ORAL INFECTIONS MYCOTIC (FUNGAL) INFECTIONS FUNGAL INFECTIONS 1. Candidiasis 2. Histoplasmosis 3. Mucormycosis (zygomycosis) 4. Cryptococcosis 5. Aspergillosis 6. Blastomycosis 7. Toxoplasmosis CANDIDIASIS Candida albicans Old name MONILIASIS Occur in 2 forms 1. Active form--- hyphae 2. Passive form--- spores/yeast Opportunistic infectious agent Takes advantage of altered immune defence CANDIDIASIS PREDISPOSING FACTORS 1. Antibiotic therapy 2. Diabetes mellitus 3. Immunologic disorders 4. Old/young age 5. HIV 6. Xerostomia 7. Steroid therapy CANDIDIASIS CLASSIFICATION OF ORAL CANDIDIASIS ACUTE 1. Pseudomembranous (thrush) 2. Atrophic (erythematous) CHRONIC 1. Hyperplastic (candidal leukoplakia) THRUSH(PSEUDOMEMBRANOUS) Acute form of candidiasis Characterized by the presence of creamy, curd like patches at various intraoral sites These white plaques are composed of tangled hyphae, yeasts, desquamated epithelial cells and debris THRUSH(PSEUDOMEMBRANOUS) Plaque can be removed with a gauze or tongue blade Underlying mucosa is usually normal May also affect infants due to their underdeveloped immune response Acute response may occur as a reaction to antibiotics THRUSH(PSEUDOMEMBRANOUS) Patient complaints of ‘blisters’ on the tongue Bitter or unpleasant taste in mouth Burning sensations on eating hot food Most common sites includes: Buccal mucosa Palate Dorsal tongue THRUSH(PSEUDOMEMBRANOUS) ATROPHIC (ERYTHEMEATOUS) Clinical form of Candida albicans infection in which the mucosa is thin and bright red Symptoms of burning and increased sensitivity are present Most common sites include palette under a denture, tongue and other mucosal surfaces Patients with this type of Candidiasis do not show the white curd like material which is seen in thrush ATROPHIC (ERYTHEMEATOUS) Erythmeatous candidiasis can be associated with the following Angular cheilitis Median rhomboid glossitis Chronic mucocutaneous candidiasis It is usually seen in patients with ill fitting dentures Patients having erythemeatous candidiasis on tongue complain of a burning sensation in mouth This is usually accompanied by a diffuse loss of filiform papillae of the dorsam of tongue resulting in a bald appearance ATROPHIC (ERYTHEMEATOUS) ATROPHIC (ERYTHEMEATOUS) CHRONIC HYPERPLASTIC CANDIDIASIS Clinical form consisting of white plaque against an erythemeatous background Most common site include buccal mucosa along the occlusal line Latero dorsal surface of tongue and alveolar ridges It is also known as candidal leukoplakia This white patch cannot be removed by scraping CHRONIC HYPERPLASTIC CANDIDIASIS Often the leukoplakia lesion associated with candidal infection has an intermingling of red and white areas producing a lesion known as “speckled leukoplakia” the diagnosis is confirmed by the presence of candidal hyphae associated with the lesion as seen in the histopath To differentiate this lesion from other white pre malignant lesions, biopsy is utmost necessary CHRONIC HYPERPLASTIC CANDIDIASIS ORAL LESIONS ASSOCIATED WITH CANDIDA ALBICANS Angular chelitis Median rhomboid glossitis Chronic mucocutaneous candidiasis ANGULAR CHELITIS Also known as PERLECHE Symptomatic bilateral fissures of corners of mouth Associated with intraoral candida infection Older patients with a loss of vertical dimensions due to tooth loss, dentures etc Saliva pools in the corners of mouth providing favorable environment to candidal infection ANGULAR CHELITIS MEDIAN RHOMBOID GLOSSITIS Asymptomatic , erythmeatous patch of atropic mucosa of the middorsal surface of tongue In past it was thought as a developmental anomly If untreated, the lesion enlarges and exhibits nodular hyperplasia in the middle of tongue Associated with chronic hyperplastic candidiasis MEDIAN RHOMBOID GLOSSITIS MEDIAN RHOMBOID GLOSSITIS Chronic multifocal oral candidiasis term is used to describe patients exhibiting more than one of the previously mentioned chronic forms of candidiasis May persist for many years CHRONIC MUCOCUTANEOUS CANDIDIASIS A term used to describe a condition in which persistent and refractory candidiasis occur on the mucous menbranes, skin and nails of the affected patient CANDIDIASIS Histopathology Candidal organisms can be seen microscopically on cytologic smear or in tissue sections obtained for biopsy The histopathologic pattern varies depending on the type of the clinical form of infection Most common features include the following ◼ Increased thickness of parakeratin on the surface of the lesion along with thickening of spinous layer of the epithelium ◼ Elongation of epithelial rete ridges CANDIDIASIS ◼ Chronic inflammatory cell infiltrate is seen in the connective tissue immediately subjacent to the infected epithelium ◼ Micro abcessess composed of collection of neutrophils are seen in the parakertin layer and superficial spinous layer ◼ Candidal hyphae are embedded in the parakeratin layer and rarely penetrate in the viable tissue unless the patient is extremely immunocompromised CANDIDIASIS CANDIDIASIS Treatment Treatment with anti fungal medications both topical and systemic has been done including ◼ Nystatin ◼ Amphotericin B ◼ Ketoconazole ◼ Fluconazole DEEP MYCOTIC INFECTIONS Pathogenesis: Inhalation of spores Symptoms: Cough, fever, weight loss, other Primary site: Lung; may be asymptomatic Oral lesions: Chronic, nonhealing ulcers resulting from lung disease Microscopy: Granulomatous inflammation with organisms Treatment: Ketoconazole, fluconazole, itraconazole, amphotericin B HISTPLOASMOSIS 2-5µm in size Yeasts in macrophages HISTPLOASMOSIS Causative organism : Histoplasma capsulatum Deep mycotic infection in which the organism infects the lungs through inhalation of airborne spores Clinical features Expression of diseases depends on quality of spores inhaled Immune status of host Strain of histoplasma capsulatum HISTOPLASMOSIS Most common oral sites include gingiva, tongue, palette and buccal mucosa They clinically present themselves as chronic ulcers with raised rolled borders and induration of the surrounding tissues They may resemble carcinoma clinically HISTOPLASMOSIS Histopathology Granulomatous inflammation characterized by formation of multiple small often inconspicuous granulomas composed of histiocytes These histiocytes contain variable number of organisms The background connective tissue has various lymphocytes, plasma cell and histiocytes Scatter multinucleated giant cells can be seen Organism is present in spore form HISTOPLASMOSIS HISTOPLASMOSIS Treatment Antifungal drugs BLASTOMYCOSIS 8-15 µm in size Budding yeast BLASTOMYCOSIS Deep mycotic infection Cause infection of lungs by inhalation of spores Initial flu like symptoms Also involves skin in the form of a rash or eruption Intraoral lesions are non healing, indurated ulcers BLASTOMYCOSIS Granulomeatous inflammation with organisms in the form of “budding yeast” Yeast cells look like mickey mouse ears Pseudoepitheliomatous hyperplasia Inflammation in connective tissue CRYPTOCOCCOSIS 2-15 µm in size Yeasts with thick capsules CRYPTOCOCCOSIS Chronic infection of lungs caused by Cryptococcus neoformans Deep mycotic infection Mode of transmission SPORES LUNGS CNS CRYPTOCOCCOSIS CLINICAL FEATURES Initial contact shows flu like symptoms Lung involvement CNS involvement in the form of meningitis Oral lesions usually occur in severely immunocompromised patients Present as non healing, indurated ulcers which cause bone perforations CRYPTOCOCCOSIS HISTOPATHOLOGY Granulomatous inflammation Yeasts with thick capsule Multiple focal granulomas exhibiting numerous lymphocytes and plasma cell Organism in the macrophages and multinucleated giant cells TREATMENT Amphotericin B ASPERGILLOSIS Aspergillus fumigatus and A.flavus Destructive lesion of maxillary sinus, anterior palate and nasal passages Severely immunocompromised patients and those with AIDS acquire it easily through spores Usually infests lungs by forming a fungus ball Causes intra oral swellings in the palate May form an aspergiloma in the sinus ASPERGILLOSIS HISTOPATHOLOGY The fungus is present in the center of a necrotic area along with granulomatous reaction Dense chronic inflammatory infiltrate is also present Septate hyphae are seen branching at right angle to each other ASPERGILLOSIS Treatment Surgical debridement if the involved bone and necrotic in which the organisms reside ZYGOMYCOSIS Chronic destructive infection of the mid face and nasal passages Caused by members of mucor or rhizopus of the phylum zygomycota Spores are transmitted by inhalation or by ingestion Organism produces lung and skin diseases Most common disease called rhinocerebral zygomycosis causing infections in nose, mid face and maxillary sinus ZYGOMYCOSIS Fungus causes blockage of major blood vessels resulting in ischemic necrosis Histopathology Extensive tissue necrosis seen with numerous large fungal hyphae Hyphae have a ribbon like appearance Treatment Surgical debridement ZYGOMYCOSIS.