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