CANDIDIASIS** *UNCONTROLLED DIABETIC* When you wipe away these plaques, you might see some Erythematous areas that causes some of the symptoms that the patient feels -This is **MILD DISEASE**

Answer 118

* *Pseudomembranous Candidiasis‐** * Uncontrolled HIV* ● This can be mistaken with materia alba (this is just food) ‐ Should ask patient if they just ate ● This is **MODERATE DISEASE**

Answer 119

**Pseudomembranous Candidiasis** *Topical Corticosteroid Use* Can be brought about from steroid use **(steroid inhaler example)** ‐ If you don’t rinse your mouth after using steroids, this can happen ■ _A proliferation of hyphae_

Answer 120

PSEUDOMEMBRANOUS CANDIDIASIS **Severe dry mouth** **This is severe disease** we would want to use **systemic treatments/ intervention**

Answer 121

● **Clinical Findings:** * Red macules or patches * Can be due to multiple things **● Subtypes:** ‐ **Atrophic Candidiasis** (acute‐feels like mouth has been scalded) ‐ **Median Rhomboid Glossitis** (asymptomatic) ‐ **Denture Stomatitis** (asymptomatic) ■ HAS THE SHAPE OF THE DENTURE ‐ **Chronic multifocal (**asymptomatic) ■ THIS HAS BEEN THERE FOR A LONG TIME

Answer 122

**ATROPHIC CANDIDIASIS** ● Erythematous on any mucosal surface **● “Bald Tongue”** ● Typically, painful ● (Chronic multifocal, looks familiar) ***a subtype of Erythematous Candidiasis***

Answer 123

**Median Rhomboid Glossitis** *a subtype of Erythematous Candidiasis* ● “**Central Papillary Atrophy”** ● _Well‐demarcated erythematous zone_ ● **Loss of papillae on midline posterior dorsal tongue** ● Usually, **asymptomatic** ● “**Kissing” palatal lesion** ‐ Because the tongue and the palate are in contact with each other ● Can have **a diamond shape**

Answer 124

**Denture Stomatitis** ● _Chronic atrophic candidiasis_ ● **Erythema** in _denture bearing areas of maxilla_ ● **Petechiae** may be noted ● Usually, **asymptomatic** ● _Consider denture care/fit/allergy/inadequate curing of acrylic_ ● This can occur if the patient NEVER takes off their denture ● **Inflammatory papillary hyperplasia** is associated with condition ● **Treatment**‐**Nystatin** applied to intaglio surface of denture and wear denture and patient to remove denture at night *a subtype of Erythematous Candidiasis*

Answer 125

*a subtype of Erythematous Candidiasis*

Answer 126

**Angular Cheilitis** ● **Erythema**, _fissuring and scaling at angles of mouth_ and _commissures of mouth_ ● ***Loss of vertical dimension*** ● ***Pooling of saliva*** ● _May be mixed bacterial/fungal infection_ ● _Differential diagnosis_ can be **Vit B Deficiency** *a subtype of Erythematous Candidiasis*

Answer 127

● a Rare and controversial form of candidiasis ● Candidiasis superimposed on pre‐existing leukoplakic lesion ● White plaque which cannot be removed by scraping (NOT WIPEABLE) ● **Increased frequency of epithelial dysplasia** ● MUST **BIOPSY** then diagnose as hyperplastic candidiasis **if you see fungi post biopsy**

Answer 128

**HYPERPLASTIC CANDIDIASIS**

Answer 129

● Group of rare disorders with immunologic pathogenesis ● Clinical: Severe infection of mucosal surfaces, nails and skin ● Oral‐ lesions‐thick white plaques that do not rub off but may see other forms

Answer 130

‐ **A**: autoimmune ‐ **PE**: polyendocrinopathy ‐ **C**: candidiasis ‐ **E**: ectodermal ‐ **D**: dystrophy **Chronic Mucocutaneous Candidiasis** is also genetic associted with **AIRE** gene

Answer 131

● Increased risk of **squamous cell carcinoma**

Answer 132

**Chronic Mucocutaneous Candidiasis** Severe infection of mucosal surfaces, nails, and skin

Answer 133

Mucocutaneous Candidiasis APECED Autoimmune Polyendocrinopathy Candidiasis Ectodermal Dystrophy Syndrome Biopsy of the tonuge revealed SCC

Answer 134

● Clinical signs ● Therapeutic diagnosis ● Cytologic smear: scrape cells and look at them under the microscope and stained with PAS stain ● Periodic Acid Schiff Stain (PAS stain) ● KOH float §Biopsy (esp. hyperplastic candidiasis) ● Culture

Answer 135

● **Polyene‐Nystatin, Amphotericin B** (not absorbed; used for deep fungal infections) ● **Imidazole‐Clotrimazole, Ketoconazole** (GI absorption) ● **Triazole‐Fluconazole, Itraconazole, Posaconazole, Echinocandins**

Answer 136

* **Clotrimazole troches**, 10 mg 5 times daily or * **miconazole mucoadhesive buccal 50 mg tablet** applied to the mucosal surface over the canine fossa once daily for 7–14 days * Alternatives for mild disease include **nystatin suspension (100 000 u/mL) 4–6 mL** swished for \>1min then swallow **4 times daily.**

Answer 137

* **Oral fluconazole, 100–200mg daily for 7–14 days** ● For **fluconazole‐refractory disease:** ‐ **Itraconazole suspension 200 mg once daily OR posaconazole** su**spension 400 mg twice daily for 3 days then 400 mg once dail**y, for up to **28 days**, are recommended *_Alternatives for fluconazole‐refractory disease include:_* ‐ **Voriconazole, 200 mg twice daily**, OR **AmB deoxycholate oral suspension, 100 mg/mL 4 times daily**(strong recommendation; moderate‐quality evidence). ‐ **Intravenous echinocandin** (caspofungin: 70‐mg loading dose, then 50 mg daily; micafungin: 100 mg daily; or anidulafungin: 200‐mg loading dose, then 100 mg daily) (weak recommendation; moderate‐quality evidence). § **Intravenous Amphotericin B** deoxycholate, 0.3 mg/kg daily, are other alternatives for refractory disease (weak recommendation; moderate‐quality evidence).

Answer 138

**this is when you keep the fungal infection under control for a long time** Usually **unnecessary in immunocompetent patients** ● For patients who have recurrent infections: ‐ **For HIV‐infected patients, antiretroviral therapy is strongly recommended to reduce the incidence of recurrent infections** (strong recommendation; high‐quality evidence). ‐ **Fluconazole, 100 mg 3 times weekly, is recommended** (strong recommendation; high‐quality evidence). ● **Clotrimazole 10mg troches 1 week out of every month?** (no evidence

Answer 139

YOU APPLY THE MEDICATION TO THE INTAGLIO PORTION antifungal medication (1) Topical Antifungal Agents ‐ Rx. Clotrimazole cream 1% vs OR ‐ Rx. Nystatin‐Triamcinolone Acetonide ointment or cream (why? To keep the inflammation down) ■ Disp: 15g tube ■ Label: apply to angles of mouth after meals and before bedtime (2) Denture adjustment, reline, remake YOU APPLY THE MEDICATION TO THE INTAGLIO PORTION

Answer 140

● **Bleach‐**1 part bleach to 10 parts water (not for dentures with metallic clasps) ● **Polident** (NYU Carries Polident) ● **Microwave**? ( could be risky, careful not to ruin the denture) CLEANSERS FOR REMOVABLE PROSTHESIS- you have to use this everynight to avoid denture stomoatits **_NYU Carries Polident_** Formulation: **sodium bicarbonate, citric acid, potassium monopersulfate**, sodium carbonate, sodium carbonate peroxide, TAED, sodium benzoate, PEG‐180, sodium lauryl sulfate, VP/VA copolymer, flavor, cellulose gum, FD&C blue 2, blue 1 lake, yellow 5, yellow 5

Answer 141

Histoplasmosis

Answer 142

**● Histoplasma capsulatum** ● **Dimorphic** (yeast at body temperature and mold in soil)

Answer 143

● Endemic in **fertile river valleys** ‐ Seen in people who spend **a lot of time outside; near Ohio and Mississippi rivers** ● Bird and bat excrement ● Airborne spores enter lungs through inhalation ● Macrophage ingests fungusà**T‐lymphocyte immunity** ● Antibodies develop several weeks later ● **Macrophages may confine fungus** (express disease later)

Answer 144

● **Most** cases produce **no symptoms or only mild symptoms** ● Acute‐Self‐limited lung infection (similar to influenza; the flu) ● Chronic‐Lung infection similar to tuberculosis ● Disseminated‐Extrapulmonary spread in immunocompromised (spreads from the lungs) **● Tongue, palate, buccal mucosa ● Solitary ulcer with firm rolled borders** ● **Clinically appear indistinguishable from malignancy (squamous cell carcinoma)**

Answer 145

● Histopathology (H&E and special stain‐GMS) ● Culture ● Serology as for histology ● **Epithelioid macrophages containing histoplasma capsulatum** (white arrows) ● Lymphocytes ● Plasma cells

Answer 146

**Histoplasmosis** ● This can be squamous cell carcinoma, shanker, ulcers ‐ Differentials for non healing ulcerations on the lateral tongue ● The white area is called the *pseudomembrane*

Answer 147

● **Acute**‐Supportive (analgesics and antipyretics) ● **Chronic**‐IV lipid preparation of amphotericin B or itraconazole ● **Disseminated**‐Lipid preparation of amphotericin B (2 weeks or more) followed by daily itraconazole for 6‐18 months

Answer 148

● _Uncommon_ **fungal infection** ● **Blastomyces dermatitidis** ● **Dimorphic**

Answer 149

● **Eastern half of US** which extends _farther north_ ● _Seen in the wild_

Answer 150

● Airborne spores enter lungs through inhalation ● **M**\>F

Answer 151

● **Acute**‐ Resembles pneumonia

Answer 152

Chronic Resembles **tuberculosis**

Answer 153

● Skin lesions‐extrapulmonary dissemination from lungs ● Oral lesions‐extrapulmonary dissemination or local inoculation ● Skin lesions ● Granular(rough looking) erythematous plaques which may become verrucous(wart‐like) or ulcerated ● Oral lesions ‐ Erythematous or white ‐ Intact surface or ulceration with rolled borders ‐ Painful ‐ Ddx‐Squamous cell carcinoma

Answer 154

**Blastomycosis**

Answer 155

● **Histopathology** (Granulomatous inflammation , Broad based budding , Double refractile cell wall) ● Cytology ● KOH ● Culture from sputum (3‐4 weeks) ● DNA probe (where you actively look for the DNA of the blastomycosis)

Answer 156

● Most cases **asymptomatic** ● **Itraconazole** (mild to moderate disease) ● **Systemic amphotericin B** (severe cases) ● There is a connection with people taking TNF‐alpha inhibitors

Answer 157

A deep fungal infecion causes by: Paracoccidioidomycosis brasiliensis

Answer 158

● South American blastomycosis

Answer 159

**nine‐ringed armadillos**

Answer 160

● More common in **males** ● _Agriculture workers_

Answer 161

Pulmonary infection

Answer 162

**Paracoccidio Mycosis** *looks like the three tail in **Naruto** lol*

Answer 163

●affects the Alveolar mucosa, gingiva and palate lesions with “Mulberry‐like” ulceration (little bumps around it) ● Looks like **strawberry gingivitis** (differential diagnosis)

Answer 164

**Paracoccidioidomycosis** looks like strawberry gingiva but it is not

Answer 165

● Histopathology (- Granulomatous inflammation, Epithelioid macrophages and multinucleated giant cells,GMS or PAS, Multiple daughter buds) ● Culture ● KOH

Answer 166

● **Trimethoprim/ sulfamethoxazole** (mild‐moderate) ● **IV Amphotericin B** (severe disease)

Answer 167

deep fungal infection that present as Pulmonary infection

Answer 168

**Valley Fever**

Answer 169

* Coccidioides immitis * Coccidioides posadasii

Answer 170

**Dimorphic organism** (spores and hyphae)

Answer 171

● Most cases are **asymptomatic** ~60% ● **Flulike** ● *Fatigue, cough, chest pain, myalgia, headache* ● May see a **hypersensitivity reaction** (_valley fever)_ ‐ When you are over responding; immune system is over reacting ● **Chronic**‐_mimics tuberculosis_ ● **Disseminated**‐ \<1% of cases

Answer 172

● Oral lesions **ulcerated granulomatous nodules** ● Skin lesions: **papules**(slightly raised), **abscesses**, **verrucous**(patchy), **plaques**, **granulomatous nodules**

Answer 173

**Coccidioidomycosis**

Answer 174

● Histopathology ( Round spherules with numerous endospores , Granulomatous inflammation, Suppurative neutrophils infiltrate, Special Stains used: GMS, PAS) ● Culture ● In situ hybridization (ISH) ● Cytology‐ scraping ulcers then stained with GMS ● Serology‐ check for antibodies ● Skin testing (limited value)

Answer 175

● **Mild symptoms**‐ no treatment usually ● **Amphotericin B** (‐ Immunosuppressed ‐ Severe pulmonary infection ‐ Disseminated disease ‐ Pregnant patients ‐ Life‐threatening situation ) ● **Itraconazole** or **fluconazole** (fewer side effects and complications)

Answer 176

●Uncommon ● Cryptococcus neoformans ● Incidence increased due to AIDS epidemic in 1990s ● Pulmonary infection ● Meningitis

Answer 177

pigeon excrement (poo)

Answer 178

● Pulmonary infection ● Meningitis ( after it spreads from the lungs to the brain. )

Answer 179

**Lung infection often asymptomatic** ● Flulike illness ● Dissemination *‐ Meninges ‐ Skin ‐ Bone ‐ Prostate ‐ Oral‐papillary/granular erythematous plaques*

Answer 180

● Biopsy ● Culture ● Serology Note: Histopathologically they appear as Granulomatous inflammation (epithelioid histiocytes trying to confide the infection) ● Yeast are surrounded by a clear halo (capsule)

Answer 181

● Mild case: ***Fluconazole or Itraconazole*** ● Cryptococcal meningitis: ***amphotericin B + other antifungals***

Answer 182

* **Infections** caused by **molds** belonging to the order **Mucorales** * _Grow in natural state on_ **decaying organic materials** (saprobic‐ recycling) * **Spores** may be _liberated into air and inhaled by humans_

Answer 183

‐ Insulin dependent diabetics ‐ Bone marrow transplant recipients ‐ AIDS ‐ Patients receiving systemic corticosteroids ‐ Neutropenic patients (no white blood cells)

Answer 184

● Rhinocerebral form ● Nasal obstruction ● Bloody nasal discharge ● Facial pain ● Facial paralysis ● Facial swelling/cellulitis ● Visual disturbances ● Into cranial vault‐blindness, lethargy, seizures ● Oral swelling/ulceration of the maxillary alveolar process/palate as a result of sinus involvement ● Black and necrotic ulcer (eschar) ● Massive tissue destruction

Answer 185

Mucormycosis‐ arrow refers to **ESCHAR**‐ always look for this and extreme-Black and necrotic ulcer ( we can see massive tissues destruction

Answer 186

Mucormycosis‐ CT Sinus opacificatio ● First thing to do is to find out more about this lesion, how did this patient get this lesion?

Answer 187

● Non‐septate hyphae with **90degrees branching** ● You see necrosis of tissue in the area because this attacks the blood vessels

Answer 188

● Histopathology ● Culture

Answer 189

● Surgical debridement (massive tissue destruction) ● High doses of lipid formation of amphotericin B ● Control underlying disease (main one) ● Prosthetic obturation of palatal defects

Answer 190

* Saprobic (in an environment rich of oxygen) * it caused by Aspergillus flavus and Aspergillus fumigatus

Answer 191

● Seen in **hospitals** and **construction sights** ●caused by _Aspergillus flavus_ and _Aspergillus fumigatus_ **● Spores** *are* **inhaled**

Answer 192

● **Noninvasive** ‐ Allergic fungal sinusitis ‐ Aspergilloma (fungus ball, mycetoma [‐oma: like a tumour made of aspergillus]) ● **Invasive** ‐ Localized (possibly after tissue damage in oral cavity) ‐ Disseminated ‐immunocompromised

Answer 193

**Aspergillosis** Histopathology includes: ●Branching septate hyphae ● Acute angle branching **● “Fruiting body**

Answer 194

● Histopathology ● Culture

Answer 195

***Aspergillosis*** arrow points toward a violaceous‐ purple colour

Answer 196

● Aspergilloma‐**debridement** ● Allergic fungal sinusitis‐**debridement and corticosteroid drugs** ● Localized invasive‐**debridement & voriconazole and amphotericin B** ● Disseminated invasive‐**consider poor prognosis even with treatment**

Answer 197

Caries (streptococcus mutans) ‐ Gingivitis/Periodontitis ‐ Necrotizing Periodontal Diseases ‐ Noma (Cancrum Oris) Impetigo ‐ Erysipelas ‐ Streptococcal Tonsillitis and Pharyngitis Scarlet Fever ‐ Diphtheria ‐ Syphilis ‐ Gonorrhea ‐ Tuberculosis Leprosy Actinomycosis ‐ Cat Scratch Disease ‐ Bacillary Angioma

Answer 198

Bacterial infection which presents with a spectrum of lesions ‐ Vary depending upon the localization of lesion and predisposing factors

Answer 199

‐ Includes: **o Necrotizing gingivitis (NG):**rapidly destructive, non-communicable microbial disease of the gingiva **o Necrotizing periodontitis (NP)**:apidly progressing disease process that results in the destruction of the periodontium o **Necrotizing stomatitis (NS):**When the bacterial infection extends further to OTHER parts of the mouth o **NOMA** (extension to skin of face) ▪ Extreme disfigurement due to bacterial infection extending onto the skin of the face

Answer 200

‐ The term "**acute**" has not been included since 1999 (ANUG=old name) o As the infections are ALWAYS acute ‐ The term "**ulcerative**" removed in 2017 World Workshop proposed classification "Necrotizing Periodontal Disease (NPD)" is term proposed in 2017 World Workshop for NG, NP and NS o There is ALWAYS ulceration as a result of necrosis

Answer 201

‐ **Ulceration with necrosis of interdental papillae** o Results in a **"punched out" crater‐like appearance of the papilla** **‐ Gray pseudomembrane** o Dead tissue **‐ EXTREMELY Painful** **‐ Fetid odor** _‐ Spontaneous hemorrhage Fever, lymphadenopathy, malaise_

Answer 202

**Young and middle‐aged adults** Prevalence \<0.1%

Answer 203

**Necrotizing Gingivitis (NG)** o No periodontitis features o SIMILAR APPEARANCE to *_gonorrhea_* ▪ Distinguishing characteristic of NG **– Fetid Odor**

Answer 204

**Necrotizing Periodontitis (NP)** o Bone loss of the periodontium seen

Answer 205

Many related factors (Multifactorial etiology): o Psychological stress o Immunosuppression o Smoking o Local trauma o Poor nutritional status o Poor oral hygiene o Inadequate sleep

Answer 206

**Necrotizing Periodontal Diseases** o During WW1, soldiers that were fighting in the trenches were under extreme stress o they commonly developed necrotizing periodontal diseases

Answer 207

**o Treponema spp.** **o Selenomonas spp.** **o Fusobacterium spp.** **o Prevotella intermedia** o \*Also always present in healthy gingiva ▪ so, No, Microbiological testing is NOT used to form a diagnosis

Answer 208

**o Removal of bacteria (scaling)** **o Chlorhexidine rinse** **o Antibiotics (fever or signs of systemic illness)** ▪ Metronidazole ▪ Penicillin **o Oral hygiene instruction** **o Supportive therapy** ▪ Rest ▪ Fluids ▪ Soft nutritious diet **o Predisposing (Immunosuppressive)factors** ▪ Smoking ▪ HIV?

Answer 209

**cancrum oris**

Answer 210

‐ **Rapidly progressive opportunistic infection caused by many bacteria** o More commonly seen in other parts of the world o Seen in the US in immunocompromised patients ▪ HIV ‐ WHO estimates the global yearly incidence = 140,000

Answer 211

**‐ Polymicrobial etiology** ‐ Normal flora become pathogenic during immunocompromised states ***‐ Key bacteria:*** o **Fusobacterium necrophorum** **o Prevotella intermedium** ‐ Other common bacteria: **o Actinomyces pyogenes** o Bacillus cereus o Bacteroides fragilis o Fusobacterium nucleatum o Prevotella melaninogenica

Answer 212

‐ Previous necrotizing periodontal disease Poverty ‐ Malnutrition or dehydration ‐ Poor oral hygiene ‐ Poor sanitation ‐ Unsafe drinking water ‐ Proximity to unkempt livestock ‐ Recent illness Malignancy ‐ Immunodeficiency disorder, including AIDS

Answer 213

**NOMA** This is an aid patient Figure 2: Extension of infection onto the face ‐ Figure 3: Lost bone and gingiva ‐ Figure 4 & 5 Bone destruction

Answer 214

Children Adults with debilitating disease

Answer 215

Gingiva (NG) ► Adjacent tissue (necrotizing stomatitis) + Non‐ contiguous tissue (trauma) ► Blue black discoloration of skin ‐ Spreads through muscle, bone (osteomyelitis) **‐ Other features:** _o Fetid odor_ ▪ Due to tissue necrosis _o Pain o Fever o Malaise_ o Tachycardia o Increased respiratory rate o Anemia o Leukocytosis o Regional lymphadenopat

Answer 216

NOMA Development of NOMA from day 1 to day 15

Answer 217

o **Antibiotics** ▪ Penicillin ▪ Metronidazole **o Local wound care** _▪ Conservative debridement_ to avoid iatrogenic tissue damage **o Consider nutrition, hydration and electrolyte imbalances** **o May cause significant morbidity**

Answer 218

**Impetigo** ‐ “Cornflakes glued to Surface" Appearance o Little papules that can form little vesicles around the mouth o Vesicles burst open and dry up around the skin of the mouth ‐ Bilateral

Answer 219

‐ Caused by: o Staphylococcus aureus o Streptococcal pyogenes _Damaged skin allows infection to enter_ **Usually affects kids**

Answer 220

**o Recurrent Herpes Labialis** ▪ Resemblance to initial impetigo stages when still unilateral **o Perioral Dermatitis** ▪ Triggered by cosmetics and other substances on the skin **o Exfoliative Cheilitis (chapped lips)**

Answer 221

Diagnosis: o Presumptive from clinical features _‐ Treatment:_ **o Topical mupirocin** **o Systemic antibiotics**

Answer 222

**Erysipelas** Superficial skin infection in immunosuppressed adults ‐ Group A beta‐hemolytic streptococci ‐ Painful ‐ Bright‐red, well‐circumscribed, swollen, indurated (firm) ‐ Warm to touch ‐ Systemic manifestations: o High fever o Swollen lymph nodes Diagnosis: Cultures not useful ‐ Treatment: **o Penicillin ‐ Complications without treatment**

Answer 223

**o Systemic Lupus Erythematosus (SLE)** ▪ Due to sparing of nasolabial folds ▪ Butterfly rash in SLE resembles erysipelas **o Cellulitis (dental infection induced):** ▪ Tooth infection burrowing through the tissues rather than forming an abscess **o Actinomycosis**

Answer 224

* Chronic infection * caused by *_spirochete_* **Treponema pallidum**

Answer 225

Three stages 1. o Primary (**chancre**) 2. o Secondary (**rash**) 3. o Tertiary (**gumma**)

Answer 226

_Primary Syphilis_ **Chancre** at site of inoculation (3 – 90 days later) ‐ Papule ► Ulceration ‐ Most chancres occur in genital area (4% oral

Answer 227

**Primary Syphilis** _Chancre_ at site of inoculation (3 – 90 days later) ‐ Papule ► Ulceration ‐ Most chancres occur in genital area (4% oral

Answer 228

1. **SCC** 2. **Fungal Ulcer** 3. **Trumatic Ulcer**

Answer 229

Secondary Syphilis ‐ Disseminated lesions are discovered 4 ‐ 10 weeks after initial infection ‐ Resolve in 3‐12 weeks **‐ Diffuse maculopapular (flat, raised) rash** o May involve oral cavity ‐ **Mucous patches** **o Most common on tongue and lip** _‐ Condylomata lata_ o **Resembles viral papillomas** ‐ Systemic symptoms

Answer 230

Secondary Syphilis ( Rash) here we see **muscus patches** (right) and **Condylomata lata** (left) ‐ Disseminated lesions are discovered 4 ‐ 10 weeks after initial infection ‐ Resolve in 3‐12 weeks ‐ Diffuse maculopapular (flat, raised) rash **o May involve oral cavity ‐ Mucous patches** **o Most common on tongue and lip** **‐ Condylomata lata** **o Resembles viral papillomas** ‐ Systemic symptoms

Answer 231

**Tertiary Syphilis** **Gumma** ‐ **Latent** period for **1 ‐ 30 years** **‐ 30% of patients develop tertiary syphilis** ‐ Serious complications develop: * Vascular system * Central nervous system * Ocular lesions What is "Gumma"? * o Granulomatous inflammation with tissue destruction * o Common on palate and tongue * o Causes a hole in the palate

Answer 232

Differential Diagnosis: 1. ▪ T‐cell Lymphoma 2. ▪ Cocaine abuse 3. ▪ Granulomatosis 4. ▪ Polyangiitis 5. ▪ Mucor

Answer 233

‐ Pathognomonic features in **Hutchinson triad**: **o 1. Hutchinson teeth** **o 2. Ocular interstitial keratitis** **o 3. Eighth nerve deafness** ‐ Other Features: o High arched palate o Saddle nose o Frontal bossing **Clinical changes secondary to fetal infection**

Answer 234

**Congenital Syphilis** ‐ Hutchinson Incisors (left image) ‐ Mulberry molars (right image) - not part of the triad

Answer 235

Not specific ‐ Stage 1 and 2 similar o Ulceration o Hyperplasia (Stage 2) o Exocytosis of neutrophils into epithelium Intense Iymphoplasmacytic inflammatory infiltrate in superficial stroma and around deeper vascular channels (blood vessels)

Answer 236

Stage 3 o Granulomatous inflammation o Ulceration may be present ‐ Special stain "**Warthin Starry"**, highlights _**corkscrew spirochetes** ‐_ **Immunohistochemical stain**

Answer 237

**o Biopsy with histopathology** **o Dark field examination of a smear of active lesion** o Serologic screening lab tests * ▪ Venereal Disease Research Lab (VDRL), RPR (non‐ specific and not highly sensitive) * ▪ Fluorescent Treponemal Antibody Absorption (FTA‐ ABS), TPHA, TPPA, MHA‐TP (specific and sensitive)

Answer 238

_o Single dose of parenteral long_‐ acting **benzathine penicillin G** (primary, secondary, early latent) o **Intramuscular penicillin** weekly for three weeks (late latent and tertiary

Answer 239

**Secondary Syphilis** Mucous Patch

Answer 240

‐ a Sexually transmitted (F\>M) caused by **‐ Neisseria gonorrhoeae**

Answer 241

‐ Genital area usually‐**purulent discharge** ‐ **Systemic bacteremia** (myalgia, arthralgia, polyarthritis, dermatitis) ‐ **Pelvic inflammatory disease** in women (affects pregnancies) ‐ **Gonococcal ophthalmia neonatorum** (infection of infant's eyes)

Answer 242

‐ Oral lesions ‐ **similar to aphthous** o Very rare _‐ Tonsils edematous and erythematous_ ‐ May **simulate necrotizing gingivitis (NG)** but _fetor oris not present_

Answer 243

**Gonorrhea** looks like necrotizing gingivitis (NG) but fetor oris not present

Answer 244

**‐ Gram stain** **‐ Culture of** _endocervical swab_ ‐ **Nucleic acid amplification tests** (NAATs)‐_detect DNA, RNA_

Answer 245

Many cases of resistance with antibiotics §Cephalosporins *Adults with gonorrhea are treated with antibiotics. Due to emerging strains of drug-resistant Neisseria gonorrhoeae, the Centers for Disease Control and Prevention recommends that uncomplicated gonorrhea be treated with the antibiotic ceftriaxone* — given as an injection — with oral azithromycin (Zithromax)

Answer 246

**Chlamydia trachomatis**

Answer 247

**Reactive arthritis (reiter)** _o Can’t see, Can’t Pee, Can’t Climb a Tree_ ▪ _Causes_: **● Conjunctivitis ● Urethritis ● Arthritis** **Remember: Chlamydia trachomatis** coininfect with Neisseria **gonorrhoeae**

Answer 248

- _Chronic granulomatous infectious disease_ - Caused by **Mycobacterium tuberculosis** §Direct person-to-person spread through **airborne droplets**

Answer 249

_affects previously unexposed, lungs - They breathe in the organisms that someone is coughing out_ 1st: C_hronic inflammatory reaction_ ► Next, **a fibrocalcific nodule** (_Ghon focus)_ forms at initial site of infection

Answer 250

Only **5%-10%** infections lead to active disease i

Answer 251

* Leads to **disseminated TB** (miliary TB) * True, active TB

Answer 252

‐ Tuberculosis

Answer 253

‐ Tuberculosis

Answer 254

* Immunosuppressive medications * Diabetes * Old age * Crowded living conditions * AIDS

Answer 255

Usually asymptomatic

Answer 256

o Typically see lung lesions (productive cough) o _Fever, malaise, anorexia, night sweats_

Answer 257

* Lymphatics * Skin * Skeletal system * CNS * Kidney * GI tract * **Oral cavity (uncommon)**

Answer 258

§Ulceration (tongue ulceration most common) §Mucosal granularity §Diffuse inflammation §Non-healing extraction socket

Answer 259

**Miliary TB** compared to miliary seeds

Answer 260

TB Ulceration (tongue ulceration most common)

Answer 261

**Primary Oral TB** tongue ulceration

Answer 262

Primary Oral TB Oral Primary TB clinical manifestation is very rare TB is directly in the **_epithelial cells._** Person coughs ⇒ organism enters broken skin somewhere in the oral mucosa ⇒directly causing TB in the mouth -this person would NOT have any issues in their lungs **-**primary TB = infection went directly into their mucosa from another person

Answer 263

**o TB o Deep fungal infections o Traumatic ulcer o SCC o Major Aphthous ulcer**

Answer 264

**Granulomas** * o Epithelioid histiocytes * o Multinucleated giant cells * ▪ \* Langhans giant cells * ● Nuclei along the periphery * o Central caseous necrosis

Answer 265

Special stain Epithelioid o Ziehl‐Neelson or AFB o Consider scarcity of organisms **o MAY NOT VISUALIZE ORGANISMS WITH STAIN** **_▪ NEGATIVE RESULT DOES NOT RULE OUT TB INFECTION_**

Answer 266

**§Multiagent therapy for active infection to prevent mutation and resistance** §8 week course §Pyrazinamide §Isoniazid §Rifampin §Ethambutol **§Followed by 16 week course** §Isoniazid §Rifampin **‐ Chemoprophylaxis** ‐ For positive PPD but no active infection **‐ BCG vaccine** o Not used in US due to controversy regarding effectiveness

Answer 267

o TB‐Test **§Delayed type hypersensitivity (Type 4)** §Checks if developed an immune response to TB §**PPD (purified protein derivative)** *(what they inject under the skin)* §**T cells** are attracted by immune system to the skin site §**Lymphokines** induce _hard raised area with clear margins_ §Need to check 48-72 hours later (measure area)

Answer 268

**Mycobacterium bovis** **Infected milk** leads to **scrofula** **RARE** today _as milk is pasteurized_

Answer 269

o Enlargement of oropharyngeal lymphoid tissues and cervical nodes o Significant caseous necrosis may occur and cause sinus tracts to skin

Answer 270

**Scrofula**

Answer 271

**Hansen disease**

Answer 272

**Mycobacterium leprae**

Answer 273

**1. Tuberculoid leprosy** ▪ High immune reaction ▪ Oral manifestations are **RARE** **2. Lepromatous leprosy** ▪ Reduced cell‐mediated response

Answer 274

**EXTREMELY RARE** o 80% of cases occur in: ▪ Brazil ▪ India ▪ Indonesia ▪ Madagascar ▪ Myanmar ▪ Nepal ▪ Nigeria

Answer 275

Clinical features: **o Leonine facies** ▪ Appearance of a lion **● Loss of eyebrows** ● **Scarring (fibrosis)** from infection prevents hair growth o **\* Oral Manifestations seen in areas of mouth with lower** temperatures: ▪ Hard/soft palate ▪ Maxillary gingiva ▪ Tongue ## Footnote **Oral‐enlarging papules ► ulcer ► necrosis**

Answer 276

**LEPROSY** _Clinical features_ * *§Bone destruction** ( hole in the palate) * *§Nodular** will become **nectortic** and then **destruction** will follow

Answer 277

**Diagnosis:** o Clinical presentation o Acid fast stain Histopahology No well‐formed granulomas o Lepromatous leprosy diffuse presentation

Answer 278

§Rifampicin, clofazimine, dapsone

Answer 279

‐ Infection caused by filamentous branching gram positive anaerobic bacteria ‐ Normal component of oral flora

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‐ Associated Bacteria: **o Actinomyces israelii o Actinomyces viscosus** ‐ Normal component of oral flora -gram positive anaerobic bacteria

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can be Acute or chronic ‐ **Hard indurated swelling** o Result of injury / trauma ▪ Tooth extraction o Erythematous o Formation of **external sinus** ▪ Drains into the skin **‐ "Sulfur granules"** o May be present in suppuration o Indurated area of fibrosis

Answer 282

**‐ 55% in cervicofacial area** ‐ Hard indurated swelling o Result of injury / trauma/tooth extraction o Erythematous **‐ Area overlying angle of mandible** o Formation of external sinus ▪ Drains into the skin ‐ Other locations include: **o Abdomen o Pelvis o Lungs**

Answer 283

**Actinomycoses** it's an external Sinus

Answer 284

‐ **Enters tissue through an area of prior trauma** o Soft tissue injury o Periodontal pocket o Non‐vital tooth o Extraction socket o Infected tonsil ‐ **Direct extension through soft tissue to the surface**

Answer 285

colonies of bacteria (o Actinomyces israelii o Actinomyces viscosus) found in suppuration (pus) which means Suppuration (pus) is dead tissue, bacteria, dead white blood cells, and other products of tissue breakdown.. Sulfur granules found in Actinomycoses yellow in color

Answer 286

o Erysipelas

Answer 287

‐ Tongue ‐ Tonsillar crypts ‐ Salivary gland involvement ‐ Osteomyelitis ‐ Periapical inflammatory lesions

Answer 288

‐ Colony of actinomycotic organisms surrounded by neutrophils ‐ Grocott‐Gomori methenamine silver stain (GMS) In this histo slide, we see: \* Sulfur Granule o 1. Collection of actinomycoses israelii organisms o 2. MANY neutrophils surround the periphery o BOTH are requirements for a TRUE diagnosis of actinomycoses

Answer 289

* **Culture** * o \< 50% of cases are positive * ▪ Due to various types of bacteria in the culture * **Presumptive diagnosis from biopsy** **in this histology: GMS stain was used** o Correlates with top H&E histopathology o Filamentous branches are the actinomycotic organisms

Answer 290

* \* **Prolonged high dose antibiotics for _cervicofacial actinomycosis_** * Due to the fibrosis that occurs * Early cases 5‐6 weeks * Deep‐seated infections up to 12 months * **Abscess drainage** * **Sinus tract excision** * **Penicillin**

Answer 291

‐ Infectious disease which is seen in _lymph nodes_

Answer 292

‐ Causative organism: o Bartonella henselae ‐ Previous contact with a cat (scratch or saliva)

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‐ 80% in patients **_younger than 21_**

Answer 294

Cat Scratch Disease

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‐ Initial **scratch** ‐ **Papule** at _inoculation site_ (3‐14 days later) **‐ Papule ► erythematous ► vesicular ►crusted** ‐ **Healing** (1‐3 weeks) ‐ **Lymph node enlargement** with _fever and malaise_

Answer 296

**‐ o Swellings in the lymph node** **o Unilateral swellings of the neck**

Answer 297

‐ **Clinical features:** o Presence of a cat ▪ Presumptive diagnosis can be made ‐ Serology (antibody detection) ‐ Histopathology (biopsy) (Stellate suppurative necrosis surrounded by a band of histiocytes and neutrophils) and the use of Immunohistochemistry and Warthin‐Starry silver stain to identify the organism Left o Histiocytes on the periphery o Stellate necrosis in the center ‐ Middle Immunohistochemistry o Antibodies allow for visualization of Bartonella henselae (red little dots) ‐ Right : Warthin‐Starry silver stain o Silver stain allows for visualization of Bartonella henselae (black areas)

Answer 298

o **Self‐limiting (resolves within 4 months)** o Local heat o Analgesics o Mechanical removal of suppuration (aspiration) o May use antibiotics for severe cases ▪ Azithromycin

Answer 299

Cat‐Scratch Disease

Infectious diseaes Kumar Flashcards

(326 cards)