4. Bacterial, Fungal, and Granulomatous Ds Etiology Flashcards
1
Q
What is Impetigo’s etiology and method of infection?
A
- Strep. pyogenes*
- Staph. aureus*
entering broken skin
2
Q
What is the etiology and method of transmission of Erysipelas?
A
B-hemolytic streptococci - Group A
via lymphatics
3
Q
What are the possible etiologies of Tonsillitis and Pharyngitis, and what is their method of transmission?
A
- Viral: adenovirus, enterovirus, influenza, parainfluenza, EBV
- Bacterial: Group A B-hemolytic streptococci
Respiratory droplet or oral secretions
2-5 day incubation
4
Q
What is the etiology and method of transmission of Scarlet Fever?
A
Group A - B hemolytic streptococci
Erythrotoxin - toxin attacks the blood vessels
5
Q
What is the etiology of Syphilis, and what are the 3 methods by which it can be spread?
A
Treponema pallidum
Spread by:
- intimate sexual contact
- transplacental transmission
- contaminated blood exposure
6
Q
What is the etiology of Gonorrhea?
A
Neisseria gonorrhoeae
7
Q
What is the etiology and transmission method of Tuberculosis?
A
Mycobacterium tuberculosis
droplet transmission
8
Q
What are the historical and current etiologies of Scrofula?
A
- Historically = infection with mycobacterium bovis from contaminated milk
- Now = mycobacterial infection involving cervical nodes
- Adults - M. tuberculosis
-
Children - nontuberculous mycobacterial infection
- Usually don’t have pulmonary symptoms
9
Q
What is the etiology and method of transmission of Cat Scratch Disease?
A
Bartonella henselae
Follows scratch from a kitten with fleas
10
Q
What are the etiologies of Bacillary Angiomatosis?
A
- Bartonella hensalae*
- Bartonellla quintana*
11
Q
What is the etiology of Lyme Disease?
A
Borrelia burgodorferi
12
Q
What is the etiology and method of transmission of Histoplasmosis?
A
H. capsulatum
bird and bat droppings - Ohio and Mississippi River Valleys
Spore Inhalation
13
Q
What is the etiology of Blastomycosis and where is it found?
A
Blastomyces dermatitidis
grows as mold in soil
14
Q
What is the etiology of Coccidioidmycosis?
A
Coccidioides immitis
- Dimorphic
- Humans - yeast
- In the ground - mold
15
Q
What is the etiology and method of transmission of Cryptococcosis?
A
Cryptococcus neoformans
- Grows as yeast, with a prominent mucopolysaccharide capsule
- Pigeon droppings contain spores which are inhaled
16
Q
What are the etiologies (4) of Zygomycosis (Mucor), and where are they found?
A
Zygomycetes Class - Absidia, mucor, Rhizomucor, Rhizopus
grow in decaying organic material
17
Q
What is the etiology of Aspergillosis?
A
A. fumigatus
18
Q
What is the etiology of Toxoplasmosis, and what is the host?
A
Toxoplasma gondii
Host = cat
19
Q
In what population is Impetigo common? (4)
A
- Children
- Crowded living conditions
- Poor Hygiene
- Hot/Humid Climates
20
Q
Where is the skin infection of Impetigo seen on the body?
A
Skin of Face or Extremities
21
Q
What is the clinical presentation of the lesions of Impetigo?
A
- Range from:
- Fragile vesicles
- Flaccid bullae that rupture and leave an amber to “honey-colored” crust
- Typically more than 1 lesion
22
Q
What is the DD for Impetigo? (3)
A
- Exfoliative Cheilitis
- Recurrent Herpes Simplex
- Mimic Child Abuse (burning skin)
23
Q
What is the tx for isolated Impetigo lesions?
A
Topical mupirocin
24
Q
What is the tx for bullous or more extensive Impetigo lesions?
A
-
1 wk course of systemic oral antibiotics
- Augmentin
- PCN Allergy = clindamycin
25
What population is susceptible to Erysipelas?
* **Young and Elderly**
* particulary the **debilitated** or **diabetic**
26
What is the clinical presentation of Erysipelas? (5)
* Occurs anywhere on the skin, common in areas of **previous trauma**
* Common on face, bridge of nose **butterfly-shaped rash**
* *Mimics LE*
* **Edema** of **eyelid**
* *Mimics Angioedema*
* Painfull, **bright red**, warm, well-circumscribed, swollen, indurated
* *Mimics a Dental Infection*
* **Fever**, **increased WBC count**, nausea and vomiting possible
27
What is the treatment for Erysipelas?
**Penicillin**
Lesion often enlarges at the start of therapy, then rapid resolution within 48 hrs
28
What are the common symptoms that Children with Tonsillitis and Pharyngitis have? (5)
* Headache
* Anorexia
* Abdominal pain
* Malaise
* Vomiting
29
What symtoms of Tonsillitis and Pharyngitis suggest a viral etiology? (6)
* Conjunctivitis
* Cough/Hoarseness
* Diarrhea
* **No Fever**
* Rhinorrhea
* Viral Exanthema
30
If the clinical features of Tonsillitis and Pharyngitis suggest a bacterial origin what is the protocol?
* **Rapid Antigen Detection Test**
* Good Sensitivity and Specificity
* If the _rapid test is negative_, then get a **throat culture**
* Antibiotic should only be Rx in confirmed bacterial infection
31
What does Scarlet Fever begin as?
* **Streptococcal tonsillitis** with **pharyngitis**
* Skin rash (exanthema)
32
In what population is Scarlet Fever common in?
Children (3-12 yrs)
33
What is the incubation period for Scarlet Fever?
Ranges from **1-7 days**
34
What occurs within the 1st 2 days of Scarlet Fever? (4)
* High Fever (~103 F)
* **Oropharynx**
* ****Erythematous, edematous, yellowish _exudate in tonsillar crypts_
* Scattered _petechiae_ may be seen on the soft palate
* **Skin**
* ****Rash (exanthema) on the trunk and extremities, _sparing the face_
* Circumoral Pallor
* **Tongue**
* ****_white_ strawberry tongue
35
What occurs during day 4-5 of Scarlet Fever?
Strawberry Tongue
36
What occurs after 1 week of having Scarlet Fever?
* Rash subsides, followed by:
* **Desquamation of skin** from face to extremites _ensues for 3-8 wks_
37
What is the Diagnosis and Treatment for Scarlet Fever?
Same as Tonsillitis and Pharyngitis
Rapid antigen detection test, if positive then give antibiotics
38
What population has the most cases of Syphilis?
Men having sex with men
39
When does Primary Syphilis develop?
3-90 days after exposure
40
What is the clinical presentation of Primary Syphilis?
* Relatively **painless** **ulceration** becomes a chancre
* **Chancre** mostly affecting **genital region**
* 4% are oral
* Lip, tongue, palate, gingiva, tonsils
41
What is the treatment for Primary Syphilis?
**Spontaneously Resolves** in **3-8 wks**
42
When does Secondary Syphilis develop?
**4-10 wks** after initial infection
43
What is the Clinical Presentation of Secondary Syphilis? (3)
* **Erythematous, maculopapular, cutaneous eruption**
* Painless, generalized **Lymphadenopathy**
* _Oral Mucosa:_
* **Mucous patches**
* **Condyloma lata**
44
When does Tertiary Syphilis develop?
Latency period of 1-30 years
45
What are the Clinical Features of Tertiary Syphilis? (5)
* Affects **30% of pts** with Syphilis
* May affect any tissue, including CNS and vasculature
* **Gumma** formation in multiple areas
* Bone and Soft tissue
* **Interstitial glossitis**
* **Luetic Glossitis** of dorsal tongue
* Atrophy, loss of papillae, and hyperkeratosis
* **Palatal Perforation** may occur (esp in opiate addicted pts)
46
What are the classic clinical features of Congenital Syphilis? (3(5))
* **Saddle Nose Deformity** (no bridge of nose)
* **Saber Shins** (anterior bowing of tibia)
* _Hutchinson's Triad_
* Malformed incisors and molars = **Hutchinson's Incisors** and **Mulberry Molars**
* **Ocular Interstitial Keratitis**
* **8th nerve Deafness**
47
What is used to Diagnosis Syphilis? (3)
* _Screening Tests_
* **VDRL** (veneral disease research laboratory)
* **RPR** (rapid plasma reagin)
* _Specific Antibody Tests_
* **FTA** (fluorescent treponemal antibody)
* **Dark-field Microscopy**
* For non-oral lesions
48
What is the use of Screening Tests (VDRL, RPR) for Syphilis?
* Test for **Reinfection**
* Positive during the 1st 2 stages, then tapers off
49
What are the implications of the Specific Antibody Test (FTA) for Syphilis?
**Positive for Life**
Can't use to test for reinfection
50
What is the histology seen in Primary and Secondary Syphilis?
Intense plasmacytic infiltrate
51
What is the histology seen in Tertiary (gumma) Syphilis?
Granulomatous inflammation
52
How can spirochetes (associated with the diagnosis of syphilis) be identified histologically?
* **Warthin-Starry Stain**, or
* Immunohistochemistry (IHC)
53
What is the drug of choice for treating Syphilis?
**Parenteral Penicillin G**
mega dose intramuscularly
54
What is use to treat syphilis in a patient with a penicillin allergy?
Doxycycline
55
What is the most common reportable bacterial infection?
Gonorrhea
56
Where does Gonorrhea occur in men, and women?
* Men = **urethra**
* Women = **cervix** (may lead to PID)
57
What can occur in a baby that was delivered by a mom who didn't know she had gonorhhea?
**Gonococcal Opthalmia Neonaturm**
can cause _blindness_
58
What are the features of oral involvement in patients with Gonorrhea?
_Oropharynx, tonsils, uvula_
* Usually transmitted via oral to genital contact
* **Oropharyngeal** **diffuse erythema** with **punctate pustules**, and **sore throat**
* *Occasionaly looks like **ANUG** but without the odor*
* Patients with _septicemia_, the bacteria spreads through their bloodstream to the oral cavity, present with **aphthous-like ulcers**
59
How is Gonorhea Diagnosed?
* Gram stain of exudate
* Culture
* PCR
60
What is the treatment for Gonorrhea?
Systemic Antibiotic
## Footnote
**fluoroquinolone**
61
What population is affected with Tuberculosis?
More common in **foreign-born persons**
1/3 of the worlds population is infected
62
What are the clinical features of Tuberculosis? (4)
Only 5-10% of infected pts progress to active disease
* Low grade fever, night sweats, fatigue
* Weight loss
* Chronic bloody cough
* Enlarged lymph nodes
63
What are the features of Scrofula?
* **Enlargement** of **oropharyngeal lymphoid tissue** and **cervical lymph nodes**
* May see **tissue necrosis** causing **fistulas** which can **calcify** and be seen on PANX
64
What are the features of TB Oral Lesions? (4)
* Rather uncommon
* May be due to hematogenous spread or direct implantation of organisms
* Most common on **Gingiva** and **Tongue**
* **Solitary chronic painless ulcer**
* *****Similar to SCCA, which is more common*
65
How is Tuberculosis diagnosed?
**+ Tuberculin Skin Test**
* If you recieved the **BCG vaccine** you will get a **+TST**, so get a blood test to confirm
* Need a further workup: exam, chest xray, sputum sample
* Culture or PCR to characterize the organism
66
What does the histology of TB show? (3)
* **Caseous Necrosis** = Necrotizing granulomatous inflammation; cheesy necrotic center
* **Multinuclead Giant Cell**
* Organisms stain using the **acid fast** method (**Ziehl-Neelsen Stain**)
67
What is the Treatment protocol for patients with active TB?
Combo of antibiotics
* **Isoniazid (INH)** + **rifampin** + **pyrazinamide (+/- ethambutol)**
* For 8 weeks
* Then, **INH + rifampin**
* For 16 weeks
68
What is the Treatment protocol for patients with latent TB, that are at risk for developing the active ds (immunocomprimised pts)?
INH +/- rifampin or rifapentine
69
What is the etiology of Actinomycosis?
* Any of several *Actinomyces* species that normally inhabit the mouth
* Often associated with local trauma
70
What areas may be affected by Actinomycosis? (3)
* Abdominal (25%)
* Pulmonary (15%)
* **Cervicofacial** (**55%**)
71
What is the initiating factor causing Cervicofacial Actinomycosis?
Dental Extraction or Untreated Dental Disease
72
What is the clinical presentation of Cervicofacial Actinomycosis?
* Diffuse swelling
* Erythema
* Broad-like **firm fibrosis** with **central soft abscess**
73
In Cervicofacial Actinomycosis where are the organisms draining out of?
Sinus tracts
74
What is in the purulent exudate in Cervicofacial Actinomycosis?
**Sulfur Granules**
Colonies of organisms in purulent exudate
75
What is the histology o Actinomycosis?
* **Filamentous**, club-shaped, anaerobic bacterial colonies forming **radiating rosettes "Ray Fungus"** surrounded by **neutrophils**
* Adjacent tissue may show **Granulomatous Inflammation** or **Granulation Tissue**
76
What is the general treatment for Actinomycosis?
Remove offending tooth
77
What is the treatment for localized and periapical Actinomycosis lesions?
**Remove infected tissue**
If surgery fails - **PCN**
78
What is the treatment for chronic cases of Actinomycosis?
**Prolonged,** **high doses** of **antibiotics**
79
What is the treatment for Cervicofacial Actinomycosis lesions?
IV PCN for a couple of weeks, then oral dosing for 5-6 weeks
80
What is the treatment for deep-seated Actinomycosis lesions?
Oral PCN for a year
81
What is the most common cause of **Chronic Regional Lymphadenopathy** in **Children?**
Cat Scratch Disease
82
What population is usually affected by Cat Scratch Disease?
Males \< 18 yrs old
83
What is the clinical presentation of Cat Scratch Disease?
* **Erythematous papule** at the site of scratch
* Followed by **Tender Lymphadenopathy**
* Usually what is noticed by parents
* Fever or Malaise may also be present
84
What is the Histology of Cat Scratch Disease? (3)
* **Necrotizing Granulomatous Inflammation** localized to lymph nodes
* Warthin-Starry staining method shows **pleomorphic bacilli**
* Can do IHC for *Bartonella henselae*
85
How is Cat Scratch Disease Diagnosed?
* **Serologic Testing** - indirect fluorescent antibody assay or ELISA testing
* Rule out other cases of Lymphadenopathy
86
What is the Treatment for Cat Scratch Disease?
* No definitive tx - **resolves spontaneously** after weeks to months
* In prolonged cases, antibiotics may be used
* Large necrotic nodes may require drainage
87
What is the clinical presentation of Bacillary Angiomatosis?
* **Painful**, subcutaneous **red/purple plaques** (vascular growths)
* Occasional **oral lesions** that occur **in AIDS pts**
* *Resembles _Kaposi Sarcoma_*
* *Warthin-Starry stain highlights the bacillus*
88
What is the clinical presentation of Lyme Disease?
* **"Bulls Eye"** skin rash = Erythema Migrans
* Fever, Headache, Fatigue
* May spread to joints, heart and nervous system
* Any CN can be involved
* _TMJ Pain_
* May cause **facial palsy** mimicking Bell's Palsey
89
What is the treatment for Lyme Disease?
Doxcycline or Amoxicillin
Early in course
90
What is the etiology of Oral Candidiasis?
* Chronic infection with *Candida albicans*
* **Dimorphic =** yeast and hyphal forms
91
What is the most common oral fungal infection?
Candidiasis
92
What are the clinical features of Pseudomembranous candidiasis (Trush)?
* **Removeable** cheesy, **white plaques** on buccal mucosa, palate, and tongue
* **Burning sensation** or **bad taste** in the mouth
* Acute Onset with Antibiotic exposure
* Slower Onset with Immunosuppresion
93
What are the clinical features of Acute Atrophic Candidiasis?
* **"Antibiotic Sore Mouth"**
* **Scalded/burning sensation** to tongue
* Diffuse **loss of filiform papillae** on dorsal tongue
94
What are the clinical features of Central Papillary Atrophy (Median Rhomboid Glossitis)?
* **Well-demarcated red zone**, flat, smooth, often symmetric
* **Posterior** dorsal tongue, in the **midline**
* Often **asymptomatic**
95
What are the clinical features of Chronic Multifocal Candidiasis?
* **Central Papillary Artophy** (Median Rhomboid Glossitis) **+ Additional Site**
* Kissing lesion on palate OR angular cheilitis
96
What are the clinical features of Angular Cheilitis (Perleche)?
* Erythema, fissuring and scaling of the **angles of the mouth**
* **Waxes and wanes**
* Can occur alone or with other forms of Erythematous candidiasis
97
What are the possible etiologies of Angular Cheilitis?
* 20% Candida alone
* **60% Candida + Staph Aureus**
* ****Usually not just candida alone
* 20% Staph Aureus alone
98
What is the term for Angular Cheilitis that shows more extensive perioral involvement, spreading all the way around the lips?
Cheilocandidiasis
99
What is the etiology of Denture Stomatitis (Chronic Atrophic Candidiasis)?
* May be related to **continuous denture wear**
* Mostly a **tissue response** rather than a true infection of mucosa
* Denture is often contaminated with Candida organisms
100
What are the clinical features of Denture Stomatitis (Chronic Atrophic Candidiasis)?
* **Erythema of palatal denture-bearing area**
* Typically **asymptomatic**
101
What can predispose to **erythematous** or **pseudomembranous candidiasis** of the **hard/soft palate**?
Steroid Inhalers
102
What are the clinical features of Chronic Hyperplastic Candidiasis?
* **Non-removable, white plaques**
* Most common sites are **buccal mucosa, tongue**
* If superimposed on pre-neoplastic lesion (Leukoplakia), often speckled appearance
103
What is the etiology/pathogenesis of Mucocutaneous candidiasis?
* Rare, **immunologic defect** leading to **infection**
* Usually **sporadic**, but can be **inherited**
104
What is the clinical presentation of Mucocutaneous candidiasis?
* Onset early in life with **infections** of **mouth, skin, nails** and other **mucosal sites**
* _Skin infections_
* Rough, **foul-smelling**, plaques/nodules
* _Oral infections_
* Thick, white oral plaques, chronic hyperplastic appearing
* May develop **endocrine abnormalities** OR **iron deficiency anemia**
* ****follow-up indicated
105
What is the treatment for Mucocutaneous candidiasis?
Control with **systemic antifungals**
106
What may develop in Mucocutaneous candidiasis pts?
Endocrine-Candidiasis Syndrome
107
What endocrine problems may develop, months to years after candida infections are noted, in Endocrine-Candidiasis Sx? (4)
* Hypothyroidism
* Hypoparathyroidism
* Hypoadrenocorticism (Addison's Ds)
* Diabetes Mellitus
108
In the diagnosis of Candidiasis what technique is more sensitive, capturing the most cases possible?
**Culture**
2-3 days to grow colonies (2-3mm creamy white) - yeast form
109
In the diagnosis of Candidiasis what are the characteristics of KOH preparation - Cytology? (4)
* Quick (mins) and Inexpensive
* Not as sensitive as culture or stained slide
* Not permanent
* Can't asses epithelial cells
110
In the diagnosis of Candidiasis what are the characteristics of Stained Slide (periodic acid schiff) - Cytology? (3)
* Next Day results
* **Permanent record**
* Fix cells to slide with alcohol and send to lab for staining
111
What is the histology of Candidiasis? (5)
* **Hyperkeratosis**
* **Elongation** of **rete ridges**
* **Chronic inflammation** in **CT**
* Neutrophils forming **"microabscesses"** in the parakeratin (trying to attack hyphae)
* **Hyphae embedded in keratin**, rarely penetrate into viable epithelium
112
What is the Histochemistry used for Candidiasis? How does it stain?
* Periodic Acid Schiff (PAS)
* Stains **carbohydrate wall magenta**
* Grocott-Gomori Methanamine Silver (GMS)
* Stains **black**
113
What antifungal medications are the Polyene Agents?
**Nystatin,** Amphotericin B
Soak partial dentures
114
What is the downside to polyene agents?
Have to use **5x/day**
115
How do polyene agents work?
**BINDS** to **ergosterol** leading to cell permeability and cell death
116
What antifungal medications are the Imidazole Agents?
**Clotrimazole (Mycelex)**, Ketoconazole, and Micronazole (denture pt, dissolves in mouth)
10mg troches (lozengens)
useful for treating all types
117
When do Imidazole agents work well?
if not responding to nystatin or fluconazole
118
How do Imidazole Agents work?
**BLOCK ergosterol synthesis** by **enzyme inhibition**
119
What antifungal medications are the Triazoles? (4)
**Fluconazole (Diflucan),** itraconazole, voriconazole, and posaconazole
long 1/2 life, good absorption
120
What is the upside to triazoles?
once a day pill
121
What is the downside to triazoles?
More chance for **side effects** since it is a systemic drug
122
How do triazoles work?
**BLOCK ergosterol synthesis** by **enzyme inhibition**
## Footnote
*Same as Imidazole Agents*
123
How do Echinocandins work?
Block **beta-(1,3)-glucan** synthesis
124
What are other antifungal medications that can be used to treat candidiasis?
1% Iodoquinol + hydrocortisone cream
use for Angular Cheilitis if it is the only area involved
125
What is the newer antifungal drug, Posoconazole used for?
Oropharyngeal Candidiasis in HIV+ pts
Expensive
126
What is the new antifungal class, Echinocandins used for?
**IV use ONLY**, for **life-threatening** candida and aspergillus **infections**
ex. caspofungin, micafungin, anidulafungin
127
What can deep fungal infections mimic in the oral cavity?
malignancy
128
What is used to treat advanced deep fungal infections?
Amphotericin B
129
What is the most common systemic fungal infection in the US?
Histoplasmosis
130
What is the etiology of Histoplasmosis? (3)
* ***H. capsulatum*** dimorphic:
* Humans = yeast
* Nature = mold
* **Bird, Bat droppings** in **Ohio** and **Mississippi River Valley**
* **Spore inhalation -** germinate in lungs
131
How does Histoplasmosis present clinically?
* **1-2 wks** of **flu-like** illness
* Organisms normally destroyed, but may **remain** **viable within macrophages**
* Can recur with immuno suppression
132
What are the characteristics of Acute Histoplasmosis?
* **Self-limited** pulmonary infection
* # of exposed pts affected depends on **concentration of spores inhaled**
133
What is the treatment for Acute Histoplasmosis?
No treatment indicated
134
In what population is Chronic Histoplasmosis most common?
* Primarily a lung infection in the:
* Elderly
* Immunosuppresed
* Pts with Emphysema
135
What is Chronic Histoplasmosis similar to?
**TB**
cough, weight loss, fever, dyspnea, upper lobe infiltrates, calcification
136
What is the Prognosis for Chonic Histoplasmosis?
* Up to 50% recover spontaneously
* Progressive pulmonary damage without tx
* Up to 20% mortality
137
What is the preferred treatment for Chronic Histoplasmosis?
**IV amphotericin B**
Itraconazole - used in non-immunocomprimised pts
138
What are the characteristics of Disseminated Histoplasmosis? (2)
* **Uncommon** - 1:2,000 - 5,000 pts with acute symptoms
* **Extrapulmonary spread** - context of most oral lesions
139
What is the prognosis for pts with Disseminated Histoplasmosis, in those that are treated vs. untreated?
* _Untreated_ = **90% mortality**
* _Treated_ with Amphotericin B = **7-23% mortality**
140
What are the characteristics of the Oral Lesions of Histoplasmosis, what can it mimic? (3)
* Most affected sites = tongue, palate, buccal mucosa
* **Solitary, +/- Painful, Ulceration** of **Short Duration** (weeks)
* **Firm, rolled margins**, in areas of **ulceration** *mimic malignancy of **SCCA***
141
What is the Histology of Histoplasmosis? (2)
* **Granulomatous Inflammation**, often with **multinucleated giant cells**
* PAS and SIlver Stain (GMS) show **1-4 um yeasts** inside **macrophages**
142
What is the etiology of Blastomycosis?
***Blastomyces dermatitidis***
Dimorphic fungus - grows as a **mold in soil**
143
What is the pathogenesis of Blastomycosis?
* Fungal **mold spores inhaled** and **grow as yeasts** within the **lungs**, where infection is normally maintained
*
144
What are the clinical features of Blastomycosis? (2)
* Usually subclinical or **mild** pulmonary symptoms
* **Dissemination through blood** to skin, bone, prostate, oral mucosa, and abdominal organs, can occur
145
What is the clinical presentation of Acute Blastomycosis?
* **Pneumonia-like** symptoms:
* **high fever**, malaise, productive cough (purulent sputum), night sweats, chest pain
146
What is the treatment for Acute Blastomycosis?
* Only Treat if:
* Seriously ill
* No improvement
* Extended illness (\> 2-3 wks)
147
What type of Blastomycosis is more common?
Chronic Blastomycosis
148
What is the clinical presentation of Chronic Blastomycosis? (2)
* **Mimics TB**
* **low-fever**, night sweats, **weight loss**, productive cough
* Chest Films are: normal, with diffuse infiltrates or pulmonary mass, and **no calcifications**
* *Like in Histoplasmosis and TB*
149
What is the treatment for Chronic Blastomycosis?
* Mild/Moderate Infection = **itraxonazole**
* Severe Infection = **amphotericin B**
150
What are the clinical features of Cutaneous Blastomycosis? (2)
May be **spread of infection**
* **Expanding erythematous nodule** that becomes **verrucous** or **ulcerated**
151
What is the clinical appearance of oral lesions of blastomycosis?
* **Irregular white/red** lesion or ulceration with **rolled borders**
* Mimicks malignancy
152
What is the Histology of Blastomycosis? (3)
* Often **mixed inflammation** (acute or granulomatous) with **8-20 um yeasts** *(bigger than Histoplasmosis)*
* Double refractile cell wall, broad budding pattern
* **PEH**
153
What is the treatment and prognosis of Blastomycosis?
Most pts = no tx
Prognosis = good
154
Where is Coccidioidomycosis most common?
**Southwestern US**
Desert soil
**"Valley Fever"**
155
What is the clinical presentation of Coccidioidomycosis?
* Most **asymptomatic**
* ~40% have **flu-like symptoms**, lasting a few wks
* *similar to histomycosis and blastomycosis*
* Occasional EM or **erythema nodosum**
* non-specific, painful, red bumps on extremities
156
What is the common presentation of Disseminated (\<1%) Coccidioidomycosis? (2)
* **Skin of face** is a common site
* Papules, **verrucous plaques**, and granulomatous nodules often around **central face and nasolabial fold**
* Oral lesions uncommon
157
What is the histology of Coccidioidomycosis?
* **20-60 um** (very large) round **spherules** containing **endospores**
* W*ay bigger than Histo and Blasto*
158
How do you dx Coccidioidomycosis?
**Biopsy** - verrucous plaques
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What is the tx for Coccidioidomycosis?
* Usually **none**
* **Amphotericin B**
* ****pts with immunosuppression, disseminated ds or life-threatening infection
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In what population are you most likely to find Cryptococcosis?
common life-threatening fungal infection in **AIDs pts**
(AIDs defining ds)
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What is a severe infection of Cryptococcosis called?
Fungal Meningitis
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What is common in Cryptococcosis, that isnt as common in histomycosis and blastomycosis?
**Dissemination is common**
* _Meninges_, skin, bone, prostate
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What is often the first sign of fungal meningitis?
* Fever, headache, neck stiffness, vomitting
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How is Fungal Meningitis dx?
* **Spinal tap** to check CSF
* Stain with **PAS**, to see if it is fungal (+)
* **Gram Stain** - CSF should be sterile and not have gram (-) or gram (+) organisms
* If both are negative then it is probably viral menengitis.
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What are the skin lesions of Cryptococcosis? (2)
* Often **H/N** area
* **Erythematous papules/pustules** - their discharge is full of organisms
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What are the oral lesions of Cryptococcosis?
* **Rare**
* Present as **tender, non-healing ulcers**
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What is the histology of Cryptococcosis? (3)
* Granulomatous inflammation
* Round to ovoid **4-6 um yeast** surrounded by a **clear halo** (capsule)
* PAS, GMS stain organisms, **mucicarmine stain** highlights the **capsule (bright pink)**
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What population does mucor most affect?
It is an _opportunistic_ fungal infection
* Poorly controlled **Type I Diabetes**
* Immunocomprimised pt
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What form of Zygomycosis is most relevant to the dentist?
Rhinocerebral Form
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What is the initial presentation of Mucor?
Maxillary swelling
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What are the symptoms associated with Mucor? (6)
* Nasal obstruction
* Bloody discharge (epitaxis)
* **Vision alterations** with **proptosis**
* Facial Pain/headache
* Facial Swelling
* **Facial Paralysis** common if facial nerves involved
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What is the radiographic appearance of mucor?
**Opacification of the sinus** mimicking malignancy
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What may the disease progression of mucor lead to? (3)
* Blindness
* Seizures
* Death
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What is the histology of mucor? (3)
* **Extensive necrosis** with **large (**6-30 um), **90 deg** **branching,** **_nonseptate_** hyphae
* *Candidia and Aspergillosis have septae*
* **Tissue destruction** due to invasion of small vessels leading to disruption of BF
* Shows **black necrosis**
* Variable neutrophilic response depending on immune status
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What is the tx for Mucor? (3)
* **Radical surgical debridement** of necrotic tissue
* High does **Amphotericin B**
* Control of predisposing ds
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What is the prognosis for Mucor?
Poor
50% die
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What is the clinical presentation of **Aspergillosis**? (3)
* **Allergic Fungal Sinusitis**
* ****Painful swelling of sinus, can also affect lungs
* **Aspergilloma** and **Antolith**
* ****Instead of an immune response, they form a _fungal mass_ which can _calcify_
* **Post-extraction** or **RCT of maxillary tooth**
* ****Painful gingival ulceration
* Diffuse gray/purple swelling
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What are the features of Disseminated Aspergillosis? (3)
* Immunocompromised pt - **1/3 survive**
* Chest pain, cough, fever
* **Hematogenous spread** to:
* CNS, eye, skin, liver, GI tract, bone, thyroid
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What is the histology of Aspergillosis? (3)
* Branching at **acute angles,** septate hyphae (3-4 um) invading and occluding small vessels
* Healthy pt - **granulomatous response**
* Immunocompromised pt - **minimal inflammation**
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How is Aspergillosis diagnosed? (3)
* Blood/sputum culture often negative despite disseminated ds
* Tx based on **clinical presentation**
* Biopsy showing organism is only suggestive
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What can infection with toxoplasmosis during the 1st trimest lead to?
* **Blindness**
* **Mental retardation** of baby
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How is Toxoplasmosis diagnosed?
**Rising antibody titers** in healthy pts **10-14 days after infection**
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What is the treatment for Toxoplasmosis?
* Healthy pt - none
* Pregnant women
* Prevention - avoid raw meat and cat litter box
* **sulfadiazine** and **pyrimethamine** often prevents transmission to fetus
* Also used for immunosuppressed pts
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What type of infection is toxoplasmosis?
Protozoal
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What is the pathogenesis of Sarcoidosis? (2)
* Multisystem granulomatous ds of **unknown origin**
* **Improper breakdown of antigens** leading to granulomatous inflammation
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In what population does Sarcoidosis occur?
* **Blacks**
* **20-40 yrs**
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What shows the most prominant symptoms in Sarcoidosis?
Pulmonary Symptoms
* Dyspnea
* Chest Pain
* Dry Cough
* *Deep fungal inf have purulent coughs*
* **Bilateral hilar lymphadenopathy** seen on chest film
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What are the skin manifestations of Sarcoidosis?
* **"Lupus Pernio"**
* **violacious, indurated lesions** (purple, firm, plaques) on **face** and **lips**
* **Erythema Nodosum**
* ****non-specific, tender red nodules on **lower legs**
* *Also in Coccidioidomycosis*
* \*\*\*May cause **Facial Paralysis**
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What are the eye and salivary manifestations of Sarcoidosis?
*Mimics **Sjogren Sx***
_Eye_
* **Keratoconjunctivitis sicca** (dry eyes)
* Most often **anterior uveitis** = inflammation of the middle layer of the eye - redness, pain, and blurred vision
* Lacrimal involvement
_Salivary Gland_
* **Enlargement** and **Xerostomia** of major and minor glands
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What are often the 1st signs of Sarcoidosis? (4)
_Oral Lesions_
* Submucosal mass, papule, granular lesion
* **Brownish/red, violaceous**, or hyperkeratotic lesion
* Buccal mucosa, gingiva, lips, FOM, tongue, or palate
* Can't diagnose based on oral lesions, because they mimic alot of other diseases
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What is the presentation of the intraosseous lesions of Sarcoidosis?
*Never put in a DD for a RL jaw lesion, unless they have all other symptoms!*
* **Ill-defined RL**
* Cortical erosion, with no expansion
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What is present in the histology of Sarcoidosis? (5)
* Granulomatous inflammation with mngc
* Epitheliod histiocytes with surrounding lymphocytes
* **Schaumann Bodies** - **l**aminated basophilic calcifications
* **Asteroid Bodies** - ****stellate inclusions (stars inside giant cells)
* **No Bug** (fungal, bacterial, foreign material)
* PAS, GMS, Acid Fast are all negative
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How is Sarcoidosis diagnosed? (2)
* Clinical and Radiographic findings
* **Elevated ACE levels + Pulmonary Involvement**
* ****Offers strong support
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What is the treatment for Sarcoidosis? (3)
* Observation period (3-12 months) to asses disease course
* _1st line therapy_ - **corticosteroids** effective in **20%**
* _Refractory Ds_
* **Chemo drugs:** methotrexate, azathiprine, chlorambucil, cyclophosphamide
* **TNF-a antagonists** (etanercept, infliximab)
* **Antimalarials** (chloroquine)
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What is the prognosis for Sarcoidosis? (3)
* _Without Treatment_ - **60% resolve** within 2 yrs
* _With Treatment_ - **10-20% don't resolve**
* **10% die** of **pulmonary, cardiac, or CNS complications**
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What is the pathogenesis of Orofacial Granulomatosis?
* **idiopathic** - **abnormal immune rxn**
* Must rule out other causes because it can be secondary to:
* _Local Factors_
* __Chronic oral infection
* Foreign material (if localized to gingiva)
* Allergy
* _Systemic Factors_
* Chronic Granulomatous Ds
* Crohn's Ds
* Sarcoidosis
* TB
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What is the classic presentation/main site of Orofacial Granulomatosis?
_Lips_
non-tender, **persistent swelling**, that **doesn't go away**
*DD: Angioedema usually goes away in 3 days*
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What is it called when the **lip signs of orofacial granulomatosis** are combined with **fissured tongue**, and **facial paralysis**?
Melkersson-Rosenthal Syndrome
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What are the intraoral lesions of Orofacial Granulomatosis? (3)
* _Gingiva_
* Swelling, erythema, pain, erosions
* _Buccal Mucosa_
* **Cobblestone appearance**
* **linear ulcerations in the mucobuccal fold**
* _Palate_
* Papules, hyperplastic tissue
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What is the histology of Orofacial Granulomatosis? (2)
* Non-necrotizing granulomatous inflammation
* **Poorly formed**, **small granulomas around blood vessels**
* Lots of normal looking tissue in between the granulomas; spread apart
* *Nor as well formed as in Sarcoidosis*
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What is the treatment for Orofacial Granulomatosis?
* Eliminate trigger
* **Intralesional corticosteroids (triamcinolone)**
* Lesions may resolve spontaneously or progress in spite of therapy
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What is the age of people affected with Wegner's Granulomatosis?
Wide age range
mean = **40 yrs**
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When occurs in Classic Wegner's Granulomatosis?
* _Initially_ - **upper and lower respiratory tract involvement**
* If the condition _remains untreated_ - **rapid renal involvement**
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When is Limited Wegner's Granulomatosis diagnosed?
* **No Renal Involvement**
* **Stays in respiratory tract** and never goes to the kidney
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What is seen in Superficial Wegner's Granulomatosis?
* Mostly **skin/mucosal signs**, with **slow development of systemic ds**
* This is usually _what dentists see_
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What is seen with upper respirtory involvement in Wegner's Granulomatosis? (8)
* Purulent nasal drainage
* Chronic sinus pain
* **Nasal ulceration**
* Congestion
* Fever
* _Otitis media_
* Sore throat
* **Epistaxis**
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What is seen with lower respirtory involvement in Wegner's Granulomatosis? (4)
* **Dry cough**
* *****Also in sarcoidosis (opposite of deep fungal infections)*
* Hemoptysis
* Dyspnea
* Chest Pain
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What seen with renal involvement in Wegner's Granulomatosis?
* **Glomerulonephritis** (nephrotic Sx) leads to **proteinuria**
* Occurs late in the ds process
* Most frequent cause of death
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What is the most frequent cause of death in Wegner's Granulomatosis?
Renal involvement
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What are the uncommon oral lesions of Wegner's Granulomatosis? (3)
* **Strawberry Gingivitis**
* ****Early sign of ds
* Attached **buccal gingiva**
* Isolated or multifocal
* **Salivary Enlargement**
* ****Early sign of ds
* **Non-Specific Ulceration**
* ****Late sign of ds
* May cause **palatal perforation**
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What are other orofacial signs/symptoms of Wegner's Granulomatosis? (3)
* **Facial Paralysis**
* Sinusitis
* Can mimic toothache or TMJ arthralgia
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What is shown in the histology of Wegner's Granulomatosis? (4)
* **Mixed inflammation** (pmns, histocytes, lymphocytes, _eosinophils_, mngc) **around blood vessels**
* *Langerhan's Histiocytosis also classically shows eosinophils*
* **Leukocytoclastic Vasculitis** = destroying wall of blood vessel
* Necrosis and nuclear dust
* **RBC extravasation**
* **Possible PEH**
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How is Wegner's Granulomatosis Diagnosed? (4)
* Combo of **clinical presentation + microscopic appearance**
* Confirm Disease Extent with:
* **Chest and sinus x-rays**
* **Serum creatinine and urinalysis**
* _Anti-Neutrophilic Cytoplasm Antibodies (ANCA)_
* p-ANCA - but it is seen in other vasculitides
* **c-ANCA (PR3-ANCA)**
* **Most useful in dx**, present in **90-95%** of classic/generalized WG
* Confirm with **ELISA** specific for **antigen proteinase 3 (PR3)**
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What is the treatment for Wegner's Granulomatosis?
Oral **cyclophosphamide** (nasty drug) and **predisone**
215
What is the prognosis for Wegner's Granulomatosis without treatment?
* _Classic WG_
* Mean survival **5 months**
* **90% die within 2 yrs**
* _Limited and Superficial WG_
* Much **better prognosis**
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What is the prognosis for Wegner's Granulomatosis in pts who receive treatment?
* **75%** have **prolonged remission**
* Cure for localized disease if dx and tx properly
217
What is the pathogenesis of Crohn's Disease?
Unknown Cause
**Inflammatory** and probably **immunologically mediated**
218
In what population is Crohn's ds diagnosed?
young adults and teenagers
219
What sites does Crohn's Disease affect?
* **Any part** of the **GI Tract** (primarily likes the distal portion)
* Extra-intestinal sites:
* Skin, eyes, joints
* Oral Mucosa in ~30% of cases
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What are the general signs/symptoms of Crohn's Disease?
* Abdominal cramping and pain, nausea and diarrhea, occasionally fever
* Weight loss and malnutrition can lead to: anemia, decreased growth, and short stature
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What are the oral lesions assocaited with Crohn's Disease? (3)
If GI is asymptomatic, this could be the 1st sign
* **Diffuse, or nodular** oral mucosal **swelling** with a **cobblestone** appearance
* *Can resemeble histoplasmosis(?) and Orofacial Granulomatosis*
* _CLASSIC_ - **deep**, granulomatous-appearing **linear ulcers** of **buccal vestibule**
* **Aphthous-like ulcers** if dramatic and occuring frequently
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What is the histology present in Crohn's Disease?
* **Non-necrotizing** granulomatous inflammation (non-specific)
* *sarcoidosis and orofacial granulomatosis*
* Special stains needed to exclude:
* Deep Fungal Infection
* Tertiary Syphilis
* TB
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What is the treatment for Crohn's Disease? (4)
* _1st Line_
* __**mesalamine** or **sulfa-type drug (sulfasalazine)**
* _2nd Line_
* __Systemic **prednisone** + azathioprine
* _Refractory Cases_
* **+ TNF-a inhibitor (infliximab)**
* _Complications_: bowel obsturction, fistula, abscess
* Require surgery
* Vitamin and mineral replacement may be neccessary
224
What is Pyostomatitis Vegetans?
**Oral manifestation** of **Ulcerative Colitis** or **Crohn's Disease**
225
What is the classic lesion of pyostomatitis vegetans?
* **Yellowish**, slightly elevated, linear, **serpentine "snail tracks"** set on an **erythematous base**
* Variable discomfort
226
What is the histology of Pyostomatitis Vegetans?
* Marked **edema** with **intraepithelial _eosinophilic_ abscesses**
* ****normally neutrophils in abscesses
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What is the treatment for Pyostomatitis Vegetans?
* **sulfasalazine** (anti-inflammatory) or **systemic steroids**
* Clears the oral lesions
