Oral Candidiasis (Thrush)


Article Author:
Michael Taylor


Article Editor:
Avais Raja


Editors In Chief:
Chaddie Doerr


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
8/17/2019 9:25:46 PM

Introduction

Oral candidiasis or thrush is an infection of the oral cavity by Candida albicans.

It was first described in 1838 by pediatrician Francois Veilleux.

Oral candidiasis is generally obtained secondary to immune suppression, whether a patient's oral cavity has decreased immune function or if it is systemic. An example of local immunosuppression is the use of inhaled corticosteroids (often in the preventive treatment of asthma and chronic obstructive pulmonary disease). This immunosuppression has been found to be dose-dependent.[1] For this reason, patients using such medications are instructed to rinse their mouth with water after each use. In this way, the beneficial effects of the corticosteroid affect the bronchioles, but the negative immunosuppressive effects become decreased in the oral cavity.

Examples of systemic immunosuppression are very young or very old age, immunocompromising conditions such as HIV/AIDS and chronic systemic steroid/antibiotic use.[2][3]

Oral thrush is transmittable via kissing as well as breastfeeding.

Etiology

Oral candidiasis is caused by the Candida species, most commonly Candida albicans.[4] It can also result from Candida glabrata, Candida tropicalis, and Candida krusei. Non-albicans Candida species have been shown to colonize patients 80 years old and above more frequently than younger patients.[5]

Epidemiology

Oral candidiasis can occur in immunocompetent or immunocompromised patients but is more common in immunocompromised hosts.

It occurs equally in males and females. 

It typically occurs in neonates and infants. It is rare for patients to have in the first week of life. It is most common during the fourth week of life and less common in infants older than 6 months (likely secondary to the development of host immunity). Signs and symptoms of immunosuppression in these patients are diarrhea, rashes, repeated infections, and hepatosplenomegaly.

Pathophysiology

Candidal species cause oral thrush when a patient's host immunity becomes disrupted. This disruption can be local, secondary to oral corticosteroid use. Overgrowth of the fungus then leads to the formation of a pseudomembrane. Vaginal Candidal infections can colonize neonates as they pass through the birth canal. Alternatively, neonates and infants may contract the disease through colonized breasts when breastfeeding. Often, a patient's oral Candidal infection can lead to GI involvement as well as subsequent Candidal diaper dermatitis. Candidal species thrive in moist environments. As such, females can develop vaginal candidiasis as well. 

In healthy patients, usually, the patient's immune system and normal flora of bacteria inhibit candida growth. Consequently, immunosuppression in forms such as diabetes, smoking, dentures, steroid use, malnutrition, vitamin deficiencies, and recent antibiotic use often leads to the disease.

Histopathology

Plaques can be cultured, gram stained and stained with potassium hydroxide. Gram stain shows large, ovoid, gram-positive yeast. Potassium hydroxide stain shows pseudohyphae.

History and Physical

On history taking, patients will often complain of patchy white lesions on the tongue and/or buccal mucosa. 

Additionally, it is crucial to elicit forms of immunosuppression such as smoking, antibiotic and/or steroid use, immunosuppressing drugs in transplant patients, use of dentures, malnutrition, etc.

Clinically, oral candidiasis consists of white pseudomembranous plaques. They are difficult to remove and affect the oral mucosa, tongue, hard, and soft palates. It is usually painless, associated with a loss of taste and angular cheilitis (cracking of the skin at the corner of the patient's mouth).

The plaques are often challenging to scrape off with a tongue blade. After scraping, inflamed, painful lesions often remain that may bleed.

Patients may also have a candidal rash in other regions of their bodies as well. Clinicians need to check for candidal diaper dermatitis as well.

Evaluation

Diagnosis of oral candidiasis is often clinical, based on appearance and risk factors. Additionally, the appearance of an erythematous, inflamed, and bleeding base after scraping off the plaques also leads to a likely oral thrush diagnosis.

For further confirmation, plaques can be cultured. Alternatively, a gram stain of plaques showing large, ovoid, gram-positive yeast is diagnostic. Lastly, pseudohyphae with a potassium hydroxide stain can be visible.

In addition to the confirmation of candidiasis, testing to diagnose an underlying immunocompromising condition is important. Patients should be interviewed, examined, and tested accordingly for diseases such as HIV, adrenal insufficiency, malnutrition, steroid use, and diabetes. 

Treatment / Management

Treatment focuses on Candida species. It should be targeted to the extent of the involvement and degree of immunosuppression of the patient. In general, antifungal agents are the recommended treatment. These treat infection by altering RNA or DNA metabolism or causing intracellular accumulation of peroxide in the fungal cells.

For patients with a mild presentation or having their first presentation of the disease, topical treatment is the recommended therapy. One option is clotrimazole troches 10 mg orally five times daily (dissolved over 20 minutes). Another is nystatin oral suspension (100000 units/mL) 5 mL orally four times daily (swished for several minutes then swallowed).[6][7] In the appropriate circumstances, miconazole oral gel may also be an option.[8]

For moderate to severe disease, fluconazole 200 mg orally once then 100 mg orally once daily for a total of 7 to 14 days is recommended. Data regarding the safety of fluconazole during breastfeeding is reassuring.[9]

For refractory disease, options are Itraconazole oral solution 200 mg once daily without food for 28 days, posaconazole suspension 400 mg orally two times daily for 3 days, then 400 mg orally daily for a total of 28 days and voriconazole 200 mg orally two times daily for 28 days.

Additionally, single-dose oral fluconazole 150 mg has shown to be effective in patients with advanced cancer, thus helping reduce pill burden.[10]

For vaginal candidiasis, several over the counter options are available: clotrimazole 1% cream vaginally for 7 to 14 nights, clotrimazole 2% cream vaginally for 3 nights, miconazole 2% cream vaginally for 7 nights, miconazole 4% cream vaginally for 3 nights, miconazole 100 mg suppository vaginally for 3 nights, tioconazole 6.5% ointment vaginally once. There are also prescription therapies: nystatin 100000-unit vaginal tablet for 14 nights, terconazole 80 mg one suppository vaginally for 3 nights, terconazole 0.8% cream vaginally for 3 nights, butoconazole 2% cream one applicator vaginally once (do not use during the first trimester of pregnancy). Lastly, an oral therapy option is fluconazole 150 mg PO once (may repeat in 72 hours if symptoms persist).

Dosing for these regimens should be adjusted according to weight for pediatric patients.

In addition to treatment, patients should receive counseling on how to decrease immunosuppressing conditions such as uncontrolled diabetes, smoking, and malnutrition. 

Differential Diagnosis

When suspecting the diagnosis of oral candidiasis in a patient with oral lesions, a differential diagnosis of oral hairy leukoplakia (a condition triggered by the Ebstein-Barr virus), angioedema, aphthous stomatitis, herpes gingivostomatitis, herpes labialis, measles (Koplik spots), perioral dermatitis, Steven-Johnsons syndrome, histiocytosis, blastomycosis, lymphohistiocytosis, diphtheria, esophagitis, syphilis and streptococcal pharyngitis amongst other conditions must be considered.

Prognosis

The prognosis of a patient with oral thrush often is dependent on his or her degree of immunosuppression. Those that are otherwise immunocompetent will often achieve resolution of the disease and symptoms. Those that are immunocompromised often need concomitant treatment of their immunosuppressing condition to fully recover.

Complications

Although unlikely in an immunocompetent host, oral candidiasis can lead to pharyngeal involvement. Symptomatically, this can lead to dysphagia and respiratory distress.

A significant concern for immunocompromised patients is the systemic dissemination of the disease.

Candidal esophagitis is a particularly common complication of oral candidiasis in those with HIV/AIDS.

Deterrence and Patient Education

Patients with oral thrush should receive counseling regarding the future spread of the disease. They also need to understand the importance of diagnosing and treating any immunosuppressing conditions.

Pearls and Other Issues

One of the most critical educational pearls regarding the diagnosis and treatment of candidal thrush is clinical suspicion. A healthcare provider must take a thorough history to know when a patient has an immunocompromising condition. Knowing this can lead to the healthcare provider evaluating for thrush in the first place and being aware of the possibility of other, potentially life-threatening, systemic infections.

Enhancing Healthcare Team Outcomes

Oral candidiasis is a diagnosis that is important to make. Patients usually have white and/or gray patches in their oral mucosa. They may also have systemic manifestations of their immunocompromised state. Examples of these are dysphagia secondary to pharyngeal candidiasis, failure to thrive, and sepsis. Case management for the majority of these patients will be by the primary care provider, nurse practitioner, and obstetrician.

Since the diagnosis and treatment of oral candidiasis have several important implications for the patient, healthcare professionals must work together. Registered nurses, physician assistants, nurse practitioners, and physicians must collaborate both in triage and diagnostic areas to correctly diagnose oral thrush. Pathologists may be involved to assess culture and stain oral scrapings. Depending on the underlying immunosuppressing condition, oncologists and infectious disease specialists may provide consult. As oral candidiasis is often the first sign of a significant systemic immunocompromising condition, the hand-off from the primary healthcare provider to see the patient to the specialists that will continue to monitor their chronic illness is very important. The pharmacist should educate the patient on the importance of medication compliance, as well as well as verifying medication dosing and checking for drug-drug interactions, and reporting any concerns to the healthcare team. Patients with diabetes should be urged to monitor their blood sugar levels. Also, the patient should receive instruction to quit smoking. Patients who take inhaled steroids should be asked to perform water gargles after each use and follow up with the clinician. Nursing will administer medications for inpatients and provide significant counseling to reinforce the points above. Only with an interprofessional collaborative team approach can candidiasis treatment achieve optimal patient results. [Level V]

Lastly, it is imperative that healthcare providers treating those susceptible to oral candidiasis be aware of the utility of preventive strategies. For example, via randomized controlled trials, probiotics, for example, have been shown to prevent oral candidiasis in the elderly.


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Oral Candidiasis (Thrush) - Questions

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A 35-year-old male presents to the emergency department with a two-day complaint of cough and fever. He is a chronic cigarette smoker. Physical examination reveals rhonchi and wheezing and the chest x-ray shows a right middle lobe infiltrate. Antibiotics and inhaled corticosteroids are started for treatment. These treatments are two of several risk factors for which of the following conditions?



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A 20-year-old female presents to the clinic with a 2-day history of a "strange feeling in my mouth." On physical examination, there is a white plaque on her tongue. It is easily scraped off. Which of the following is most likely to increase the development of this condition in an adult patient?



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A 70-year-old patient with a history of HIV presents to the infectious disease clinic with a new lesion in his oral cavity. He reports a history of nephrotic syndrome during childhood which resolved with medical treatment. On examination, his vital signs are within normal limits, and he has a whitish layer on his tongue that is scraped off, leaving an erythematous base. He is diagnosed with a fungal infection. What is the most common fungal infection of the oral cavity in immunocompromised individuals?



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A 16-year-old male presents with non-specific viral symptoms. He is an IV drug abuser. Which of the following is the most common finding leading to the diagnosis of HIV infection?



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A 2-week-old female presents to the emergency department with irritability. On exam, there is a white adherent coating and erythema of the tongue and buccal mucosa and bleeding when the coating is removed. What is the appropriate step in its management?



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A 17-year-old male with asthma is well controlled on occasional albuterol, inhaled budesonide, and montelukast. He has white patches on his buccal mucosa. Which of the following would be appropriate?



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A 34-year-old female with AIDS presents to her primary care provider with white plaques on her oral mucosa that scrapes off, leaving erythematous bases. Which of the following microscopic examination of the plaque will be noticed in this patient?



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A 32-year-old female with a history of systemic lupus erythematous presents to the emergency department with the chief complaint of "my tongue looks different." Oral examination shows a whitish tongue. She also reports of dry mouth as well as a recently increased course of prednisone. What is the most appropriate diagnosis?



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A 57-year-old male with a history of HIV, nonadherent with highly active antiretroviral therapy (HAART), presents to the clinic with a dry sensation in his mouth. He describes "something white in my mouth." What is the most likely complication of his current condition if left untreated?



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A 3-week old male presents to the pediatric emergency department with white lesions in his mouth. He is diagnosed with oral thrush. Which of the following is the most common causative organism?



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A 30-year-old male presents with white patches on his tongue. On physical exam, it is scraped off with underlying erythema. Such patches have been recurring over and over again. What is the most appropriate treatment for this patient's recurrent symptoms?



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A 57-year-old female presents to the emergency department with throat pain. It started with a "funny feeling in my mouth." She complains of a "grayish-white" appearing tongue as well. What underlying condition is most likely to cause the progression of this disease?



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A 2-month-old male is brought to the clinic by his mother, who is worried about his tongue appearing more gray than usual. The mother's obstetrical course and vaginal delivery have been uncomplicated, receiving adequate prenatal care. The patient appears well overall, with mild irritation upon oral examination. A fungal infection is suspected. Aside from the most likely diagnosis, what is most appropriate to include in the differential diagnosis?



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A 16-year-old female presents with dysuria. Last week, she had an upper respiratory tract infection for which she was prescribed antibiotics for a week. On vaginal examination, white discharge is seen. A urinalysis is negative for any significant findings. Which of the following is associated with this patient's diagnosis?



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A 52-year-old man presents with a rash between his gluteal folds. He states it is itchy and painful. He has a history of diabetes mellitus type 2 and is currently not taking any medication for it. On examination, mild erythematous patches are present on both sides of the skinfolds with smaller lesions surrounding it. Which of the following is used for treating this patient's condition?



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Oral Candidiasis (Thrush) - References

References

Dekhuijzen PNR,Batsiou M,Bjermer L,Bosnic-Anticevich S,Chrystyn H,Papi A,Rodríguez-Roisin R,Fletcher M,Wood L,Cifra A,Soriano JB,Price DB, Incidence of oral thrush in patients with COPD prescribed inhaled corticosteroids: Effect of drug, dose, and device. Respiratory medicine. 2016 Nov;     [PubMed]
Lagman R,Davis M,LeGrand S,Walsh D,Parala A,Gamier P,Cothren B,Cheema B,Gopal S,Rybicki L, Single-Dose Fluconazole Therapy for Oral Thrush in Hospice and Palliative Medicine Patients. The American journal of hospice     [PubMed]
Zhang LW,Fu JY,Hua H,Yan ZM, Efficacy and safety of miconazole for oral candidiasis: a systematic review and meta-analysis. Oral diseases. 2016 Apr;     [PubMed]
Fangtham M,Magder LS,Petri MA, Oral candidiasis in systemic lupus erythematosus. Lupus. 2014 Jun;     [PubMed]
Sivabalan S,Mahadevan S,Srinath MV, Recurrent oral thrush. Indian journal of pediatrics. 2014 Apr;     [PubMed]
Lyu X,Zhao C,Yan ZM,Hua H, Efficacy of nystatin for the treatment of oral candidiasis: a systematic review and meta-analysis. Drug design, development and therapy. 2016;     [PubMed]
Hellfritzsch M,Pottegård A,Pedersen AJ,Burghle A,Mouaanaki F,Hallas J,Grove EL,Damkier P, Topical Antimycotics for Oral Candidiasis in Warfarin Users. Basic     [PubMed]
Benito-Cruz B,Aranda-Romo S,López-Esqueda FJ,de la Rosa-García E,Rosas-Hernández R,Sánchez-Vargas LO, Oral Candida isolates and fluconazole susceptibility patterns in older Mexican women. Archives of gerontology and geriatrics. 2016 Jul-Aug;     [PubMed]
Kaplan YC,Koren G,Ito S,Bozzo P, Fluconazole use during breastfeeding. Canadian family physician Medecin de famille canadien. 2015 Oct;     [PubMed]
Astvad K,Johansen HK,Høiby N,Steptoe P,Ishøy T, Oropharyngeal Candidiasis in Palliative Care Patients in Denmark. Journal of palliative medicine. 2015 Nov;     [PubMed]

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