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Candidiasis, Oral, Emergency Medicine

Basics

Description

- More common in neonates, elderly, and immunosuppressed individuals - Usually benign course in healthy patients - In immunocompromised patients, more likely to be recurrent and a non-albicans species - May represent an early manifestation of AIDS in HIV-infected patients - Typically localized - Risk factors for systemic infection: - AIDS - Diabetes - Hospitalization - Immunosuppressive therapy - Malignancy - Neutropenia - Organ transplantation - Prematurity

- Pseudomembranous candidiasis (thrush): - Painless white mucosal plaques - Adherent but removable plaques - Erythematous base - May become confluent and curdlike - Anorexia, dysphagia

- Angular cheilitis: - Cracking or erythema at the corners of mouth - Lesion can be asymptomatic, pruritic, or painful - Superinfection with Staphylococcus or Streptococcus is common

- Clinical diagnosis often sufficient - CBC if suspect severe infection - Glucose testing - Periodic acid-Schiff stain/KOH/fungal culture: - Branching, thread-like hyphae, spores or pseudohyphae may be seen - Obtain culture and sensitivity if failed first line treatment or high-risk individuals (HIV/AIDs, neutropenic, AIDs, transplant, etc.)

- Topical antifungal medications: - Suspension, troches, lozenges - Ointments (angular cheilitis)

  • Infection of oral mucosa with any species of Candida
  • Up to 80% of isolates are Candida albicans (most common), Candida glabrata, and Candida tropicalis.
  • Candida normally present as oral flora in 60% of the healthy population.
  • Variations include:Pseudomembranous (thrush)Chronic and acute atrophic candidiasisAngular cheilitisHyperplastic candidiasis
  • More common in neonates, elderly, and immunosuppressed individuals
  • Usually benign course in healthy patients
  • In immunocompromised patients, more likely to be recurrent and a non-albicans species
  • May represent an early manifestation of AIDS in HIV-infected patients
  • Typically localized
  • Risk factors for systemic infection:AIDSDiabetesHospitalizationImmunosuppressive therapyMalignancyNeutropeniaOrgan transplantationPrematurity

Etiology

  • Usually overgrowth of C. albicans from alterations in intraoral environment
  • May be medication induced-commonly antimicrobials, inhaled or systemic steroids, chemotherapy, immunosuppressive agents
  • Immunocompromised patients
  • Alterations or impairment of salivary flow:Anticholinergic or psychotropic medicationsSj ¶gren diseaseHead or neck radiation
  • Presence of dentures or other orthodontics:Occurs in up to 50-65% of denture wearersCommon etiology for chronic atrophic candidiasis
  • Interruption of epithelial barrier (cheek biting)
  • Endocrinopathies (diabetes, hypothyroidism)
  • Acute pseudomembranous candidiasis (thrush) is common in infancy likely because of immaturity of their immune system and lack of mature oral flora
  • Initial presentation may be feeding difficulty secondary to dysphagia
  • May have concurrent Candida diaper rash
  • Consider maternal treatment if breastfeeding:Maternal breast colonization may be cause for persistent thrush. Query maternal nipple pain, burning, itching, or cracked skin
  • Candida organisms are normally present as oral flora from 65-88% of elderly or those in long-term care facilities
  • Dentures can lead to Candida overgrowth
  • Angular cheilitis more common in the elderly secondary to facial wrinkling

Diagnosis

Signs and Symptoms

  • Pseudomembranous candidiasis (thrush):Painless white mucosal plaquesAdherent but removable plaquesErythematous baseMay become confluent and curdlikeAnorexia, dysphagia
  • Acute atrophic candidiasis:Also referred to as erythematous candidiasisBurning sensation in mouth or on tongueErythematous with few, if any white patches usually on the palate or dorsum of tongueTongue may be bright red in color-similar to nutritional deficiency
  • Chronic atrophic candidiasis:Also referred as denture stomatitisIrritation around denture-bearing mucosa
  • Angular cheilitis:Cracking or erythema at the corners of mouthLesion can be asymptomatic, pruritic, or painfulSuperinfection with Staphylococcus or Streptococcus is common
  • Hyperplastic candidiasis:Chronic, invasive ulcersTypically on lateral borders of tongue or buccal mucosaHigh incidence of malignant degeneration in tobacco users

Essential Workup

  • Minimal workup needed in otherwise healthy infant. Diagnosis can be made clinically.
  • Determine whether there is a cause for a breakdown of host factors
  • If no reason is found, evaluate for possible HIV infection or diabetes
  • Exclude a systemic infection

Diagnosis Tests & Interpretation

Lab

  • Clinical diagnosis often sufficient
  • CBC if suspect severe infection
  • Glucose testing
  • Periodic acid-Schiff stain/KOH/fungal culture:Branching, thread-like hyphae, spores or pseudohyphae may be seenObtain culture and sensitivity if failed first line treatment or high-risk individuals (HIV/AIDs, neutropenic, AIDs, transplant, etc.)

Differential Diagnosis

  • Hairy leukoplakia
  • Lichen planus
  • Squamous cell carcinoma
  • Adherent food/milk

Treatment

Ed Treatment/Procedures

  • IV fluids if dehydration and/or unable to tolerate PO fluids
  • Topical analgesia: "Magic mouthwash":Mixture of equal parts of 2% viscous lidocaine, Maalox, and diphenhydramine elixirSwish for 1-2 min, then expectorate
  • Topical antifungal medications:Suspension, troches, lozengesOintments (angular cheilitis)
  • Systemic agents reserved for those with severe disease or resistant to topical therapy
  • Provide oral hygiene education:Instruct those using steroid inhalers to rinse mouth immediately after useDenture and orthodontic care

Medication

  • Dissolve troche in bottle nipple
  • Mix suspensions with fruit juice and freeze into popsicle
  • Apply suspensions to affected areas with a cotton-tipped swab
  • Instruct parents to disinfect or replace toothbrushes, pacifiers, bottle nipples
  • Angular cheilitis: Treat with topical nystatin ointment
  • Dentures: Remove, brush, and soak nightly. Consider overnight rinse with 2% chlorhexidine

First Line

  • Nystatin: Oral suspension; neonates 100,000 U; older infants: 200,000 U; children/adults: 400,000-600,000 U. Swish and swallow QID for 7-14 days
  • Nystatin pastilles: 200,000 U PO QID for 7-14 days
  • Clotrimazole troches: 10 mg PO dissolved slowly 5 times per day for 7-14 days (children >3 yr)

Second Line

  • Oral fluconazole: Loading dose of 200 mg (peds: 6 mg/kg) on day 1, followed by 100 mg (peds: 3 mg/kg) PO daily for 7-14 days
  • Itraconazole solution: 200 mg (peds: >5 yr, 2.5 mg/kg BID, not FDA approved) PO daily for 7-14 days
  • Posaconazole 100 mg (peds: >13 yr refer to adult dosing) PO BID on day 1, then 100 mg PO daily for 13 days
  • Systemic Amphotericin B (0.3 mg/kg) daily is the treatment of choice for candidiasis in pregnant women

Follow-Up

Disposition

Admission Criteria

  • Inability to tolerate oral intake
  • Newly diagnosed immunocompromised state
  • Systemic infection

Discharge Criteria

If the candidiasis does not threaten patients hydration status, discharge

Followup Recommendations

Additional workup for immunodeficiency is warranted in older children and adults with unexplained candidiasis.

Pearls and Pitfalls

  • Failure to recognize immunodeficiency
  • Failure to recognize other intraoral pathology such as squamous cell carcinoma

Additional Reading

  • Gonsalves WC, Chi AC, Neville BW. Common oral lesions: Part I. Superficial mucosal lesions. Am Fam Physician. 2007;75:501-507.
  • Krol DM, Keels MA. Oral conditions. Pediatr Rev. 2007;28:15-22.
  • Kuyama, K, Sun Y, Taguchi C, et al. A clinico-pathological and cytological study of oral candidiasis. Open J Stomatology. 2011;1:212-217.
  • Pappas PG, Kauffman CA, Andes D, et al. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009;48:503-535.

Codes

ICD9

  • 112.0 Candidiasis of mouth
  • 771.7 Neonatal Candida infection

ICD10

  • B37.0 Candidal stomatitis
  • P37.5 Neonatal candidiasis

SNOMED

  • 79740000 Candidiasis of mouth (disorder)
  • 30799000 neonatal thrush (disorder)