Good morning

Mycotic infections of the oral cavity

PRESENTED BY :PUSHKAR S. DAHIWAL GUIDED BY: DR. SONIA SODHI MAM DR. LATA DABHADE MAM

FUNGAL / MYCOTIC INFECTIONS

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

CANDIDIASIS HISTOPLASMOSIS BLASTOMYCOSIS PARACOCCIDIOIDOMYCOSIS MUCORMYCOSIS CRYPTOCOCCOSIS COCCIDIODOMYCOSIS GEOTRICHOSIS SPOROTRICHOSIS RHINOSPORIDIOSIS ASPERGILLOSIS

CANDIDIASIS
It is also called as candidosis. Refers to infection with yeast like fungal organism candida

albicans.. Most common oral fungal infection. It is a component of normal oral flora in the gastrointestinal and genitourinary tracts of humans. Can occur in persons who are debilitated by other diseases or in otherwise healthy individuals also. Candida species albican non-albican: C. glabrata, C. krusei, C. parapsilosis, C. tropicalis, C. parapsilosis

Frequency

The Situation

- most common fungal pathogen worldwide - 4th leading causes of nosocomial infections, 40% mortality - significant mortality and morbidity in low birth-weight infants - affects 75% women, 45% experience recurrenceA > 10 million visits/year

Immunocompromised - cancer and HIV-AIDs patientsC

- most commonly manifested in patients with leukemia or HIV-AIDs infections. Oral candidiasis is often a clue to acute primary infectionC

Public Concerns - increasing resistance to drug therapies due to antibiotics

and antifungals

Commensal

Biology of Candida albicans

Pathogen

A thin-walled dimorphic fungus

Morphogenesis Unicellular yeast (harmeless) Filamentous (pathogenic) Principal Cell Wall Polymers Gluccan Mannan
Figure 1. Yeast in Oral Scraping A sample of an oral scraping contains yeast cells and pseudohyphae

Strict aerobe, favors moist surfaces Commensally found in gut, genitals, and lungs Body Temp 37 C, neutral pH

Rapid Multiplication & Spread

PREDISPOSING FACTORS:
a) Local Factors :
- Mucosal trauma (local irritant) - Denture wearers - Denture hygiene - Tobacco smoking - Drugs (Broad spectrum antibiotics,steroids, immunosuppressant / cytotoxic agents) - Xerostomia

b) Systemic factors : - Iron deficiency anaemia

- Megaloblastic anaemia - Acute leukaemia - Diabetes mellitus - HIV infection - Other immunodeficiency states

CLASSIFICATION OF CANDIDIASIS: Acute - Acute pseudomembranous candidiasis (thrush) - Acute atrophic candidiasis (antibiotic sore-mouth)

Chronic 1. Chronic hyperplastic candidiasis 2.chronic mucocutaneous candidiasis 3. Chronic atrophic candidiasis (adapted from lanhar t .classification & clinicopathological features of candida infections in the mouth)

DENTURE STOMATITIS(DENTURE SORE MOUTH) ANGULAR CHEILITIS MEDIAN RHOMBOID GLOSSITIS

A ) primary candidiasis 1)Acute form Pseudomembranous. Erythematous 2) Chronic form Hyperplastic form Erythematous Pseudo-membranous 3)Candida associated lesion denture stomatitis Angular stomatitis Median rhomboid glossitis 4) Keratinised primary lesion superinfected with candida Leukoplakia,lichen planus, lupus erythematous B) Secondory candidiasis Oral manifestations of systemic mucocutaneous candidosis

ACUTE PSEUDOMEMBRANEOUS CANDIDIASIS

(THRUSH )

Best recognized form of candidiasis.

Characterized by development of white plaques that

can be scraped off with tongue blade. Can be initiated by broad spectrum antibiotics or immune dysfunction.

 Occurs characteristically

on buccal mucosa, palate and dorsal tongue. Usually asymptomatic or patients may c/o burning sensation of mucosa or unpleasant taste in mouth. Can occur in infants also.

ACUTE ATROPHIC CANDIDIASIS: Also called antibiotic sore mouth, as it follows course of broad spectrum antibiotics. Patients c/o burning sensation of mucosae. Seen as diffuse loss of filliform papillae resulting in a bald appearance of tongue.

CHRONIC HYPERPLASTIC CANDIDIASIS:

Least common of all types. Appears as non scrapable white patch resembling leukoplakia (candidal

leukoplakia)

Believed that it represents candidiasis superimposed on pre-existing leukoplakia. Diagnosis confirmed by demonstration of candidal hyphae within the lesion and resolution of lesion after antifungal therapy.

CHRONIC MUCOCUTANEOUS CANDIDIASIS: Severe oral candidiasis can also occur

as a component of a rare immunological disorder called mucocutaneous candidiasis. Autosomal recessive disorder. Immune dysfunction becomes evident in early life patient develops candidiasis of mouth, nails, skin and other mucosae. Oral lesions appear as thick, white non scrapable patches.

3. CHRONIC ATROPHIC CANDIDIASIS: Denture stomatitis Characterized by varying degrees of erythema in denture bearing areas of usually maxillary prostheses. Usually asymptomatic. Patients give h/o wearing denture continuously.

2. MEDIAN RHOMBOID GLOSSITIS: Also called central papillary atrophy of tongue. Well demarcated erythematous zone affecting midline of dorsum of tongue. Often asymptomatic. Erythema due to loss of filliform papillae. Sometimes, other areas of oral cavity like hard palate and angles of mouth also show lesions (Chronic multifocal

candidiasis).

ANGULAR CHEILITIS: Also called perleche. Characterized by erythema, fissuring and scaling of corners of mouth. Typically occurs either along with multifocal candidiasis or in old patients with reduced vertical dimension. Saliva pools in these areas, keeping them moist and thus favoring fungal infection

HISTOLOGICAL FEATURES: Biopsy specimen show

hyperparakeratinization, elongation of rete ridges, chronic inflammatory cell infiltration of underlying CT and small microabscesses collection of PMNLs) within parakeratin layer. Candidal hyphae can be seen embedded in parakeratin layer and superficial spinous layer.

Treatment

Amphotericin B 0.7 mg/kg per day

Caspofungin is 50 mg/day after a loading dose of 70 mg Voriconazole is 3 mg/kg twice daily after a loading dose

of 6 mg/kg twice daily for one day.

Duration of therapy for candidemia : A minimum of two weeks of therapy after blood cultures become negative

Topical treatment:
Limit the systemic absorption

Clotrimazole -1 troche 10 mg tablet five times daily Nystatin preprations.

It includes suspension,vaginal &an oral pastile Vaginal tab.- 1 tab, 100,000 units dissolved in mouth 3 times a daily Nystatin oral pastile 200,000 units Five times a daily Nystatin suspension 1 teaspoon mixed wiyh water & rinse Topical creams & oinements of nystatin,ketoconazole,or clotrimazole

 Amphotericin B 0.08 mg/ kg 2 to 3 hourly in

oinetment, cream based , suspension

Rinses Nystatin for 7 -10 days 3- 4 times daily 0.2 % chlorhexidine

Systemic treatment
Nystatin 250 mg TDS for 2 weeks followed by 1

troche / day for 3rd week Ketoconazole 200 mg with food daily ( careful monitoring required of liver function) Fluconazole 100 mg tab once daily for two weeks Itraconazole 100 mg cap. For 2 weeks

HISTOPLASMOSIS
It is also called as DARLINGS DISEASE.

It is caused by histoplasma capsulatum, a dimorphic

fungus that grows in yeast form in infected tissue. Infection results from inhalation of dust contaminated with droppings , particularly from infected birds.

TYPES OF HISTOPLASMOSIS
Acute primary histoplasmosis Primary infection is mild ,manifesting as self limited pulmonary disease that heals to leave fibrisis and calcification. 2. Progressive disseminated histoplasmosis -manifested by hepatosplenomegaly & lymphodenopathy . -patients show evidence of bone marrow involvement by anemia & leucopenia.
1.

 3. chronic cavitary histoplasmosis

lesions mimics the chronic cavitary tuberculosis.

Histoplasmosis is an intracellular mycotic infection of the reticuloendothelial system caused by the inhalation of conidia from the fungus Histoplasma capsulatum. Histoplasmosis has a world wide distribution, however, the Mississippi-Ohio River Valley in the U.S.A. is recognized as a major endemic region. Africa, Australia and parts of East Asia, in particular India and Malaysia are also endemic regions

Approximately 95% of cases of Histoplasmosis are in apparent, subclinical or benign. Five percent of the cases have chronic progressive lung disease, chronic cutaneous or systemic disease or an acute fulminating fatal systemic disease. All stages of this disease may mimic tuberculosis

ORAL MANIFESTATIONS:
ORAL MANIFESTATIONS:

oral leasions are commonly seen in the Progressive disseminated histoplasmosis sites.- it is seen on buccalmucosa,gingiva,tongue, palate or lip Symptoms- patient may complain of sore throat, painful chewing,hoarseness,&difficulty in swallowing Oral lesions are nodular, ulcerative or vegetative if left untreated it will progress to form firm papule or nodules which ulcerate & slowly enlarge

DIAGNOSIS
Made by culture on sabourauds media Biopsy will show small oval yeasts within the macrophages &

reticoendothelial cells As well as chronic grannulomas , epitheloid cells, giant cells & occaisionally caseation necrosis .
Diffrential diagnosis: Tuberculosis-sputum examination, tuberculin test Blastomycosis- biopsy &culturing the organism from tissue. Mucormycosis-biopsy Cryptococcosis-organism cultured on saborauds glucose agar

Treatment of histoplasmosis:
Mild to moderate cases treated with ketoconazole for

6 12 months Immunesuppresed patients /severe patients require Amphotericin B to 10 weeks

African histoplasmosis
It is caused by fungus histoplasma dubosii

It is larger than h.capsulatum

Disease has clinically distinct form & geographical

distribution so called african histoplasmosis

BLASTOMYCOSIS
It is cause by blastomycosis dermatitidis.(north

american blastomycosis) also called as gilchrists disease. Organism is a normal inhabitat of soil & so that is commom in agricultural worker . It is transmitted by respiratory tract.

Types of the blastomycosis

Primary pulmonary blastomycosis Cutaneous blastomycosis Disseminated or systemic blastomycosis Blast mycosis is a chronic granulomatous and

suppurative disease having a primary pulmonary stage that is frequently followed by dissemination to other body sites, chiefly the skin and bone. Although the disease was long thought to be restricted to the North American continent, in recent years autochthonous cases have been diagnosed in Africa, Asia and Europe.

Oral manifestations
It may be primary or secondary to some infections

elsewhere in the body. Symptoms & signsOrophayrngeal pain with enlargement of cervical lymph nodes.

Diagnosis
When chronic, painless,oral ulcer appears in an

agricultural worker or when review of system reveals pulmonary symptoms. Diagnosis is made on the basis of biopsy & on culturing the organism from the body.
Differential diagnosis-

1.Squamous cell carcinoma- older patient 2.Tuberculosis 3.Histoplasmosis culture & biopsy 4. mucormycosis-biopsy

TREATMENT

I ntrvaenous Amphotericin B Itraconazole Ketoconazole For 8- 10 weeks

PARACOCCIDIOIDOMYCOSIS

Paracoccidioidomycosis is a chronic

granulomatous disease that characteristically produces a primary pulmonary infection, often in apparent, and then disseminates to form ulcerative granulomata of the buccal, nasal and occasionally the gastrointestinal mucosa. .
The only etiological agent,

Paracoccidioides brasiliensis is geographically restricted to areas of South and Central America also called as south american blastomycosis/ lutz disease

 Chronic granulomatus infection

Paracoccodioides brasilensis, Lungs- Mucosa Skin Lymphatic vessels Enter through the lungs Saprophytic in nature, Humid forests of South and Central Common in 20 40 years,

MUCORMYCOSIS
It is also called as phycomycosis.

Etiology & predisposing factors-

-caused by saprophyte fungus -more common in patients with decreased resistance due to diseases like diabetes , tuberculosis , renal failure ,leukemia , cirrhosis of liver & in severe burn cases.

 Types of mucormycosis:

1. superficial 2.Visceral - Pulmonary - Gastrointestinal - Rhinocerebral/ rhinomaxilary

 Rhinomaxillary form begins with inhalation of

fungus by susectible individual

Infection usually arises in the lateral wall of nose &

maxillary sinus,may rapidly spread by arterial invasion to involve orbit,palate,maxillary alveolus,then cavernous sinus & then brain through hematogenous spread & may cause death

Differential diagnosis:
Squamous cell carcinoma.

Necrotising sialometaplasia..usually painless

Management

1. Surgical debridement treatment of choice

2. Systemis amphtericin 3. Control of systemic disease

CRYPTOCOCCOSIS
It is also called as torulosis

It is chronic fungal infection caused by cryptococcus

neoformans & cryptococcus bacillispora. Infection usually occurs in lungs Oral manifestationslocations lesions of hard palate ,soft palate ,gingiva , Extraction socket, tongue& tonsillar pillar TREATMENT: Ketoconazole for 6 -12 weeks for mild cases Amphotericin B for 10 weeks for severe cases.

THANKS FOR YOUR PATIENCE !