Fungal Infections

FUNGAL
INFECTIONS
Post graduate 2nd year

 Introduction
 Structure of fungi
 Classification of fungi
Contents  fungal infections
 Candidiasis
 Deep fungal infections
 Diagnosis
 Treatment
Fungi
 A separate kingdom
 Neither a plant nor an animal
Includes
 mushrooms, rusts, smuts, puffballs, truffles, morels,
molds, and yeasts.
A variety of sizes
 Microscopic single-celled organisms e.g. yeast
 Multicellular macroscopic organisms.
 Human feet harbours over 200 species of fungi more than
any other body sites .

Eukaryotic organisms
Two basic forms:
- Yeasts
- Molds
 Have rigid cell wall composed of chitin (bacterial cell

wall is composed of peptidoglycan)
 Fungal cell membrane contains ergo sterol , human cell
membrane is composed of cholesterol
Structure
 The main body of most fungi is made up
of fine, branching, usually colorless
threads called hyphae
 Several of these hyphae, all
intertwining to make up a tangled web
called the mycelium
 Most fungi are multinucleate and
multicellular organisms with cross wall
called septa or aseptate (coenocytic)
Classification
Classified by method of reproduction
 Zygomycetes
 Basidomycetes
 Ascomycetes
 Deuteromycetes
Depending on Morphology
 Yeasts
 Yeast like fungi
 Molds
 Dimorphic fungi
Based on their spore formation
 Phycomycetes
 Ascomycetes
 Basidiomycetes
 Fungi imperfecti
Fungal infections
1. Superficial Affects stratum corneum only
2. Cutaneous Affects superficial keratinized

tissue only
3. Subcutaneous reach subcutaneous tissue by

traumatic
inoculation
4. Endemic (primary, systemic):
5. Opportunistic
 Superficial : Affect skin – mucous membrane
– Tinea versicolor
– Dermatophytes : affect keratin layer of skin, hair, nail.

e.g.tinea pedis, ring worm infection
– Candidiasis : Yeast-like, oral thrush, vulvo-vaginitis ,

nail infections.
 Deep Infections : – Affect internal organs as :

lung ,heart , brain leading to pneumonia ,
endocarditis , meningitis.
Endemic (primary, systemic):
 Histoplasma capsulatum,
 coccidioides immitis,
 blastomyces dermatitidis,
 paracoccidioides brasiliensis
Opportunistic
Endogenous
 Candida (different species)
 Pneumocystis carinii
Exogenous
 Cryptococcus neoformans
 Aspergillus (different species)
 Zygomycetes
 Many other fungi
Candidiasis
 Candidosis, moniliasis, thrush
 Most prevalent opportunistic infection affecting the oral
mucosa.
 Candida albicans
 Oral candidiasis is divided in to primary and secondary
infections.
 Primary – oral and perioral sites.
 Secondary – systemic mucocutaneous manifestations.
Burkett's oral medicine text book 12th edition

 Although other species, such as C. tropicalis, C. parapsilosis,
C. stellatoidea, and C. krusei. C. guilliermondii and C.
glabrata may also be involved.
 Candida exists in three forms namely, pseudohyphae, yeast,

and chlamydospore forms.
 It reproduces by asexual budding and forms pseudohyphae.

These species grow rapidly at 25–37°C.
 The incidence of oral candidiasis has increased after the

advent of human immunodeficiency virus. It is reported that
more than 90% of the HIV infected individuals develop oral
candidiasis during some part of their disease
Epidemiology
 Most species are part of the normal flora of the mouth, skin,
vagina, gastrointestinal or respiratory tracts; they are found
worldwide.
 They are also found on plants, in water and dairy products, on

fruits and vegetables, etc.
 Candida sp. is the most common cause of opportunistic fungal

infections, and are the fourth most common cause
ofsepticemia.
 C. albicans is the most frequent species found in clinical

specimens; recently there has been a shift such that non-
albicans Candida species are increasingly encountered.
Predisposing factors for oral candidiasis
Medications Broad-spectrum antibiotics, systemic steroids, steroid
inhalers, cytotoxic agents
Nutritional factors Iron, folate, B12 deficiencies, high
carbohydrate intake, protein energy
malnutrition , Vitamins C and A
 deficiencies
Systemic diseases Diabetes mellitus, hypothyroidism,
hypoparathyroidism, Addison’s
disease, Sjogrens syndrome,
hereditary myeloperoxidase deficiency,
Chediak-Higashi syndrome, DiGeorge
syndrome
HIV and AIDS Human immunodeficiency virus
infection and acquired
immunodeficiency syndrome, related
to the progressive depletion of the
CD4+ T lymphocytes
Xerostomia Caused by medications, systemic
diseases, irradiation
Malignancy and cancer therapy Acute leukemia, cancer patients
undergoing chemotherapy and
radiotherapy
Other factors Wearing dentures, smoking, persons
with increased blood group H antigen,
Immunopathogenesis of Candidiasis
 Many specific and nonspecific factors have a role in the

development of candidiasis.
 Various anticandidal factors and antiadherence factors also

play a major role in its development. Salivary IgA affects the
adherence of Candida to mucosal cells.
 T cells and neutrophils also play a role in preventing and

clearing the infection.
Clinical Features
 It has a variety of clinical manifestations, making the
diagnosis sometimes difficult.
 Candidal infection may range from mild superficial mucosal

involvement to severe, fatal disseminated form seen in
immunocompromised individuals.
 The classification proposed by Samaranayake in 1991 and

modified by Axéll et al, in 1997 divides candidiasis into two
major categories namely:
 (1) primary oral candidiasis (infection exclusively confined to

oral and perioral tissues), and
 (2) secondary oral candidiasis (oral lesions as a manifestation

of systemic mucocutaneous candidiasis).
Classification
Primary oral candidiasis Secondary oral candidiasis
Acute familial chronic mucocutaneous
candidiasis
Pseudomembranous diffuse chronic mucocutaneous
candidiasis
Erythematous Candidiasis endocrinopathy syndrome
familial mucocutaneous candidiasis
Chronic Severe combined immunodeficiency
Pseudomembranous Di George syndrome
Erythematous Chronic granulomatous disease
Plaque like Acquired immunodeficiency syndrome
Nodular
Candida associated lesions
Denture stomatitis
Angular chelitis
Median rhomboid glossitis

Pseudomembranous candidiasis
 Oral thrush
 It may occur at any age
 acute and chronic
 The oral lesions are characterized by the
appearance of soft, white, slightly elevated
plaques most frequently occurring on the buccal
mucosa and tongue, but also seen on the palate,
gingiva, and floor of the mouth
 Less pronounced infections some times have
clinical features that are difficult to discriminate
from food debris like egg and yoghurt.

 The plaques, which have often been described grossly
as resembling milk curds, consist chiefly of tangled

masses of fungal hyphae with intermingled
desquamated epithelium, keratin, fibrin, necrotic
debris, leukocytes, and bacteria.
 Infection typically with loosely attached membrane
comprising fungal organism, cellular debris which

leaves an inflamed, sometimes bleeding are if pseudo
membrane removed.
Treatment
 Nystatin is drug of choice.
 It is commonly used as topical agent to suppress Candida infection.
 Thrush is treated by holding 5 ml of nystatin suspension (for infants- 2
ml) in oral cavity for several minutes 4 times daily before swallowing.
 Nystatin oral pastille (200,000 units) dissolved slowly in the mouth 5
times a day—can be mixed with glycerin.
 Mycostatin oral rinse - 1 teaspoon of nystatin oral suspension
(100,000unit/cc) mixed with ¼ cup of water is used as oral rinse for 3-
4 times a day for 7-10 day
 Amphotericin B is mostly applied topically in the form of ointment,
suspension, drops, cream, and lotion. It is applied 2-3 times a day.
Tapaswini Bagh,Laxmikanth Chatra, Prashanth Shenai,Veena

K M ,Prasanna Kumar Rao ,Rachana V Prabhu. ANTIFUNGAL
DRUGS USED IN DENTISTRY. Int J Dent Health Sci 2014;
1(4):523-539 .
Erythematous candidiasis
 Also called atrophic candidiasis
 antibiotic sore mouth, includes central papillary atrophy of the
tongue and cheilocandidiasis

 Appears as erythematous patches in the mucosa
 The redness is due to increased vascularity.
 Could be chronic or acute
 Commonly seen in the palate, dorsal tongue
 Tongue depapillation
 Mainly associated with broad spectrum antibiotics or
corticosteroids
Chronic hyperplastic candidiasis
 Also called candidal leukoplakia
 The oral lesions consist of firm, white persistent

plaques, usually on the lips, tongue, and cheeks
and appear similar to leukoplakia .
 White plaque present in the commissural region,
palate and tongue

Candida associated lesions
Denture stomatitis
 denture sore mouth
 A chronic inflammatory condition in

denture bearing mucosa
 Erythematous lesions
 Denture provides ideal environment for

Candida growth
 Attachment sites
 Denture hygiene is critical

Treatment
 0.2% chlorhexidine solution with Mycostatin tablet
dissolves in it forming gel used mainly in such

patients.
 In denture wearing patients, nystatin ointments are to
be applied to the fitting surface of clean denture

thoroughly and regularly and should be left out of
mouth at night keeping it in 0.02% of sodium
hypochlorite solution.
 Bergendal and Isacsson reported similar results by
treating denture stomatitis with nystatin powder,

placed on the fitting surface of the denture; three
Median rhomboid glossitis
 Uncommon condition
 Men are affected more
 Rhomboid shape hypertrophic or
atrophic plaque in the mid dorsal tongue

 Association of Candida with median
rhomboid glossitis is controversial

Angular Cheilitis
 Mixed bacteria fungal infections
 Corners of the mouth is affected
 Staphylococci and streptococci are often

associated
 Erythematous fissuring in the angle of mouth
 Accompanied by a pseudomembranous covering
 Can affect anterior nostril region too
 Predisposing factors: facial wrinkling, reduced

occlusal vertical dimension, nutritional deficiencies
( e.g. Thiamine, Riboflavin, Iron and Folic acid)

Chronic familial Mucocutaneous Candidiasis
 Chronic localized mucocutaneous candidiasis is a
severe form of the disease also occurring early in life,

but there is no genetic transmission.
 There is widespread skin involvement and
granulomatous and horny masses on the face and scalp.

 There is an increased incidence of other fungal and
bacterial infections.
 The mouth is the common primary site for the typical
white plaques, and nail involvement is usually present

Candidiasis Endocrinopathy Syndrome
 Candidiasis endocrinopathy syndrome is also a
genetically transmitted condition characterized by
Candida infection of the skin, scalp, nails, and mucous
membranes, classically the oral cavity, in association
with either hypoadrenalism (Addison’s disease),
hypoparathyroidism, hypothyroidism, ovarian
insufficiency or diabetes mellitus.
 The oral findings in the autoimmune
polyendocrinopathy-candidiasis syndrome, including the
common finding of enamel hypoplasia.

Chronic Diffuse Mucocutaneous
Candidiasis
 Chronic diffuse mucocutaneous candidiasis is the least
common form of the disease and appears to be of late

onset over 55 years of age.
 They exhibit extensive raised crusty sheets involving
the limbs, groin, face, scalp and shoulders as well as

mouth and nails.
 In general, their clinical appearance is similar to the
lesions described in chronic hyperplastic candidiasis

and occur in the same intraoral locations.
Diagnosis of oral fungal infections
Method Main steps

Smear Scraping, smearing directly on to slide
swab Taken by rubbing cotton tipped swabs over

lesional tissue
Imprint culture Sterile plastic foam pads dipped into

sabouraud broth, placed on lesion for 60 s,
pad pressed on sab agar plate and incubated;
colony counter used.
Impression culture Maxillary and mandibular alginate
impressions; casting in agar fortified with sab
broth; incubation
Salivary culture Patient expectorates 2 ml, saliva in to sterile
container; vibration; culture in sab agar by
spiral plating; counting
Oral rinse Subject rinses for 60 s with PBS at pH 7.2 ,
0.1M, and returns it to the original container ;
concentrated by centrifugation; cultured and
counted as in previous methods.

Treatment of oral Candidal infections
Drug Form dosage comments
Amphotericin b Lozenge , 10mg Slowly dissolved in Negligible
mouth 3-4 /d after absorption from
meals for 2 weeks gastrointestinal
minimum tract .when
given iv for deep
Oral suspension, Placed in the mycoses may
100mg/ml mouth after food cause
and retained near thrombophlebiti
lesions 4/d for 2 s, anorexia,
wk. nausea,
vomiting, fever,
headache,
weight loss,
anemia,
hypokalemia,
nephrotoxicity,
hypotension
arrhythmias etc.
Nystatin Cream Apply to affected re Negligible
3-4 /d absorption from
Pastille, 100,000u Dissolve 1 pastille git, nausea and
slowly after meals vomiting with
4v/d , usually for 7 high doses
Oral d
Drug Form Dosage Comment
Clotrimazole Cream Apply to the Mild local effects,
affected area 2-3 also has anti
times daily for 3-4 staphylococcal
Solution wk. activity
5ml, 3-4 times

daily for 2wk
minimum
Miconazole Oral gel Apply to the Mild local
affected re 2-3 reactions,
times daily interacts with
Cream anticoagulants(wa
Apply twice per rfarin),
day and continue terfenadine,
for 10-14 d after cisarpide and
the lesion heals astemizole. avoid
in pregnancy and
liver disease.
Ketoconazole Tablets 200- 400 mg Nausea, vomiting,
tablets taken once rashes, pruritis ,
or twice daily liver damage.
with food for 2 Interacts with
wk. anticoagulants
Contraindicated
in pregnancy and
Drug form dosage Comments
Fluconazole Capsules 50-100mg Interacts with
capsules once anticoagulants,
daily for 2-3 wk. contraindicated
in pregnancy ,
liver and renal
disease.may
cause nausea,
vomiting,
headache, rash,
liver dysfunction
Itraconazole Capsules 100 mg capsules Interacts with

daily taken terfenadine,
immediately after cisapride.
meals for 2 wk. Contraindicated
in pregnancy and
liver disease. May
cause nausea,
neuropathy, rash.

Uncommon oral fungal infections
Aspergillosis
 Second commonest fungal infection in human
 Commonly seen with high dose of corticosteroid use, organ

and marrow transplantation, increase use of
immunosuppression against autoimmune diseases
 Lungs are commonly affected
 Also invade blood vessels causing thrombosis and infarctions
 Less commonly affect maxillary sinuses
 Oral lesions are typically black or yellow necrotic soft tissues
Krishnan PA. Fungal infections of the oral mucosa. Indian J

Dent Res 2012;23:650-9.
Clinical manifestations
 There are five major clinical forms of
aspergillosis, of which rhino cerebral
(sinuses and brain) and pulmonary (lung)
infections are the most common.
 The clinical hallmark of aspergillosis is the

rapid onset of tissue necrosis (tissue
death) with or without fever.
 Necrosis is the result of invasion of blood

vessels and subsequent thrombosis (blood
clotting).
Oral manifestations
 Oral infections are rare.
 Lingering chronic sinusitis of the maxillary
sinuses.
 Oral aspergillosis is predominantly seen in
immunocompromised individuals.
 Marginal gingiva and the gingival sulcus have
been cited as the portal of entry of the spores.
 Painful gingival ulcerations and mucosal soft
tissue swellings with gray or violaceous hue have
been reported.
 This can advance to extensive necrosis and
present clinically as a yellow or black ulcer with
facial swelling.
Treatment
 Amphotericin B at either 3 mg/kg/day or 10 mg/kg/day
for 14 days.
 Intravenous therapy for critically ill patients can include
 voriconazole - 4 mg/kg, twice daily,
 posaconazole - 300 mg IV, daily,
 micafungin - 150 mg IV, daily or amphotericin B - 1 mg/kg,

daily for a 6 to the 12-week course.
 Voriconazole is considered the first-line treatment.

Cryptococcosis
 Torulosis and European blastomycosis
 Primarily affects lungs and can lead to meningitis
 Caused by Cryptococcus neoformans, usually isolated in
pigeon’s and other birds’ droppings

 Cutaneous lesions : Face, neck and scalp
 Oral lesions are rare; resembles superficial ulcerations,
granulomas, nodules or indurated ulceration similar to

carcinoma
Dent Res 2012;23:650-9.
 The skin lesions appear as multiple brown papules
which ultimately ulcerate; the clinical picture is not
specific.
 The lesions of the lungs produce symptoms of a
nonspecific pneumonitis, while the meningeal lesions
produce a variety of neurologic signs and symptoms
generally associated with increased intracranial
pressure.
 Cryptococcosis has been repeatedly reported in
patients already suffering from some form of
malignant lymphoma, evidence of the opportunistic
nature of the disease.

Krishnan PA. Fungal infections of the oral mucosa. Indian
J Dent Res 2012;23:650-9.
Oral manifestations
 Ulcers and tumors like nodules
occurring on the gingiva and tongue.
 Intraoral sites commonly affected

are gingiva, palate and tooth socket
after extraction.
 Violaceous nodules of granulation

tissue, swellings and ulcers are the
various forms of oral lesions
reported.

Dent Res 2012;23:650-9.
Treatment and Prognosis
 The use of amphotericin B has been found to give
excellent results.
 The ultimate prognosis of the patient is variable;
however, and especially dependent upon the sites of

involvement.
 Amphotericin B (0.7–1 mg/kg/d) plus flucytosine (5-FC)
(100 mg/kg/d) 2 wk- 4 weeks

Coccidioidomycosis
 Valley Fever
 San Joaquin valley fever
 Coccidioides immitis - causes coccidioidomycosis
 Arthrospores inhaled from dust, creates spherules and
nodules in the lungs
Krishnan PA. Fungal infections of the oral mucosa. Indian J Dent

Res 2012;23:650-9.
 There are two basic forms of the disease:
primary nondisseminated and progressive
disseminated coccidioidomycosis
 In primary coccidioidomycosis, patients

generally develop manifestations suggestive of
a respiratory disease such as cough, pleural
pain, headache, and anorexia.
 In addition, about 20% of the patients develop

skin lesions, either erythema nodosum or
erythema multiforme. This form of the disease
is self-limiting and runs its course within 10-14
days.
Krishnan PA. Fungal infections of the oral mucosa.

Indian J Dent Res 2012;23:650-9.
 In the disseminated form of the disease that occurs in only
about 1% of the cases, there is a mortality rate of
approximately 50%.
 The disease usually runs a rapid course and the dissemination

extends from the lung to various viscera, bones, joints, skin,
and to the central nervous system where meningitis is the
most frequent cause of death.
Oral manifestations
 The lesions of the oral mucosa and skin
are proliferative granulomatous and
ulcerated lesions that are nonspecific in
their clinical appearance.
 These lesions tend to heal by

hyalinization and scar. Marked chronicity
is often a feature of these lesions.
 Lytic lesions of the jaws may also occur

and such a case has been reported by Igo
and his associates.

Dent Res 2012;23:650-9.
Treatment
 Amphotericin B has been found to provide effective

chemotherapeutic control of the disease.
 Amphotericin B deoxycholate - 0.5 – 1.5 mg/kg IV daily or

every other day.
 Lipid associated Amphotericin B - ≥ 2-5 mg/kg IV daily
 Fluconazole- 400-800 mg daily
 Itraconazole- 200 mg twice or thrice daily
 Posaconazole- 400 mg BID for 5-10 days

Paracoccidioidomycosis
 South American blastomycosis
 Paracoccidioidomycosis brasiliensis
 Primarily effects men
 Fever, weight loss, and productive cough with bloody
sputum
 Involves gastrointestinal tract, liver, bones, central
nervous system.
Oral manifestations
 In many cases, the first and main clinical
manifestations are oral lesions.
 The oral lesions are usually multiple and

involve the lip, gingival, buccal mucosa, palate,
tongue and floor of the mouth.
 They are often described as mulberry-like

ulcerations.
 Gingival mucosa > palate >lips.
 Lesions are frequently painful.
 Ulcerative lesions with crusting also occur on

the facial skin and may infiltrate
subcutaneously.
Treatment
 P. brasiliensis is very sensitive to most antifungal
agents, including amphotericin B, the azoles

(ketoconazole, fluconazole, itraconazole, voriconazole,
and posaconazole
 Itraconazole (200 mg/d) is considered the drug of
choice for the treatment of non severe forms of PCM

inadults
 ketoconazole (200–400 mg/d), and
 sulfadiazine (100–150 mg/kg/d)
Histoplasmosis
 Ohio Valley Fever
 Darling’s disease
 Caused by Histoplasma capsulatum; a dimorphic fungi
 Two forms; pulmonary and mucocutaneous
 Mucocutaneous form cause ulcerative/erosive lesions on tongue,
palate and buccal mucosa
 Oral lesions: single ulcers, long term and may or may not be painful
 Always misinterpreted as malignant ulcers
 Biopsy is mandatory
 The disease is characterized by a chronic low-

grade fever, productive cough, splenomegaly,
hepatomegaly and lymphadenopathy, and chiefly
involve the spleen, liver, lymph nodes, and bone
marrow.
 Anemia and leukopenia may also be present.

Oral manifestations
 Oral mucosal lesions begins as an erythema
later becomes papule and eventually forms
painful, granulomatous appearing ulcer
often with indurated border, on the
gingiva ,palate, or tongue
 The ulcerated areas are usually covered by

a nonspecific gray membrane which is
indurated with raised and rolled out
borders resembling carcinoma.
 Cervical lymph nodes are often enlarged

and firm.
Treatment
 it is a self-limited process, generally warrants no speci c treatment
other than supportive care with analgesics and antipyretics.
 Chronic histoplasmosis, intravenous amphotericin B and

itraconazole, can be used.
 Disseminated histoplasmosis, amphotericin B, itra-conazole or

ketoconazole, can be used.
 Pulmonary histoplasmosis usually, resolves spontaneously, while

severe forms of the disease are usually treated by amphotericin B.
 Prophylaxis with itraconazole (200 mg daily) is recommended in

patients withHIVinfectionwithCD4cellcounts 150 cells/mm3.
 Liposomal amphotericin B (5.0 mg/kg daily for a total of 175 mg/kg

given over 4–6 weeks.)
Blastomycosis
 North American Blastomycosis
 Caused by Blastomyces dermatitidis
 When inhaled, spores produce disseminated or local respiratory
infections
 Oral lesions are rare
 May produce ulcerated mucosal lesions in the oral cavity
 Can diagnose by using real time pcr , antibody identification
through enzyme immunoassay, biopsy, and culture on sabouraud

agar.

Dent Res 2012;23:650-9.
Clinical features
 North American blastomycosis is far more common in
men than in women and typically occurs in middle age.
 Skin lesions usually begin as small red papules which
gradually increase in size and form tiny miliary
abscesses or pustules which may ulcerate to discharge
the pus through a tiny sinus.
 Crateriform lesions are typical and these often exhibit
indurated and elevated borders
 The infection commonly spreads through the
subcutaneous tissues and becomes disseminated
through the blood stream.
 The systemic disease is characterized by fever, sudden
weight loss, and in cases of lung involvement, a

Oral manifestations
 When the disease affects the oral cavity, it

produces ulcerating mucosal lesions as
well as sessile projections, granulomatous
or verrucous lesions.
 Non specific, painless ulcer with

indurated borders and verrucous mucosal
hyperplasia.
Treatment
 AmB deoxycholate has a long track record of clinical
success with high cure rates.

 Itraconazole is the first-line agent for the treatment of
mild to moderate.
 AmB deoxycholate 1.0 mg/kg per day
 Oral itraconazole 200mg 3× daily for 3 days
 Oral fluconazole 800mg daily
 Voriconazole (200–400 mg 2× daily)

Mucormycosis
 Caused by a saprophytic fungi found in soil, bread mold,
decaying vegetation etc.
 Involvement of the oral cavity is secondary to Para nasal sinuses
or nasal cavity
 Usually present as a palatal necrosis or ulcerations
 Extends to adjacent structures causing extensive tissue necrosis
and invasion of brain
 Organ transplant and poorly controlled diabetic patients are
susceptible
Camara-Lemarroy C, González-Moreno E, Rodríguez-Gutiérrez R,

Rendón-Ramírez E, Ayala-Cortés A, Fraga-Hernández M et al. Clinical
Features and Outcome of Mucormycosis. Interdisciplinary Perspectives
on Infectious Diseases. 2014;2014:1-5.
Clinical features
 Mucormycosis infection may have a rhino
cerebral, rhino orbital, pulmonary and soft-
tissue extension, among others.
 Moreover, it can also present as a

devastating disseminated form.
 the lung (58.5%) was the main site of

infection, followed by rhino cerebral or
rhino orbital involvement .
 The most common signs and symptoms were

fever, rhinorrhea, and headache, while the
most ominous symptom was vision loss.
Oral manifestations
 Ulceration of palate, which results from

necrosis due to invasion of palatal vessel.
 Lesion characteristically large and deep and

may lead to exposure of underlying bone.
 Ulcers on gingiva, lip and alveolar ridge.

Features and Outcome of Mucormycosis. Interdisciplinary
Treatment
 liposomal AMB 5 mg/kg/d or isavuconazole especially in patients
for whom amphotericin B is inappropriate (loading dose 372 mg 8
h for 6 doses IV/oral). Continue regimen for at least 3 weeks
 posaconazole tablets (300 mg/d)
 In one retrospective case series, 32 patients with hematological

malignancies or aplastic anemia, and mucormycosis unresponsive
to prior monotherapy (mainly with LAMB), were treated with
combination of polyene and posaconazole.
 After three months of treatment, 18 patients (56%) had clinical

improvement and nine patients (28%) did not respond or died
from progression of disease
Sporotrichosis
 Sporothrix schenckii
 rose-gardener’s disease
 Very common saprobic fungus that decomposes plant
matter in soil
 Infects appendages and lungs
 Lymphocutaneous variety occurs when contaminated
plant matter penetrates the skin and the pathogen

forms a nodule, then spreads to nearby lymph nodes

Perspectives on Infectious Diseases. 2014;2014:1-5.
Clinical features
 S. schenckii gains access to the

subcutaneous tissues via traumatic lesions,
and proliferation of the fungus leads to the
appearance of a nodule or small ulcer.
 Rarely primary oral sporotrichosis may be

seen but more commonly occurs secondary
to disseminated disease from the skin or
lung.
 Oral lesions can manifest in various forms

such as erythematous, ulcerative,
suppurative, granulomatous, vegetative or
papillomatous. The oral lesions are usually
painful and heal without scarring
 Potassium iodide: saturated solution -100 mg / 100 ml -5
drops thrice. Itraconazole - 100-200mg
 Fluconazole - 400 mg
 Terbinafine - 250 –500 mg

Zygomycosis
 The two orders of Zygomyces that are of clinical
concern are Mucorales and Entomophthorales .

 Mucorales includes the genera Rhizopus, Mucor,
Absidia and Cunninghamella , which are more often

implicated in human diseases.
 These microorganisms are capable of causing deep
fungal infections that can rapidly deteriorate the
condition of immunocompromised patients.

Clinical features
 Oral zygomycosis has more
often manifested in
immunocompromised patients
with blood dyscrasis, diabetes,
immunosuppressive therapy,
corticosteroid therapy,
malignancy, hepatitis,
tuberculosis, etc
Rendón-Ramírez E, Ayala-Cortés A, Fraga-Hernández M et al.
Clinical Features and Outcome of Mucormycosis. Interdisciplinary
Oral manifestations
 The most common oral
manifestations are palatal

ulcers, which are frequently
necrotic, well-delimited, with
well-defined borders and may
appear as either black or white.

Treatment
 Liposomal amphotericin B was the most commonly
used antifungal agent.

 Surgical intervention
 Almyroudis et al. determined that in overall,
amphotericin B was the most active agent, followed by

posaconazole.
 Posaconazole was usually given as an oral suspension
of 200 mg four times a day or 400 mg twice a day.

Geotrichosis
 This is caused by the fungus Geotrichum
candidum which has been isolated from the skin,

sputum and feces of humans.
 It is carried in the alimentary tract of some
individuals and can sometimes cause
opportunistic infection.

Clinical features
 The fungus infects the bronchi, lung, mouth and
intestine.
 The oral lesions of geotrichosis are similar

clinically to pseudomembranous candidiasis and
differentiation can be done only by
histolopathological examination and culture of
the organism.
 Besides the pseudomembranous form, other

clinical presentations of oral geotrichosis have
been reported such as the villous hyperplastic
and ulcerative forms.

Treatment
 Multiple therapies including potassium iodide,
colistin, neomycin sulfate, tetracycline and nystatin

shown success.
 Prolonged oral nystatin has been used to effectively
manage superficial oral geotrichosis in the setting of
HIV
 Amphotericin B had become the treatment of choice
for invasive disease by the late 1980s, with or without

adjunctive antifungal medications.
Penicilliosis
 Penicilliosis is caused by Penicillium marneffei , and was
considered a rare disease before the advent of
HIV/AIDS.
 P. marneffei is endemic to Southeast Asia, southern
China, northern Thailand and Hong Kong but its ecology
and the mode of transmission to man are unknown.
 The prevalence of infection has increased considerably
in the past decade, especially in persons who are
infected with HIV.
Clinical features
 Currently, penicilliosis is reported to
be the third most common
opportunistic infection in patients with
AIDS in Thailand, followed by
tuberculosis and cryptococcosis.
 infection may either be disseminated

or focal in patients who are otherwise
healthy. In HIV seropositive patients
the disease usually manifests in the
disseminated form.
Oral manifestations
 Oral lesions usually appear as shiny

papules, erosions, or as shallow
ulcers covered with whitish yellow,
necrotic slough and are found on the
palate, gingiva, labial mucosa,
tongue and oropharynx.

Treatment
 In one case report, The dosage and duration of
treatment among HIV-infected patients were

intravenous amphotericin B deoxycholate 0.6-1.0
mg/kg/ day for 2 weeks, followed by oral itraconazole
400 mg/day for 8 to 10 weeks.
 After completion of treatment, all HIV infected
patients received oral itraconazole 200 mg/day for

secondary prophylaxis.
PHYCOMYCOSIS
 Phycomycosis is a fungal infection caused by the order mucorales.
 It is worldwide in distribution and the organisms normally occur in
soil, manure, fruits, and in decaying matter.
 These organisms are present in the nasal passages and oral cavities
of normal persons.
 This is an opportunistic infection associated with debilitation and a
secondary occurrence in cancer patients, especially those with any
of the malignant lymphomas and in patients having renal failure,
organ transplant, AIDS, and cirrhosis.
 It is also especially common in patients with diabetes mellitus,
especially those with diabetic ketoacidosis, immunosuppressed
patients, patients with burns or open wounds.
Clinical Features
 Two main types of phycomycosis infection occur in human
beings:
(1) superficial and
(2) visceral, or localized and disseminated.

 The superficial infection includes involvement of the
external ear, the fingernails, and the skin.

 The visceral forms of phycomycosis are of three main
types:
 (a) pulmonary,
 (b) gastrointestinal,
 (c) rhinocerebral.
 The infection apparently enters the tissues through the
nasal mucosa and extends to the paranasal sinuses,
pharynx, palate, orbit, and brain.
 One early clinical manifestation of the disease is the
appearance of a reddish-black nasal turbinate and
septum with a nasal discharge.
 The necrosis may extend to the paranasal sinuses and
orbital cavity, with the development of sinus tracts and
sloughing of tissue.
 Treatment of the disease consists of control of the
predisposing factors such as diabetes surgical excision

if the lesion is localized, and administration of
amphotericin B, since it is the only drug with proven
efficacy.
 Treatment of phycomycosis respond well to oral
potassium iodide, oral itraconazole (200 to

400mg/day), ketoconazole (200 to 400 mg/day),
fluconazole (100-200 mg/day).
RHINOSPORIDIOSIS
 Rhinosporidiosis is a chronic granulomatous disease
caused by a fungus called Rhinosporidium seeberi,

which affects chiefly the oropharynx and
nasopharynx as well as the larynx, skin, eyes, and
genital mucosa.
 The mode of infection is not known. This infection is
common in India and Sri Lanka.

Clinical Features
 Nasal mucosa is the most common site

involved.
 Lesions appear as small verrucae or warts,
which ultimately become pedunculated.
 Genital lesions resemble condylomas.
Oral Manifestations
 The oronasopharyngeal lesions are often
accompanied by a mucoid discharge and appear
as soft red polypoid growths of a tumor like
nature, which spread to the pharynx and larynx.
 The lesions are vascular and bleed readily.
 Though any intraoral site may be involved, soft
palate appears to be the most frequent site.
 The oral lesions have been reviewed by
Ramanathan and his coworkers. In addition, an
unusual case involving the parotid duct has been
reported by Topazian.
Treatment
 Surgical removal of the growths is recommended as treatment of

choice.
 In one case report pt. was having polypoid growths on skin,
nasopharynx and oropharynx. The lesions recurred all over the body
within months of their excision.
 The patient received amphotericin B (Fungisome) at a dose of 1.5
mg/kg/day for 6 weeks. Although some reduction in the size of the
lesions was noted.
 Another case report(nasal cavity, nasopharynx ) Complete excision
of the nasal mass along with its nasopharyngeal extension was done
and the base was cauterized with Nd YAG Laser (20 watt pulse).
 Local (topical) treatment  Systemic
Clotrimazole Fluconazole
Mycelex Diflucan
10mg troche 200mg first
5 times daily day, then 100
for 7-14 days mg for 7-14 d
Miconazole
Itraconazole
Oravig
Sporanox
50 mg tablet
200mg d for 7-
Upper gum
14 d
above incisor
Nystatin Posconazole
Mycostatin Noxafil
Oral 400mg d- bid
suspension for 7-14 d in
(100,000units/ refractory
ml) disease.

Drug interactions
 Warfarin
 Interaction with fluconazole, ketoconazole, itraconazole
 Increase blood levels and risk of bleeding
Drug-disease interactions :
 Prolonged use of systemic fungals may result in renal or

hepatic dysfunction
 Administer fluconazole, ketoconazole, or itraconazole with

caution in patients with hepatic disease or when taking other
hepatotoxic medications
Tapaswini Bagh,Laxmikanth Chatra, Prashanth Shenai,Veena K

M ,Prasanna Kumar Rao ,Rachana V Prabhu. ANTIFUNGAL
DRUGS USED IN DENTISTRY. Int J Dent Health Sci 2014;
References
 Burkett's oral medicine text book 12th edition
 Krishnan PA. Fungal infections of the oral mucosa. Indian J Dent

Res 2012;23:650-9.
 Tapaswini Bagh,Laxmikanth Chatra, Prashanth Shenai,Veena K M

,Prasanna Kumar Rao ,Rachana V Prabhu. ANTIFUNGAL DRUGS
USED IN DENTISTRY. Int J Dent Health Sci 2014; 1(4):523-539 .
 Camara-Lemarroy C, González-Moreno E, Rodríguez-Gutiérrez R,

 SN Arseculeratne. Recent advances in rhinosporidiosis
and rhinosporidium Seeberi Indian Journal of Medical
Microbiology, (2002) 20 (3):119-131.
 Lt Col A Das. Endoscopic Excision of Recurrent
Rhinosporidiosis
MJAFI 2008; 64 : 76-77.
 Garima Sharma, Anil Kumar Gupta. “Subcutaneous
Phycomycosis: A case report”. Journal of Evolution of
Medical and Dental Sciences 2014; 3(72):15324-
15326.
 Prasad P V, Paul EK, George RV, Ambujam S,
Viswanthan P. Subcutaneous phycomycosis in a child.
Indian J Dermatol Venereol Leprol 2002;68:303-4
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Fungal Infections

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FUNGAL

Post graduate 2nd year

Contents  fungal infections

 Deep fungal infections

 Neither a plant nor an animal

molds, and yeasts.

any other body sites .

 Have rigid cell wall composed of chitin (bacterial cell

 Yeast like fungi

2. Cutaneous Affects superficial keratinized

3. Subcutaneous reach subcutaneous tissue by

4. Endemic (primary, systemic):

– Dermatophytes : affect keratin layer of skin, hair, nail.

– Candidiasis : Yeast-like, oral thrush, vulvo-vaginitis ,

 Deep Infections : – Affect internal organs as :

 Most prevalent opportunistic infection affecting the oral

 Oral candidiasis is divided in to primary and secondary

 Secondary – systemic mucocutaneous manifestations.

Burkett's oral medicine text book 12th edition

 Candida exists in three forms namely, pseudohyphae, yeast,

 It reproduces by asexual budding and forms pseudohyphae.

 The incidence of oral candidiasis has increased after the

 They are also found on plants, in water and dairy products, on

 Candida sp. is the most common cause of opportunistic fungal

 C. albicans is the most frequent species found in clinical

 Many specific and nonspecific factors have a role in the

 Various anticandidal factors and antiadherence factors also

 T cells and neutrophils also play a role in preventing and

 Candidal infection may range from mild superficial mucosal

 The classification proposed by Samaranayake in 1991 and

 (1) primary oral candidiasis (infection exclusively confined to

 (2) secondary oral candidiasis (oral lesions as a manifestation

Burkett's oral medicine text book 12th edition

Burkett's oral medicine text book 12th edition

as resembling milk curds, consist chiefly of tangled

comprising fungal organism, cellular debris which

Tapaswini Bagh,Laxmikanth Chatra, Prashanth Shenai,Veena

 antibiotic sore mouth, includes central papillary atrophy of the

tongue and cheilocandidiasis

 The redness is due to increased vascularity.

 Could be chronic or acute

 Commonly seen in the palate, dorsal tongue

 Mainly associated with broad spectrum antibiotics or

 The oral lesions consist of firm, white persistent

 White plaque present in the commissural region,

palate and tongue

Burkett's oral medicine text book 12th edition

 A chronic inflammatory condition in

 Denture provides ideal environment for

 Denture hygiene is critical

Burkett's oral medicine text book 12th edition

dissolves in it forming gel used mainly in such

be applied to the fitting surface of clean denture

treating denture stomatitis with nystatin powder,

 Men are affected more

 Rhomboid shape hypertrophic or

atrophic plaque in the mid dorsal tongue

rhomboid glossitis is controversial

Burkett's oral medicine text book 12th edition

 Corners of the mouth is affected