Oropharyngeal candidiasis
Background
- Also known as thrush
- Typically occurs when the normal host immunity or host flora are disrupted, allowing for overgrowth of Candida albicans
- Most commonly seen in infants, immunocompromised, older adults with dentures
Risk Factors
- Extremes of age
- Antibiotics
- Corticosteroids
- Immunocompromised (AIDS, immunosuppressant medications)
- Diabetes
- Malignancy
Clinical Features
- White curd-like (pseudomembraneus) plaques that are difficult to remove and leave behind an erythematous base on the oral mucosa, tongue, palate, or oropharynx
- Usually painless
- Cotton sensation in mouth
- Angular cheilitis
- Loss of taste
Differential Diagnosis
Tongue diagnoses
- Tongue laceration
- Strawberry tongue
- Black hairy tongue
- Oropharyngeal candidiasis (oral thrush)
- Hairy Oral Leukoplakia
- Tongue swelling
- Trauma
- Angioedema
- Hereditary
- Allergic (ACE)
- Idiopathic
Oral rashes and lesions
- Angioedema
- Aphthous stomatitis
- Herpes gingivostomatitis
- Herpes labialis
- Measles (Koplik's spots)
- Perioral dermatitis
- Oral thrush
- Steven Johnson syndrome
- Streptococcal pharyngitis
- Tongue diagnoses
- Vincent's angina
Evaluation
- Most cases are diagnosed clinically and need only one of the treatments listed below[1]
- May consider KOH prep of skin scrapings (using a tongue depressor), if available
- Consider HIV testing if no other etiology is determined or if risk factors are present
Management
Treatment is targeted against Candida species
- Topical agents
- Patients with their first presentation of mild thrush
- Azole therapy
- Patients with moderate to severe oropharyngeal candidiasis or for those
- Patients with recurrent disease
- HIV-positive patients who are at risk of developing esophageal candidiasis (CD4 count <100 cells/microL)
Antifungals
- Voriconazole 200mg BID up to 28 days until symptom resolution
- only for Candida species resistant to fluconazole
- Nystatin oral suspension 400,000-600,000 units (swish and swallow) Q6H until 48 hours after symptoms disappear OR
- Clotrimazole 10 mg troches 5 times/day for 14 consecutive days OR
- Fluconazole 200 mg (Peds: 6 mg/kg) PO on day one, followed by 100 mg (Peds: 3 mg/kg_ daily for two weeks.
- Fluconazole is reserved for moderate to severe disease
Pediatric Dosing
If the patient is breast feeding it is important for the mother to treat her nipples before and after feeding
- Nystatin Oral Suspension
- 100,000 units/ml for 14 days for all ages
- Premature infants should only have 0.5 - 1 mL given to each side of the mouth every 6 hours
- Clotrimazole 10mg PO five times daily for 14 days
- reserved for patients > 3 years old
Disposition
- Thrush is typically self-limited and patients may be discharged home unless concomitant symptoms require further work-up
See Also
References
- ↑ Pappas PG, Kauffman CA, Andes DR, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 62:e1.