Candidiasis Fungal Infections

Dr. Ioannis G. Koutlas Division of Oral Pathology

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Candida albicans Spores and pseudohyphae (dimorphism) 30-50% carry the organism Three factors can determine infection
The immune status The environment of the mouth The strain of candida albicans

Types of Candidiasis
Pseudomembranous
White removable plaques of yeasts, epithelial cells and debris Underlying mucosa is erythematous or normal Non-bleeding

Cause: Antibiotics, impaired immune system

Differential Diagnosis

Types of Candidiasis
Erythematous
Acute atrophic: patchy denuded areas; bald tongue Central papillary atrophy of tongue (median rhomboid glossitis) and chronic multifocal candidiasis Angular cheilitis (perlche): sometimes staph. aureus with candida albicans or alone; cheilocandidiasis Denture stomatitis: Not always associated with candida

Types of Candidiasis
Chronic hyperplastic
Cannot be removed Candida albicans can cause hyperkeratosis Speckled leukoplakia Presence of epithelial dysplasia

Types of Candidiasis
Mucocutaneous
Immunologic dysfunction Sporadic or A.R. Endocrine-candidiasis syndrome

Laboratory Tests for Candidiasis

Exfoliative cytology & histopathology KOH (10% solution)
Single drop on a slide containing smear tissue; epithelial cells are resolved

Culture in Sabourauds agar

Treatment
Nystatin (polyene): Mycostatin; suspension or pastille; direct contact with fungus Amphotericin B (polyene): Fungizone; suspension (not available anymore); intravenous use for severe and life-threatening infections Clotrimazole (imidazole): Mycelex; cannot be absorbed in the GI tract; Ketokonazole (imidazome): Nizoral; can be absorbed; acidic environment needed; rarely causes liver toxicity; drug interactions with erythromycin, cisapride and astemizole (life threating cardiac arrhythmia)

Treatment
Fluconazole (triazole): Diflucan; once daily, can be absorbed, rare liver toxicity, can interact with several medications and cause side effects Itraconazole (triazole): Sporanox; severe and lifethreatening side effects Iodoquinol: antifungal and antibiotic properties, combination with corticosteroid (Vytone) excellent for angular cheilitis

Histoplasmosis
Histoplasma capsulatum Yeast and mold; river valleys Ingested by macrophages, T-lymphocytic immunity; flu-like symptoms Acute (self-limiting), chronic (old, COPD, immunosuppressed) and disseminated (AIDS) forms Mouth: Ulceration, plaques or growths, can mimic squamous cell carcinoma Medications: Amphotericin B, itraconazole, ketoconazole

Blastomycosis
Blastomyces dermatitidis Same region as histoplasmosis Primarily lung, can become disseminated Mouth: Ulceration, erythematous areas Histologically can show pseudoepitheliomatous hyperplasia (mimics squamous cell carcinoma)

Paracoccidioidomycosis (South American Blastomycosis)

Cryptococcosis
Cryptococcus neoformans Most common life-threatening fungal infection in AIDS
Cryptococcal meningitis Disseminated skin involvement (head and neck)

Pigeons Mucopolysaccharide wall for protection Asymptomatic or flue-like illness; severe in immunocompromised patients

Zygomycosis (mucormycosis, phycomycosis)

Saprobic organism Insulin-dependent diabetics with uncontrolled disease or ketoacidosis; immunocompromised patient; rarely in healthy individuals Rhinocerebral involvement Nasal obstruction, cellulitis, cranial involvement, sinus involvement, oral destruction (can mimic malignancy); small blood vessel invasion resulting in infarction In some cases, therapy should start prior to culture results

Aspergillosis
Aspergillus flavus & fumigatus (most frequent) Noninvasive and invasive Invasive: immunocompromised patients and diabetics Allergic fungal sinusitis Aspergilloma and antrolith Fungi occlude vessels

Parasitic infections
Toxoplasmosis
Developing fetus Immunocompromised patients
AIDS, transplant & cancer patients

Leishmaniasis (kala-azar)
AIDS Cutaneous involvement Rarely intraoral lesions