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oropharyngeal candidiasis (thrush)
Etiology:
1) Candida albicans (most common)
2) other species of Candida
3) risk factors
a) diabetes mellitus
b) immunosuppression
- HIV1 infection
- Pneumocystis pneumonia
c) inhaled glucocorticoids
Clinical manifestations:
1) white, cottage cheese-like, non-adherent, mucosal plaques (hyphae) [2] (pseudomembranous candidiasis)
- plaques are painless [1]
- plaques can be rubbed off with gauze [2]
- plaques may be adherent [1]
2) circumscribed patches of mucosal erythema
3) grayish-white membrane with an erythematous base [1]
4) distribution commonly buccal mucosa, throat, tongue & gingivae
5) angular cheilosis
6) classic thrush can be found on any mucosal surface
7) erythematous candidiasis most commonly occurs on the palate
* images [8,9]
Laboratory:
1) yeast forms or pseudohyphae in KOH preparations of lesion scrapings
2) fungal culture
3) biopsy
4) HIV testing
5) Candida isolated from sputum not useful, including patients with mechanical ventilation [1]
Complications:
- dysphagia suggests esophageal candidiasis
Differential diagnosis:
- oral leukoplakia
- patches or plaques of the oral mucosa, associated with tobacco or chronic trauma
- oral hairy leukoplakia
- adherent white plaques, associated with EBV, HIV1 infection
- oral lichen planus
- occurs in older persons, associated with chronic trauma or medications
- lesions variable: reticular white plaques of the oral mucosa
- erosions & ulcerations may be painful
- geographic tongue
- appearance of denuded red patches migrating across the surface of the tongue
- map-like erythematous patches with white hyperkeratotic rims on dorsal surface of tongue [12]
Management:
1) topical therapy for mild-moderate disease (7-14 days)
a) clotrimazole troches
b) miconazole
c) nystatin swish & swallow
d) fluconazole
e) amphotericin B mouthwash
f) liquid formula itraconazole
g) 1/2 strength OTC hydrogen peroxide (3%) gargle BID [4]
2) systemic therapy for more severe disease (7-14 days) or evidence of esophageal candidiasis [1]
a) fluconazole
b) itraconazole
3) resistant organisms
a) switching to an alternate agent may be effective
b) intravenous amphotericin B is usually effective
Related
esophageal candidiasis
General
candidiasis
oral cavity infection
References
- Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 18.
American College of Physicians, Philadelphia 1998, 2009, 2012, 2018.
- Medical Knowledge Self Assessment Program (MKSAP) 19
Board Basics. An Enhancement to MKSAP19.
American College of Physicians, Philadelphia 2022
- Geriatrics Review Syllabus, American Geriatrics Society,
5th edition, 2002-2004
- Geriatric Review Syllabus, 8th edition (GRS8)
Durso SC and Sullivan GN (eds)
American Geriatrics Society, 2013
- Geriatric Review Syllabus, 9th edition (GRS9)
Medinal-Walpole A, Pacala JT, Porter JF (eds)
American Geriatrics Society, 2016
- UpToDate Online 12.3, 2004
- Veterans Administration, Infectious Disease, VISN21
Mather, CA
- Kaplan JE, Benson C, Holmes KH et al
Guidelines for prevention and treatment of opportunistic
infections in HIV-infected adults and adolescents:
recommendations from CDC, the National Institutes of Health,
and the HIV Medicine Association of the Infectious Diseases
Society of America.
MMWR Recomm Rep. 2009 Apr 10;58(RR-4):1-207
PMID: 19357635
- Sharon V, Fazel N.
Oral candidiasis and angular cheilitis.
Dermatol Ther. 2010 May-Jun;23(3):230-42
PMID: 20597942
- Giannini PJ, Shetty KV.
Diagnosis and management of oral candidiasis.
Otolaryngol Clin North Am. 2011 Feb;44(1):231-40, vii. Review.
PMID: 21093632
- Wikipedia: Oral candidiasis (image)
https://en.wikipedia.org/wiki/Oral_candidiasis
- DermNet NZ. Oral candidiasis (images)
http://www.dermnetnz.org/fungal/oral-candidiasis.html
- Williams D, Lewis M.
Pathogenesis and treatment of oral candidosis.
J Oral Microbiol. 2011 Jan 28;3.
PMID: 21547018 Free PMC Article
- Manfredi M, Polonelli L, Aguirre-Urizar JM et al
Urban legends series: oral candidosis.
Oral Dis. 2013 Apr;19(3):245-61. Review.
PMID: 22998462
- NEJM Knowledge+