Oral Pathology 1

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Histoplasmosis

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- Endemic to Ohio and Mississippi River Valleys
- Spores in bird or bat dropping
- Most cases are asymptomatic- calcified hilar lymph nodes seen coincidentally
- Acute: may have flu-like symptoms
- Chronic: cavitary pulmonary lesions
- Disseminated: elderly, debilitated, or immunocompromised

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Histoplasmosis- Oral Lesions

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- Usually seen in the disseminated form of the disease
- Affects tongue, palate, or buccal mucosa
- Presents as a chronic variably painful ulcer or granular erythematous plaque
- Clinically may be identical to malignancy (rolled margins)
- Granulomatous inflammation, w/ or w/o necrosis
- 1-2 micron yeasts, usually w/in macrophages
- Best visualized w/ PAS stains
* Looks similar to TB

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Histo Diagnosis

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- ID'd by small yeasts in tissue sections
- Serological testing for antibodies or yeast-related antigens

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Histoplasmosis Tx

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- Acute: no Tx usually necessary; good prognosis
- Chronic/disseminated: may require amphotericin B. Fair prognosis for chronic; mortality rate of 90% for unTx disseminated
- Ketoconazole or itraconazole for mild cases or as maintenance therapy

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Coccidiomycosis

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- "Valley fever" represents a hypersensitivity
- Inhalation of spores
- Flu-like illness in 40 % of infected patients
- Dissemination in <1%
- Skin of central face may be affected; oral lesions are rarely described
- Large spherules w/ endospores
- Variable host response, ranging from acute to granulomatous inflammation
- Dx made from culture or biopsy

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Tx and Prognosis for Coccidiomycosis

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- Amphotericin B for disseminated cases
- Fluconazole or itraconazole for milder cases
- May be more aggressive in persons of color
- Generally good prognosis if patient is not immunocompromised

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Cryptococcosis

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- From pigeon droppings and transmitted by air-borne spores
- Affects immunosuppressed patients almost exclusively

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Crypto- Clinical

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- Flu-like symptoms w/ initial pulmonary infection
- Disseminates to meninges, resulting in headache, vomiting, neck stiffness
- Cutaneous lesions may develop in 10-20%
- Oral lesions are rare

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Crypto Histo

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- 4 to 6 micron yeasts w/ a clear halo
- Organisms may be visualized w/ mucicarmine, PAS, or silver stain
- Dx based on culture or identification of organisms in tissue sections

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Crypto Tx

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- Severe cases treated w/ amphotericin B and flucytosine
- Fluconazole for less severe cases and for maintenance
- Poor prognosis because most patients are immunocompromised

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Zygomycosis

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- AKA Mucormycosis
- Several genres of molds
- Affects severe diabetic or immunocompromised patients

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Zygomycosis- Clinical

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- Nasal obstruction, bloody nasal discharge
- Facial pain, swelling, palatal perforation
- Black necrotic lesions
- With progression superiorly, visual disturbances and blindness result
- Seizures and death occur with intracranial invasion

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Zygomycosis Histo

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- Diagnosis is usually based in histopathologic findings because culture is too slow
- Large, branching, nonseptate hyphae w/ extensive tissue necrosis
- Hyphae are often seen plugging small BV

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Zygomycosis Tx

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- Radical surgical debridement
- IV ampotericin B
- If patient is diabetic, control diabetes is important
- Poor prognosis

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Aspergillosis

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- Common; 2nd in frequency to Candidiasis
- Spectrum of disease that includes allergy, localized infection or invasive aspergillosis
- Spores in soil, water, decaying organic debris
- May be nosocomial infection

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Aspergillosis- Clinical

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- Features vary, depending in immune status and extent of tissue invasion
- Allergy: allergic fungal sinusitis (may trigger asthma)
- "Aspergilloma"- maxillary sinus fungus ball
- Tissue damage post-extraction or RCT
- Immunocompromised patient- disseminated

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Aspergillosis- Diagnosis

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- Biopsy shows branching septate hyphae
- Occlusion of small BV by hyphae
- Granulomatous inflammation if the host is not immune compromised
- Little inflammation if immunocompromised
- Culture can be done, but may be too slow

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Aspergillosis- Tx and Prognosis

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- Non-invasive disease: debridement
- Invasive disease: Voriconazole or itraconazole w/ or w/o debridement
- Good prognosis if normal immune status
- Poor prognosis if patient is immunocompromised

Front 19

Candida Albicans

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- Very common dimorphic yeast
- Yeast form: commensal
- Hyphal form: pathogen
- Ability of the yeast to undergo transformation to hyphal form under appropriate conditions, producing germinative tubes

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Pathogenesis of Candidiasis

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- Severity depends on 3 factors:
1) Host immune status
2) The oral mucosal environment
3) The virulence of the candidal strain

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Acute Pseudomembranous Candidiasis

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- "Thrush"
- White, curled milk or cottage cheese-like plaques; can be wiped-off
- Buccal mucosa, palate or tongue
- May be asymptomatic, but burning or unpleasant taste occasionally noted

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Erythematous Candidiasis

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- Usually area of redness, variable borders
- Tongue is common site
- Diffuse atrophy of dorsal tongue papillae, particularly after broad-spectrum antibiotics
- Typically causes "burning" sensation
*Smooth, shiny, "bald" tongue

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Central Papillary Atrophy

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- Probably referred to as "median rhomboid glossitis" in the past
- Most are undoubtedly due to chronic candidiasis
- Well-defined area of redness; mid-posterior dorsal tongue
- Usually asymptomatic

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Denture Stomatitis

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- Often referred to as "chronic atrophic candidiasis"
- Not much evidence to support this concept
- Denture is often contaminated w/ candidial organisms, but no invasion of mucosa is seen
- Erythema of palatal denture-bearing area; typically asymptomatic

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Hyperplastic Candidiasis

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- AKA "candidial leukoplakia"
- White patch that cannot be rubbed off
- Often seen on anterior buccal mucosa
- May be problematic because a true leukoplakia may have candidiasis superimposed on it
- Should resolve w/ antifungal therapy

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Angular Chelitis

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- Usually unrelated to candidiasis, but may have other cutaneous bacterial microflora admixed
- Redness, cracking of corners of mouth
- Waxes and wanes
- Typically responds well to topical anti fungal therapy

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Multifocal Candidiasis

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Patient will have angular chelitis, central papillary atrophy, and a kissing lesion of the posterior hard palate

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Perioral Candidiasis

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Assoc. with lip-licking or chronic use of petrolatum-based materials

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Chronic Mucocutaneous Candidiasis

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Assoc. with specific immunologic defects related to how the body interacts w/ Candida albicans

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Invasive Candidiasis

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Seen in situations of severe uncontrolled diabetes mellitus or immune suppression

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Diagnosis of Candidiasis

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- Sometimes clinical signs and symptoms are sufficient
- Culture- may not distinguish between carrier and infection
- Exfoliative cytology
- Biopsy- usually not necessary

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Histopathic features of Candidiasis

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- Variable host response to the organism: micro abscesses may be seen in the superficial epithelium; chronic inflammation of the CT
- Acanthosis is often present
- In almost all cases, the candidal hyphae never penetrate deeper than the keratin layer

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Candida Prognosis

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- Good in normal patients
- Fair to poor prognosis, depending on degree of immune suppression

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Candidiasis Tx

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- Depends on the severity of the infection
- Superficial oral mucosal infections can usually be treated with one of the milder topical or systemic anti fungal agents
- Life-threatening infections usually require intravenous amphotericin B