Oropharyngeal candidiasis

Background

• 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)

Clinical Features

Oral thrush

• 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)
• 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
• Strep pharyngitis

Evaluation

• Most cases are diagnosed clinically and need only one of the treatments listed below
  • 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

• Tongue diagnoses
• Candidiasis

References

Authors

Ross Donaldson