Mycotic Infections OF ORAL CAVITY

8/13/2019 Mycotic Infections OF ORAL CAVITY

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o o d m o r n i n g



P R E S E N T E D B Y : P U S H K A R S . D A H I W A L

G U I D E D B Y : D R . S O N I A S O D H I M A M

D R . L A T A D A B H A D E M A M

M y c o t i c i n f e c t i o n s

o f t h e o r a l

c a v i t y



FUNGAL / MYCOTIC INFECTIONS

1. CANDIDIASIS2. HISTOPLASMOSIS3. BLASTOMYCOSIS4. PARACOCCIDIOIDOMYCOSIS5. MUCORMYCOSIS6. CRYPTOCOCCOSIS7. COCCIDIODOMYCOSIS8. GEOTRICHOSIS9. SPOROTRICHOSIS10. RHINOSPORIDIOSIS11. 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





Biology of Candida albicans Commensal Pathogen

A thin-walled dimorphic fungus

MorphogenesisUnicellular yeast (harmeless)Filamentous (pathogenic)

Principal Cell Wall PolymersGluccan

Mannan

Strict aerobe, favors moist surfacesCommensally found in gut, genitals, and lungsBody Temp 37º C, neutral pH

Figure 1. Yeast in Oral Scraping A sample of an oral scraping

contains yeast cells andpseudohyphae

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) S ystemic 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 candidiasisDENTURE STOMATITIS(DENTURE SORE MOUTH)

ANGULAR CHEILITIS

MEDIAN RHOMBOID GLOSSITIS

( adapted from lanhar t .classification & clinicopathological features of candida infections in the mouth)



A ) primary candidiasis1)Acute form Pseudomembranous. Erythematous2) Chronic form Hyperplastic form Erythematous

Pseudo-membranous3)Candida associated lesion denture stomatitis Angular stomatitis

Median rhomboid glossitis4) Keratinised primary lesion superinfected with candida Leukoplakia,lichen planus, lupus erythematousB) Secondory candidiasisOral manifestations of systemic mucocutaneous candidosis





Occurs characteristicallyon buccal mucosa, palateand dorsal tongue.

Usually asymptomatic orpatients may c/o burningsensation of mucosa orunpleasant taste inmouth.

Can occur in infants also.



ACUTE ATROPHICCANDIDIASIS:

Also called “antibiotic sore

mouth” as it follows courseof broad spectrum antibiotics.

Patients c/o burning sensationof mucosae.

Seen as diffuse loss offilliform papillae resulting ina bald appearance of tongue.



CHRONIC HYPERPLASTIC CANDIDIASIS:

Least common of all types.

Appears as non scrapable white patchresembling leukoplakia candidal

leukoplakia)

Believed that it represents candidiasissuperimposed on pre-existingleukoplakia.

Diagnosis confirmed bydemonstration of candidal hyphaewithin the lesion and resolution oflesion after antifungal therapy.



CHRONIC MUCOCUTANEOUSCANDIDIASIS:

Severe oral candidiasis can also occuras a component of a rareimmunological disorder calledmucocutaneous candidiasis.

Autosomal recessive disorder.

Immune dysfunction becomes evidentin early life – patient develops

candidiasis of mouth, nails, skin andother mucosae.

Oral lesions appear as thick, white nonscrapable patches.



3. CHRONIC ATROPHICCANDIDIASIS:

Denture stomatitis Characterized by varying

degrees of erythema indenture bearing areas ofusually 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 zoneaffecting 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 alsoshow lesions Chronic multifocal

candidiasis).



ANGULAR CHEILITIS: Also called perleche.

Characterized by erythema,fissuring and scaling of corners ofmouth.

Typically occurs either along with

multifocal candidiasis or in oldpatients with reduced verticaldimension.

Saliva pools in these areas, keeping

them moist and thus favoringfungal infection



HISTOLOGICAL FEATURES:

Biopsy specimen showhyperparakeratinization,elongation of rete ridges, chronic

inflammatory cell infiltration ofunderlying CT and smallmicroabscesses collection ofPMNL’s) within parakeratin

layer. Candidal hyphae can be seen

embedded in parakeratin layerand superficial spinous layer.



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 doseof 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

Treatment



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 3times 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,orclotrimazole



Amphotericin B 0.08 mg/ kg 2 to 3 hourly inoinetment, 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 1troche / 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 DARLING’S DISEASE.

It is caused by histoplasma capsulatum, a dimorphicfungus that grows in yeast form in infected tissue.

Infection results from inhalation of dustcontaminated with droppings , particularly frominfected birds.



TYPES OF HISTOPLASMOSIS

1. Acute primary histoplasmosis

Primary infection is mild ,manifesting as self limitedpulmonary disease that heals to leave fibrisis and

calcification.2. Progressive disseminated histoplasmosis

-manifested by hepatosplenomegaly &lymphodenopathy .

-patients show evidence of bone marrowinvolvement by anemia & leucopenia.



3. chronic cavitary histoplasmosislesions mimics the chronic cavitary tuberculosis.

Histoplasmosis is an intracellular mycoticinfection of the reticuloendothelial system

caused by the inhalation of conidia fromthe fungus Histoplasma capsulatum.Histoplasmosis has a world widedistribution, however, the Mississippi-Ohio

River Valley in the U.S.A. is recognized as amajor endemic region. Africa, Australia andparts of East Asia, in particular India andMalaysia are also endemic regions



Approximately 95% of cases ofHistoplasmosis are in apparent,

subclinical or benign. Five percent ofthe cases have chronic progressivelung disease, chronic cutaneous or

systemic disease or an acute

fulminating fatal systemic disease. All stages of this disease may mimic

tuberculosis





DIAGNOSIS

Made by culture on sabouraud’s 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 saboraud’s glucose agar



Treatment of histoplasmosis:

Mild to moderate cases treated with ketoconazole for6 – 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.(northamerican blastomycosis) also called as gilchrist’s disease.

Organism is a normal inhabitat of soil & so that iscommom 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 andsuppurative 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 restrictedto the North American continent, in recent years autochthonous cases have beendiagnosed in Africa, Asia and Europe.





Oral manifestations

It may be primary or secondary to some infectionselsewhere in the body.

Symptoms & signs-

Orophayrngeal pain with enlargement of cervicallymph nodes.



Diagnosis

When chronic, painless,oral ulcer appears in anagricultural worker or when review of system revealspulmonary 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.Tuberculosis3.Histoplasmosis –culture & biopsy

4. mucormycosis-biopsy



TREATMENT

I ntrvaenous

Amphotericin B

Itraconazole Ketoconazole

For 8- 10 weeks



PARACOCCIDIOIDOMYCOSIS

Paracoccidioidomycosis is a chronicgranulomatous disease that characteristically produces aprimary pulmonary infection, often in apparent, and thendisseminates to form ulcerative granulomata of the buccal,

nasal andoccasionally the gastrointestinal mucosa.

. The only etiological agent,

Paracoccidioides brasiliensis is

geographically restricted to areas of Southand Central America also called as south american

blastomycosis/ lutz’ disease



Chronic granulomatus infectionParacoccodioides 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 resistancedue to diseases like diabetes , tuberculosis , renalfailure ,leukemia , cirrhosis of liver & in severe burncases.



Types of mucormycosis:

1. superficial

2.Visceral

- Pulmonary- Gastrointestinal

- Rhinocerebral/ rhinomaxilary



Rhinomaxillary form begins with inhalation offungus by susectible individual

Infection usually arises in the lateral wall of nose &maxillary sinus,may rapidly spread by arterialinvasion to involve orbit,palate,maxillaryalveolus,then cavernous sinus & then brain through

hematogenous spread & may cause death



Differential diagnosis:

Squamous cell carcinoma.

Necrotising sialometaplasia…..usually painless

Management1. 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 manifestations-

locations –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.



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Mycotic Infections OF ORAL CAVITY