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orofacial fungal infections Flashcards

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1
Q

what % of healthy individuals is candida species found in?

A

35-55%

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2
Q

what other fungi species can be found in healthy individuals that rarely cause disease?

A

saccharomyces
geotrichum
cryptococcus

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3
Q

are candida harmless?

A

usually harmless but under certain conditions may switch to pathogenic form and cause disease

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4
Q

name some e.g of candida species

A

C albicans (most common/principal)
C glabrata
C tropicalis
C kefyr
C krusei
(all pathogenic)

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5
Q

name some e.g of other rare fungal species

A

Aspergillus spp
Cryptococcus spp
Geotrichum spp
Saccharomyces spp

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6
Q

when does candida cause problems ?

A

when it overgrows due to e.g dry mouth, antibiotics, immunosuppressed pts

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7
Q

what word describes candida existing in diff shapes/morphology

A

pleomorphic

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8
Q

what’s the main form of C albicans?

A

ovoid

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9
Q

what filamentous forms does C albicans change to due to environmental changes?

A

hyphae
pseudohyphae (elongated, not true hyphae)

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10
Q

name e.g of environmental changes that cause a morphological change in C albicans

A

decrease in pH
increase in temp
increase in CO2
increase in nutrients e.g glucose

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11
Q

what are ovoid cells well suited to do in immunosuppressed pts?

A

haematogenous spread

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12
Q

what are hyphal cells adapted to do and how?

A

invasion, colonisation and avoiding macrophages
due to elongated form

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13
Q

what is tongue coating caused by and how is it managed?

A

-build up of food + bacteria deposits in filiform papillae on dorsum of tongue
-manage by increasing fluid intake & roughage in diet + gentle tongue brushing

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14
Q

where is candida mainly found?

A

dorsum of tongue

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15
Q

in who does candida increase?

A

pregnant women
smokers
poorly controlled diabetics
denture wearers

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16
Q

list general predisposing factors of pathogenic C albicans

A

broad spectrum antibiotics
corticosteroids
cytotoxics (chemo)
poorly controlled diabetes
xerostomia
nutritional deficiencies
immunosuppression

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17
Q

list local predisposing factors of pathogenic C albicans

A

trauma e.g ill fitted dentures
tobacco smoking
reduced salivary flow
carb rich diet

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18
Q

how do broad spectrum antibiotics affect candida levels

A

cause change in oral microflora which control candida levels by competing for dietary substrates and epithelial cell adhesion

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19
Q

how do xerogenic agents affect candida levels

A

cause reduction in salivary flushing and antifungal salivary components

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20
Q

why is oral candidosis sometimes the first presentation of immunodeficiency?

A

bc cell mediated immunity & humoral immunity are important in prevention + elimination of fungal infections

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21
Q

what is a predisposing haematological factor of candidosis & how?

A

blood type o -> increased H antigen which is a receptor for C albicans

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22
Q

what is a predisposing dietary factor of candidosis & how?

A

-malnutrition/deficiencies (iron, vit b12, c) -> reduced host defences + mucosal integrity allowing hyphal invasion and infection
-CHO rich diet -> can increase adherence of candida to epithelilal cells

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23
Q

is candidosis usually a local or systemic infection?

A

local

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24
Q

symptoms of oral candidosis

A

altered taste
oral dryness
dysphagia (if oesophageal infection occurs)

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25
what are the acute forms of candidosis
pseudomembranous ('thrush") erythematous/atrophic
26
what are the chronic forms of candidosis
chronic hyperplastic candidosis (CHC) erythematous (denture stomatitis)
27
what are the secondary forms of candidosis
median rhomboid glossitis angular cheilitis chronic mucocutaneous candidosis
28
clinical features of thrush (pseudomembranous candidosis)
detachable creamy-white/yellowish patches on oral mucosal surfaces wipes off & has erythematous base asymptomatic lesions
29
who is thrush classically found in?
immunocompromised (HIV, extremes of age, DM)
30
what is thrush frequently associated with?
angular cheilitis oesophageal candidosis (in HIV)
31
management of thrush
improve OH smoking cessation investigate & treat systemic issues (e.g immunosuppression, DM, anaemia) live active yogurt topical agents -> chlorhexidine m/w, anti-fungal agents (nystatin, miconazole gel)
32
clinical features of erythematous candidosis
painful erythematous patches commonly on dorsum of tongue & palate associated with chronic use of broad spectrum antibiotics ('antibiotic sore mouth') & corticosteroids found in HIV
33
clinical features of CHC (chronic hyperplastic candidosis)
white/erythematous raised lesions that don't rub off usually on buccal mucosa bilaterally towards commissures may have associated angular cheilitis may be nodular/speckled -> more prone to malignancy OR white plaque like generally asymptomatic
34
who is CHC most commonly found in
middle-aged male smokers
35
what is CHC a form of
chronic hyperkeratosis (in which candida is identified)
36
management of CHC
biopsy to recognise if premalignant check iron/folate/vit b12 levels remove predisposing factors (smoking, controlled DM) systemic anti-fungals (oral fluconazole 2-4+ weeks)
37
clinical features of chronic erythematous candidosis ( denture stomatitis)
marked erythema of palatal mucosa with sharply defined margins if relief area present, may result in underlying spongy granular change asymptomatic (except angular cheilitis) rarely involves lower arch
38
cause of denture stomatitis
denture fit excludes saliva from supporting mucosa allowing candida to overgrow inadequate OH/ denture hygiene poorly fit dentures affects 65%
39
describe newtons classification
type 1 - pinpoint hyperaemia (red spots) type 2 - diffuse erythema limited to denture fit surface type 3 - nodular appearance of palatal mucosa
40
management of denture stomatitis
improve denture hygiene eliminate tissue trauma (tissue conditioners) miconazole gel applied to denture fit surface (caution as absorbed systemically & can interact with drugs e.g warfarin) if lack of resolution consider systemic issues
41
clinical features of angular cheilitis
symmetrical erythematous fissuring in commissures decreased vertical dimension with maceration of underlying skin (assoc with saliva pooling)
42
predisposing aetiological factors in angular cheilitis
lip morphology reduced haematinic levels (B12, iron) malabsorption disorders e.g chrons immunosuppression DM broad spectrum antibiotics xerostomia
43
management of angular cheilitis
correct predisposing factors correct vertical dimension improve OH and denture hygiene treat intraoral candida with topical agents miconazole gel to corners of mouth if chronic, trimovate cream
44
who does angular cheilitis mainly affect
elderly edentulous with denture stomatitis people with thrush, CHC
45
clinical features of median rhomboid glossitis
localised candidal infection with atrophy of filiform papillae asymptomatic diamond shaped smooth area anterior to circumvallate papillae
46
what is median rhomboid glossitis strongly associated with
smoking corticosteroid inhalers
47
management of median rhomboid glossitis
smoking cessation address inhaler technique check for predisposing factors systemic anti-fungal (fluconazole)
48
aetiology/cause of chronic mucocutaneous candidosis (CMC)
impaired cellular immunity to candida
49
what is CMC associated with
rare congenital disorders e.g APS-1
50
what is APS-1 (autoimmune polyendocrine syndrome type 1)
rare monogenic autosomal recessive disease with varied onset (0-18yrs) CMC usually first major feature
51
clinical features of CMC in APS-1
initially presents as as oral thrush with angular cheilitis becomes more chronic with atrophy and leukoplakia painful with acidic/spicy food
52
how is oral candidosis diagnosed
usually clinically (with thrush and denture stomatitis) if possible take microbial sample (to identify, quantify and assess resistance)
53
which candida species are more resistant to some anti-fungal agents
C glabrata C krusei
54
what are 6 diff candidal sampling methods & their adv/disadv
1) whole saliva culture + gives fungal load - not suitable in xerostomia 2) concentrated oral rinse + gives fungal load - requires specialised lab 3) sponge imprint culture + gives fungal load, site specific - requires specialised lab 4) swab + site specific - doesn't give load 5) smear + no lengthy culture required - doesn't give species 6) biopsy + indicated for CHC - doesn't give load or species, MOS procedure
55
4 types of anti-fungal agents
1) polyenes (nystatin, amphoterecin) 2) azoles (fluconazole, miconazole, ketoconazole) 3) 5-flucytosine 4) echinocandins (caspofungin, micofungin, anidulafungin)
56
MoA (mechanism of action) & administration of polyenes
disrupts fungal cell membrane (fungicidal) topical
57
MoA & adminsitration of azoles
inhibition of ergosterol synthesis (fungistatic) topical/ systemic
58
MoA & adminsitration of 5-flucytosine
inhibition of protein & DNA synthesis systemic
59
MoA & administration of echinocandins
inhibition of B1,3 D-glucan synthesis intravenous
60
therapeutic indications for topical anti-fungal agents
superficial infection denture wearers, AB drug use, diabetics
61
therapeutic indications for systemic anti-fungal agents
immunosuppressed candidal leukoplakia (e.g CHC)
62
MoA of nystatin, dose & adverse effects
MoA - prevents fungal membrane ergosterol synthesis dose - oral suspension 4x day for 1-2 weeks effects - oral irritation, sensitisation, nausea
63
MoA of amphotericin, dose & adverse effects
MoA - binds with fungal membrane ergosterol -> cell death dose - lozenges 10mg 4x day 10-15 days effects - mild GI disturbances
64
MoA of azoles
inhibit lanosterol demethylase -> no ergosterol synthesis
65
why is there azole resistance
overproduction/altered lanosterol demethylase compensation by other sterol synthesis enzymes
66
2 types of azoles and e.g
1) imidazoles (miconazole, ketoconazole, clotrimazole) 2) triazoles (fluconazole, itraconazole, voriconazole, posaconazole)
67
how is miconazole used & dose
gel applied to affected area (e.g denture fit surface, dentures can be left in) has anti-staphylococcal activity dose - gel 25mg, 4x day for 2 weeks after meals
68
how is ketaconazole used & dose
systemic non-specific (inhibits testosterone & cortisol synthesis) dose - 200mg 1x for 2 weeks
69
contraindications for ketoconazole
not used in in pts with liver disease or alcoholics as hepatotoxic
70
contraindications for fluconazole
pregnancy breast feeding
71
side effects of fluconazole
nausea/vomitting diarrhoea, flatulence rashes hepatitis
72
what drugs does fluconazole affect & how?
reduces metabolism of several drugs by inhibiting CYP3A -benzodiazepines -calcium channel blockers -ciclosporin -warfarin results in increased conc and toxicity
73
which candida species may show decreased susceptibility/frank resistance to fluconazole
C glabrata C dublinensis
74
what has been developed to combat resistant species
echinocandins (C parapsilosis and C guillermondii often resistant)

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