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Oral Disease for FINALS > Oral infections: viral and fungal > Flashcards

Oral infections: viral and fungal Flashcards

1
Q

Viral infections of oral importance (4)

A 
Herpes viruses
– Simplex	1	and	2	
– Varicella	zoster	
– Cytomegalovirus	
– Epstein	Barr	
Coxsackie viruses
(Measles)
Human papilloma virus
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2
Q

What is herpes simplex? (5)

A 
• Enveloped, DNA virus, highly cytolytic,
infects via heparan sulphate
• Type 1 associated with skin and oral
mucous membranes
• Type 2 associated with genital mucosa
• Transmitted by droplet spread or intimate
contact
• 90-100% individuals have antibodies to
herpes simplex
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3
Q

Herpes simplex type 1 - virus (4)

A

• Virus enters trigeminal sensory neurones
• Migrates to the ganglion by retrograde axonal flow
• Latency
- 50% of cases lies dormant

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4
Q

Herpes simplex type 1 - reactivation (4)

A 
In 30% of cases virus is reactivated
Migrates to peripheral nerve endings
Virus is shed
Reactivation can be caused by
•UV
•Stress
• Illness
•Immunosuppression
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5
Q

Herpes simplex - primary gingivostomatitis - natural history (4)

A 
– Children, young adults
– Incubation period 5 days
– Heal within	10-14 days	
– Many cases	are	subclinical and so	
asymptomatic
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6
Q

Herpes simplex - primary gingivostomatitis - signs and symptoms (5)

A 
– Malaise and fever
– Vesicles which ulcerate
– Secondary infection
– Erythematous gingivitis
– Extra-oral lesions
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7
Q

Diagnosis of herpes simplex - primary gingivostomatitis (2)

A
  • Made on clinical features

* Patients have a rising antibody titre to herpes simplex.

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8
Q

Pathogenesis of herpes simplex - primary gingivostomatitis (3)

A

– Herpes virus replicates in epithelial cells
– causes epithelial cell destruction and
“ballooning” degeneration of cells
– Results in intra-epithelial vesicles

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9
Q

Clinical features of herpes labialis (5)

A 
– "Cold sore"
– Prodromal tingling	
– Vesicles at the muco-cutaneous junction	
– Ulcerate and crust over	
– Lasts 7-10	days
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10
Q

How common is herpes labialis (1)

A

Occurs in 30% of patients

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11
Q

Main difficulty in diagnosing herpes labialis (1)

A

Differentiating erythema multiforme

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12
Q

Treatment for herpes labialis (3)

A

Effective in prodromal stage
Aciclovir cream (Zovirax)
Penciclovir

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13
Q

What is herpes (varicella) zoster virus (4)

A

Type 3 herpes virus
Primary infection - chicken pox
Secondary lesion - shingles
Most commonly affects one of the divisions of the trigeminal nucleus

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14
Q

3 phases of herpes zoster (3)

A

Pre-herpetic neuralgia
-pain in the affected division; may mimic dental pain
Rash
-unilateral vesicles; ophthalmic, maxillary, mandibular
-ulcers (mucosa); crusting lesions (skin)
-lasts 2-3 weeks
Post-herpetic neuralgia
-burning pain, affects 10-20%
-more common in the elderly

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15
Q

Management of herpes zoster (4)

A 
Aciclovir 800mg 5x daily, 7 days
– Valaciclovir	1g	3x	daily,	7	days	
– Famciclovir	250mg	3x	daily,	7	days	
Analgesics and other supportive measures
Referral to Ophthalmology if eye involved
Post-herpetic neuralgia
– Treat	pain	with	neuropathic	pain	drugs	
– Gabapentin,	antidepressants
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16
Q

What is Epstein-Barr virus? (5)

A 
HV4
Infectious mononucleosis
-tonsils
-petechiae on soft palate
-cervical lymphadenopathy
Burkitt's lymphoma
Nasopharyngeal carcinoma
Hairy leukoplakia
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17
Q

Oral hairy leukoplakia (4)

A

Corrugated white patches
Bilateral on lateral borders of tongue
Seen in 25% of HIV infected patients
Can occur in non-HIV patients

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18
Q

Diagnosis of oral hairy leukoplakia (1)

A

Demonstration of EBV in tissues

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19
Q

Pathogenesis of cytomegalovirus (HV5) (2)

A

Inclusion bodies

Dormant in lymphocytes - interferences with MHC1 presentation

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20
Q

Rare appearances of HV5 (2)

A

Glandular fever-like illness (no lymphadenopathy)

Salivary gland swelling

21
Q

HV5 in immunocompromised (3)

A

Large ragged oral mucosal ulcers
Salivary gland swelling
Retinitis

22
Q

HV5 in new born (1)

A

Life threatening

23
Q

Cocksackie A viruses - which cause the most problems? (4)

A

Types 4, 5, 10, 16

24
Q

Cocksackie A viruses - herpangina (6)

A 
– CVA4	(occ.	Others)	
– Usually trivial; mild	febrile illness
– Young	children	and	young adults	
– Vesicles and ulcers	on	soft	palate	
– Lasts	a	few	days	
– Usually no	treatment	
• analgesic mouthwash		
• e.g Difflam
25
Q

Cocksackie A viruses - hand, foot and mouth disease (4)

A 
– CV	A16	
– Similar	to	herpangina;	
mild	systemic	upset	
– Rash/vesicles	on	palms of	hands	and	soles	of feet	
– Intra-oral vesicles	and	
ulcers
26
Q

Measles - what is it and features (5)

A 
Paramyxovirus infection
Systemically unwell
Koplik’s spots
– White	papules	on	
buccal	and	palatal	
mucosa	during	
prodromal	phase	
Skin rash
Long term effects
27
Q

HPV - types (4)

A 
> 40 types
DNA virus - just 9 genes
Only infects keratinocytes 
-basal cells - integrins
"High risk" oncogenic subtypes
-HPV 16 & 18
-cervica, oropharynx and anal cancer
28
Q

HPV - main oral lesions include (4)

A

Squamous cell papilloma/ verruca vulgaris
Condyloma accuminatum
Focal epithelial hyperplasia
• HPV13
• Common in small native communities and HIV infection
• Treatment – excision, imiquimod 5% cream
Dysplasia/SCC - controversial

29
Q

Fungal infections (7)

A
  • Aspergillosis
  • Blastomycosis
  • Candidosis
  • Coccidioidomycosis
  • Cryptococcosis
  • Histoplasmosis
  • Rhinosporidiosis
30
Q

Candida species (5)

A
  • C.albicans - most common
  • C.tropicalis
  • C.krusei
  • C.glabrata
  • C.dubliniensis
31
Q

Predisposing factors to candida (4)

A

Prostheses - no exfoliation
Low saliva
Antibiotics - reduced bacterial competition
Immuno-suppresion

32
Q

Predisposing factors to candida - low saliva (3)

A

No flow; reduces soluble defences

Low pH induced by high sugar diet

33
Q

Predisposing factors to candida - Immuno-suppresion (6)

A 
– Very	young/old	
– Diabetes	
– Corticosteroids,	including	steroid	inhalers	
– Malignancy	
– HIV	
– Immunosuppressive	therapy
34
Q

Pathogenic/ virulence factors (3)

A

Tissue invasion and pathogenesis
Yeast to hyphal transition and growth is essential for virulence and pathogenesis
Hyphae secrete candidalysin - a pore forming toxin that kills human cells and also initiates an immune response
Proteases - Secreted Aspartyl Proteases (SAP) used to invade between/ through epithelial cells
-sap 1-3 - needed for mucosal infection
-sap 1-3 - degrade complement
-sap 4-6 - contribute to systemic infection

35
Q

Classification of candida infections (4)

A

Acute forms
Chronic forms
Candida-associated lesions
HIV-related candidosis

36
Q

Acute forms of candida (2)

A

– Acute pseudomembranous candidosis (Thrush)

– Acute atrophic candidosis (antibiotic sore mouth)

37
Q

Chronic forms of candida (3)

A

– Chronic atrophic candidosis (denture stomatitis)
– Chronic hyperplastic candidosis (candidal leukoplakia)
– Chronic mucocutaneous candidosis (various: inherited syndromes)

38
Q

Candida-associated lesions (2)

A

– Median rhomboid glossitis

– Angular cheilitis

39
Q

Acute pseudomembranous candidosis (2)

A

Creamy thick white plaques
-thick biofilm of yeast and hyphal forms
Easily rubbed off

40
Q

Causes of acute atrophic candidosis (2)

A

– Prolonged corticosteroid or
antibiotic therapy
– Bacterial flora altered, allows candida to flourish

41
Q

Treatment of acute atrophic candidosis (1)

A

Reduce antibiotic use if possible

42
Q

Management of acute atrophic candidosis (3)

A 
Confirm diagnosis
– Swab(s)	or	oral	rinse	+/-	MC+S	
Investigate and treat underlying cause
Treat with anti-fungal agents
– Topical		
• Miconazole	oral	gel	
• Nystatin	suspension	
• Amphotericin	B	(only	available	in	hospital	pharmacies)	
– Systemic	
• Fluconazole	
• Itraconazole
43
Q

Denture related candidosis (3)

A 
Palate protected from saliva
Poor denture hygiene
Treatment
– Improve	denture	hygiene	
• Leave	out	at	night	
• Clean	denture	and	soak	in	Milton	
or	Corsodyl
– Antifungals	
• Nystatin	+/-	Miconazole	gel	to	
fitting	surface	tds
• 2-3	weeks
44
Q

Median rhomboid glossitis (5)

A 
• Erythematous area on
dorsum tongue
• Epithelial proliferation
• Candida in epithelium
• Not premalignant
• Diagnosis usually on
clinical grounds
45
Q

Angular cheilitis (3)

A 
• Reduced vertical
dimension
– drooling	of	saliva	
• Haematological
deficiency
– Iron,	B12,	folate	deficiency	
– Crohn’s	disease	
• Some cases associated
with Staph. aureus
46
Q

Treatment of angular cheilitis (2)

A

– Address underlying cause

– miconazole cream or fusidic acid, depending on cause

47
Q

Chronic hyperplastic candidosis (5)

A 
• White or red/white
patch, nodular
• Can’t be rubbed off
• Labial commissures
or tongue
• Premalignant:
– “Candida	leukoplakia”	
– up	to	25%	risk	of	
malignant	change.	
• Diagnosis by biopsy
48
Q

Aetiology of chronic hyperplastic candidosis (4)

A 
– Usual	candida	risk	factors	
– Smoking	
– Not	clear	if	candida	cause the lesion	or	invade	a	preexisting	lesion.	
– Some	lesions	regress	
following	antifungal therapy
49
Q

Management of hyperplastic candidosis (3)

A

• Diagnosis
– Biopsy will establish diagnosis
– Assess degree of dysplasia and risk of malignant
transformation
• Treatment
– Systemic antifungals
• 7-14 days fluconazole or amphotericin B
– Smoking cessation
• If no improvement and high risk of malignant
transformation then excise

Oral Disease for FINALS (34 decks)

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