Antiviral and antifungal agents

Question 1

what is the herpes simplex virus and what are the 2 types

Answer 1

• occurs as primary or recurrent infection
• health and immunocompromised
• 2 types:
  herpes virus type 1 (HSV-1) = oral
  herpes virus type 2 (HSV-2) = genital (STD)

Question 2

what is a primary herpes infection

Answer 2

• also called primary herpetic gingivostomatitis
• occurs in infants and childhood
• characterized by fever, malaise, nausea and vomiting
• painful intraoral vesicles on the oral mucosa, rapidly rupture to form small ulcers with erythematous (red) haloes
• generalized severe gingivitis present and cervical lymphadenopathy

Question 3

when do the lesions appear and what are the lesions like in primary herpes infection

Answer 3

• lesions first appear 12-36 hours after the first symptoms

- lesions are self-limiting and will resolve within 10-14 days

Question 4

what is the treatment for primary herpes infection

Answer 4

• palliative

- fluids and analgesics (NO ASA)

Question 5

what is recurrent herpes simplex virus infection

Answer 5

• adults who previously had primary herpes, latent stage - reactivated
• occurs in the mouth and is referred to as herpes labials, ‘cold sore’ or ‘fever blister’ or ‘feu sauvage’
• reactivation common in immunocompromised patients (eg HIV/AIDS)
• small vesicles or ulcers appear on heavily keratinized oral mucosa (gingiva, palate, alveolar ridges, and vermillion border of lips)

Question 6

what are the lesions like in recurrent herpes simplex virus and how long do they last

Answer 6

• lesions may be painful, symptomatic treatment using antiviral agents is acceptable
• lesions will resolve within 10-14 days of appearance

Question 7

what drug therapies are available for herpes

Answer 7

• topical creams
• oral: valtrex, 500 mg - 4 tabs every 12 hours for 1 day
• oral acyclovir recommended in immunocompromised (HIV +) individuals with HSV-1
• corticosteroids should not be used in viral infections as they increase susceptibility to and mask symptoms of infection

Question 8

what are fungal infections

Answer 8

• infections are caused by either molds or yeasts

- many types of fungal infections can be caused by different species of fungi

Question 9

what are common fungal infections to see in the mouth and why

Answer 9

• candida species in the oropharyngeal (mouth) area
• normal flora in the GI tract and vaginal tract
• usually causes a localized superficial infection. in immunocompromised hosts, the infection spreads

Question 10

what are the 3 groups involved in fungal infections

Answer 10

• systemic mycosis (eg soft tissue, meningitis, UTI)
• superficial or mucocutaneous mycoses (eg nails, skin, and mucous membranes)
• subcutaneous mycoses (eg infections from contaminated soil)

Question 11

what is mucocutaneous mycoses of the mouth

Answer 11

• candida albicans
• thrush (acute pseudomembranous candidiasis)
• chronic atopic candidiases (denture sore mouth)
• candidial esophagitis

Question 12

what is acute pseudomembranous candidiasis

Answer 12

• thrush
• oral mucous membranes present with a creamy, white plaque that easily wipes off with gauze leaving a raw, red, bleeding connective tissue surface
• caused by candida albicans
• immunocompromised individuals - xerostomia (HIV, chemo, transplants)
• broad-spectrum antibiotics affect a broad range of bacteria allowing fungi to grow - take acidophillus or yogurt to reduce overgrowth

Question 13

who is most at risk for acute pseudomembranous candidiasis (thrush)

Answer 13

• elderly, children, pregnant women, postmenopausal women
• in patients taking inhaled steroids for asthma or allergic rhinitis
• patients with poorly fitting dentures

Question 14

what is the treatment for acute pseudomembranous candidiasis (thrush)

Answer 14

• depends on the age of the patient
• nystatin oral suspension is good in infants
• for adults, treatment is with topical or systemic anti fungal agents such as fluconazole (diflucan)
• clotrimazole: a troche that is slowly dissolved in the mouth. patient sixth a high caries index should not be given troches because they contain sugar
• severe and extensive oropharyngeal candidiasis treated with fluconazole (Diflucan), 100-200 mg orally twice a day
• prophylactic fluconazole is good for candida suppression in HIV disease

Question 15

how do we treat oral candidiasis

Answer 15

• responds to topical therapy if non systemic complications (oral suspensions)
• vaginal cream or ointment
• troches/pastilles (lozenges): remain in mouth for extended period, increased caries risk
• vaginal suppositories: no sugar and less cost, psychological adjustment

Question 16

what are systemic antifungal agents used for

Answer 16

• primarily used for fungal infections NOT involving the oropharyngeal area
• used for severe mucocutaneous candidiasis infections

Question 17

how long should patients take antifungals

Answer 17

• many fungal infections tend to recur after discontinuing drug treatment
• use drug for about 2 days after oral lesions disappear

Question 18

what is nystatin

Answer 18

• functions to cause fungal lysis
• oral suspension that is swished around in the mouth then swallowed
• lozenge that slowly dissolves in the mouth

Question 19

what is chronic atrophic candidiasis

Answer 19

• under max denture
• palatal tissue appears as either small, asymptomatic red spots
• treatment: topical antifungal agents

Question 20

what is angular cheilosis

Answer 20

• commissures of the lips
• causes:
  fungal infection caused by candida albicans
  B complex deficiency
  drooling/overclosure (moisture)
• treatment: topical antifungals

Question 21

drug interactions for fungal treatment

Answer 21

• systemic antifungal drugs metabolized by the P450 cytochrome liver enzymes
• topically applied antifungals are not involved in this metabolism so there are no drug interactions