Definition:
“Oral thrush,” a fungal disease of the
oral mucosa and tongue, is caused most often by Candida albicans, although there have been reports of increased
incidence of non-albicans species. In
the absence of other known causes of immune suppression, oral thrush in an
adult is highly suggestive of HIV infection.
Three clinical presentations are common in people with HIV:
pseudomembranous, erythematous, and angular cheilitis. As HIV disease progresses, candida infection
may invade the esophagus (See Esophageal Complaints in Complaint-specific
section, and Esophageal Candidiasis in Disease-Specific section), causing dysphagia or
odynophagia.
S: Patient complains of
white patches on tongue and oral mucosa, smooth red areas on dorsal tongue,
burning or painful mouth areas, changes in taste sensation, sensitivity to
spicy foods, and decreased appetite. Erythematous
candidiasis tends to be symptomatic with c/o oral burning, most often while
eating salty or spicy foods or drinking acidic beverages.
O: PE: Patients presenting with oral candidiasis may be totally
asymptomatic, so it is important to inspect the oral cavity thoroughly. Lesions can occur anywhere on the hard and
soft palates, under the tongue, on the buccal mucosa or gums, or extending back
into the posterior pharynx.
Pseudomembranous candidiasis appears as creamy white curd-like
plaques on the buccal mucosa, tongue, and other mucosal surfaces that will wipe
away, leaving a red or bleeding underlying surface. Lesions may be as small as 1-2 mm. in size,
or extensive plaques covering the entire hard palate.
Erythematous candidiasis presents as a flat red, subtle lesion
or lesions either on the dorsal surface of the tongue and/or the hard/soft
palates. The tongue may have
depapillated red mucosal areas on its dorsal surface.
Angular cheilitis presents with fissuring and redness
at either one or both corners of the mouth, and may appear alone or in
conjunction with another form of oral candida infection.
A: Partial Differential: For suspected pseudomembranous candidiasis,
rule out oral hairy leukoplakia, coated tongue, and other fungal
infections. For suspected erythematous
candidiasis: R/O burn or trauma.
P: LABS: Clinical exam alone is usually diagnostic. Organisms may
be detected on smear or culture.
1. Do a KOH preparation of a smear collected
by the gentle scraping of the affected area with a wooden tongue depressor.
Visible hyphae or blastospheres on KOH mount indicate candida infection.
2. Culture is diagnostic.
3. Refractory cases of oral candidiasis may be
caused by Candida glabrata, C. tropicalis,
or C. Krusei, all of which are
azole-resistant. Candidiasis which does
not respond to therapy should be cultured to check the identity of the fungal
species.
TX: Topical therapies are recommended for mild
to moderate cases of intraoral candidiasis. Treatment with fluconazole can
result in selective growth of non-albicans species, and should only be
implemented when necessitated by more severe disease.
1. Clotrimazole troches (Mycelex) dissolved in
mouth 5 times/day x 2 weeks.
2. Alternative therapy: Nystatin vaginal pastilles dissolved in mouth
are very effective, or may use nystatin oral suspension "swish and
swallow", 4-6 ml. Swish, retain in mouth as long as possible, then swallow.
Recommended therapy with either is QID x two weeks. Note that the oral suspension has a high
sugar content, which may precipitate caries or xerostomia.
In
moderate to severe cases:
1. Fluconazole 200, then 100 mg po QD X 14
days; note that azole drugs are not recommended during pregnancy.
2. In refractory
cases, check to ensure that the causal organism is not azole-resistant. If
discovered to be of mycotic etiology, treat with IV Amphotericin B
3. In cases so severe as to interfere with
adequate nutrition and hydration, patient may require hospitalization for
hydration and nutritional support.
4. In patients who wear partials or dentures,
have them soak the prosthesis in chlorhexidine solution (such as PerioGard),
then apply a thin coating of Nizoral cream on the acrylic portion of the
appliance that will be in contact with the oral mucosa before reinserting into
the mouth. This will prevent
re-infection by the appliance.
5. Maintenance therapy for future suppression
may be necessary, and can range from one Mycelex lozenge per day to one lozenge
TID. Fluconazole suppressive therapy is
generally not recommended except for those patients with documented esophageal
candidiasis due to the possibility of azole resistance with long term use.
Patient Education:
1. Maintain
good oral hygiene by brushing teeth after each meal.
2. Rinse mouth of all food before using either
lozenges or suspension for treatment.
Teach proper use of all medications.
3. Avoid mouth trauma: use a soft toothbrush,
don't eat food or drink liquids that are too hot in temperature or too spicy.
4. For patients who
have candidiasis under a denture or partial denture: Remove prosthesis before use of topical
agents such as Mycelex or Nystatin. At
bedtime, place the prosthesis in a chlorhexidine solution, then apply a thin
coating of Nizoral cream on the acrylic portion of the appliance before
reinserting into the mouth.
5. Women on azole drugs should avoid pregnancy
due to possible skeletal and craniofacial abnormalities in infants.
References:
Magaldi S, Mata S, Hartung C, et
al. In vitro susceptibility of 137 Candida
sp. isolates from HIV positive patients to several antifungal drugs. Mycopathologia 2001; 149(2):63-68.
Sande MA, Gilbert DN,
Moellering RC Jr. The
CDC. USPHS/IDSA
Guidelines for Preventing Opportunistic Infections Among
HIV-Infected Persons. MMWR 2002; 51 (No. RR-8).
New York State Department of Health AIDS
Institute. Oral
health care for people with HIV infection. Downloaded