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Oral Disease > Oral Infections - viral and fungal > Flashcards

Oral Infections - viral and fungal Flashcards

1
Q

What viral infections are important orally?

A

Herpes viruses

  • Simplex 1 and 2
  • Varicella zoster
  • Cytomegalovirus
  • Epstein Barr

Coxsackie virus
Measles
Human papilloma virus

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2
Q

Herpes simplex bacteria characteristics?

A 
Enveloped
DNA virus
Highly cytolytic
Infects via heparan sulphate
90-100% of individs have antibodies to herpes simplex
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3
Q

What is type 1 herpes simplex associated with?

A

Skin and oral mucous membranes

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4
Q

What is type 2 herpes simplex associated with?

A

Genital mucosa

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5
Q

How is herpes simplex transmitted?

A

By droplet spread or intimate contact

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6
Q

Pathogenesis of herpes simplex 1?

A

Virus enters trigeminal sensory neurones
Migrates to the ganglion by retrograde axonal flow
Latency - 50% of cases lie dormant
In 30% of cases virus is reactivated
Migrates to peripheral nerve endings
Virus is shed
Reactivation can be caused by UV, stress, illness, immunosuppression

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7
Q

Herpes simplex - primary gingivostomatitis history?

A

Children, young adults
Incubation period 5 days
Heal within 10-14 days
Many are subclinical and asymptomatic

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8
Q

Herpes simplex - primary gingivostomatitis signs and symptoms?

A 
Malaise and fever
Vesicles which ulcerate
Secondary infection
Erythematous gingivitis
Extra-oral lesions
Patchy whiteness on ventral of tongue and/or gingiva
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9
Q

How to diagnose herpes simplex - primary gingivostomatitis?

A

Made on clinical features
Patients have a rising antibody titre to herpes simplex
Pathogenesis:
- Herpes virus replicates in epithelial cells
- Causes epithelial cell destruction and ballooning degeneration of cells
- Results in intra-epithelial vesicles

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10
Q

Herpes labialis features?

A

“cold sore”

Occurs in 30% of pts

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11
Q

Herpes labialis clinical features?

A

Prodromal tingling
Vesicles at the muco-cutaneous junction
Ulcerate and crust over
Lasts 7-10 days

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12
Q

Why is herpes labialis diagnosis difficult?

A

Difficulty differentiating erythema multiforme

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13
Q

Treatment of herpes labialis?

A

Effective in prodromal stage
Aciclovir cream (zovirax)
Penciclovir

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14
Q

Herpes varicella zoster virus - what number herpes virus is it?

A

Type 3 herpes virus

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15
Q

Herpes zoster primary infection and secondary lesion?

A

Primary infection - chicken pox (varicella)

2ndry - shingles (zoster)

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16
Q

What does herpes zoster most commonly affect?

A

One of the 3 divisions of the trigeminal nucleus

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17
Q

What are the 3 phases of herpes zoster?

A

Pre-herpetic neuralgia
- Pain in the affected division, may mimic dental pain

Rash

  • Unilateral vesicles: (does not cross the midline) opthalmic, maxillary, mandibular
  • Ulcers (mucosa) and crusting lesions (skin)
  • Lasts 2-3 weeks

Post-herpetic neuralgia

  • Burning pain, affects 10-20%
  • More common in elderly
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18
Q

Management of herpes zoster?

A

Aciclovir 800mg 5 x daily for 7 days

  • Valaciclovir 1g 3x daily, 7 days
  • Famciclovir 250mg 3x daily, 7 days

Analgesics
Referral to opthalmology if eye involved

Post herpetic neuralgia

  • Treat pain with neuropathic pain drugs
  • Gabapentin, antidepressants
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19
Q

Epstein-Barr virus (SV4) - what can it cause?

A

= Infectious mononucleosis (glandular fever)

Burkitt’s lymphoma
= non-hodgkin’s lymphoma

Nasopharyngeal carcinoma

Oral hairy leukoplakia

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20
Q

Clinical signs of Epstein Barr virus infection - infectious mononucleous?

A

Affects tonsils - increased size
Petechiae on soft palate
Cervical lymphadenopathy

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21
Q

Oral hairy leukoplakia features?

A

Seen in 25% of HIV infected patients
Can occur in non-HIV patients
Corrugated white patches
Bilateral on lateral borders of the tongue

22
Q

How to diagnose oral hairy leukoplakia?

A

Demonstration of EBV in tissues

23
Q

Cytomegalovirus (HV5) pathogenesis?

A

Inclusion bodies

Dormant in lymphocytes - interfere with MHC1 presentation

24
Q

When is cytomegalovirus concerning?

A

In immunocompromised pts

  • Large ragged oral mucosal ulcers
  • Salivary gland swelling
  • Retinitis

New born
- Life threatening

25
Q

How can cytomegalovirus (HV5) present?

A

Rarely causes problems in healthy subjects

- Rare appearances are glandular fever like illness (no lymphadenopathy) and salivary gland swelling

26
Q

Coxsackie A viruses - what types cause the most problems in the oral cavity?

A

Types 4, 5, 10 and 16

27
Q

What can coxscakie A virus 4 cause? Clinical features of this?

A 
Herpangina
= Looks like herpes and gives the pt a choking sensation
- CVA4 causes it 
- Mild febrile illness
- Young adults and children
- Vesicles and ulcers on soft palate
- Lasts a few days
28
Q

Herpangina treatment?

A

Usually no tx

- Analgesic MW e.g. difflam

29
Q

What can CVA16 cause? Clinical features of this?

A

Hand foot and mouth syndrome

  • Similar to herpangina, mild systemic upset
  • Rash/vesicles on palms of hands, soles of feet
  • Intra-oral vesicles and ulcers - anywhere in mouth
30
Q

What type of infection is measles?

A

Paramyxovirus

31
Q

Clinical features of measles?

A 
Pt will be systemically unwell
Koplik's spots
- White papules on buccal and palatal mucosa during prodromal phase
Skin rash 
Long term effects
32
Q

Human papilloma virus features?

A

> 40 types of HPV:

  • DNA virus - just 9 genes
  • Only infects keratinocytes- gets into basal cells via integrins = virus is internalised and can replicate
  • High risk oncogenic subtypes (HPV16 and 18) = cervical, oropharynx and anal cancer
33
Q

Main oral lesions with human papilloma virus?

A

Squamous cell papilloma/verruca vulgaris
Condyloma accuminatum = genital warts inside the mouth
Focal epithelial hyperplasia (Heck’s disease)
- HPV13
- Common in small native communities and HIV infection
- Tx - excision, imiquimod 5% cream

Dysplasia/SCC

34
Q

List the fungal infections that can impact the oral cavity

A 
Aspergillosis
Blastomycosis
Candidosis
Coccidioidomycosis
Cryptococcosis 
Histoplasmosis
Rhinosporidiosis
35
Q

What species cause candidosis?

A 
Candida albicans - most common
C.tropicalis
C.krusei
C.glabrata
C.dubliniensis
36
Q

Predisposing factors for candida?

A

Prostheses: No exfoliation
Low saliva - no flow = reduces soluble defences (Low pH induced by high sugar diet)
Antibiotics: reduced bacterial competition

Immuno-suppression - reduced cellular defence:

  • Young/old
  • Diabetes
  • Corticosteroids, including steroid inhalers
  • Malignancy
  • HIV
  • Immunosuppressive therapy
37
Q

Pathogenic/virulence factors of candida?

A

Hyphal transition and growth is needed for virulence and pathogenesis
Hyphae secrete candidalysin = pore forming toxin that kills human cells and initiates a human response

Proteases - produce SAP:
Sap 1-3 = needed for mucosal infection, degrade complement
Sap 4-6 = contribute to systemic infection
= Invade between/through epithelial cells

ALS1 mediates binding to epithelial surface

38
Q

Classification of candida infections?

A

Acute forms

  • Acute pseudomembraneous candidosis (thrush)
  • Acute atrophic candidosis (antibiotic sore mouth)

Chronic form

  • Chronic atrophic candidosis (denture stomatitis)
  • Chronic hyperplastic candidosis (candidal leukoplakia)
  • Chronic mucocutaneous candidosis (various: inherited syndromes)

Candida associated lesions

  • Median rhomboid glossitis
  • Angular cheilitis

HIV related candidosis

39
Q

Acute pseudomembranous candidosis?

A

Creamy thick white plaques
- Thick biofilm of yeast and hyphal forms
Easily rubbed off

40
Q

Acute atophic candidosis causes?

A

Prolonged corticosteroid or antibiotic therapy

Bacterial flora altered, allows candida to flourish

41
Q

How to treat acute atrophic candidosis?

A

Reduce antibiotic use if possible

Antifungals

42
Q

Management of acute atrophic candidosis?

A

Confirm diagnosis
- Swabs or oral rinse with/without microbial culture
Investigate and treat underlying cause
Treat with anti-fungal agents:
- Miconazole oral gel
- Nystatin suspension - gross taste and use for a month
- Amphotericin B (only in hospital pharmacies)
Systemic:
- Fluconazole = interacts with warfarin
- Itraconazole

43
Q

Denture related candidosis - when/why does it occur? Clinical appearance?

A

Palate protected from saliva = antimicrobial properties
Poor denture hygiene
Do not remove denture at night
Redness of palate which follows outline of denture

44
Q

Treatment for denture related candidosis?

A

Improve denture hygiene

  • Leave out at night
  • Clean denture and soak in milton (NOT for CoCr dentures - can use something that is chlorhexidine based) or corsodyl

Antifungals

  • Nystatin +/- miconazole gel to fitting surface tds
  • 2-3 weeks
45
Q

Median rhomboid glossitis presentation?

A

Red depapillated (erythematous area) area in the centre of the dorsum of the tongue
Sometimes have matching lesion in the palate
Epithelial proliferation
Candida in epithelium
Not premalignant
Diagnosis usually on clinical grounds

46
Q

Angular cheilitis predisposing factors?

A

Often occurs with denture associated candidosis
Crusting/weeping in corners of mouth

Reduced vertical dimension = drooling of saliva

Haematological deficiency

  • Iron, B12, folate deficiency
  • Crohn’s disease

Pt may have undiagnosed type 2 diabetes

Some cases associated with staph aureus

47
Q

Tx for angular cheilitis?

A

Address underlying cause

Miconazole cream or fusidic acid, depending on cause

48
Q

Chronic hyperplastic candidosis

A

White or red/white patch, nodular
Whiteness cannot be rubbed off
Classic sites - labial commissures (start of buccal mucosa next to lip) or tongue

Premalignant
- Up to 25% of malignant change

Diagnosed by biopsy

49
Q

Aetiology of chronic hyperplastic candidosis?

A

Usual candida risk factors
Smoking
Not clear if candida cause the lesion or invade a pre-existing lesion
Some lesions regress following antifungal therapy

50
Q

Histology of chronic hyperplastic candidosis?

A

Candida at right angles to surface

Hyperplastic epithelium

51
Q

Management of chronic hyperplastic candidosis?

A

Diagnosis

  • Biopsy
  • Assess degree of dysplasia and risk of malignant transformation

Tx

  • Systemic antifungals (7-14 days fluconazole or amphotericin B)
  • Smoking cessation

If no improvement and high risk of malignant transformation then excise

Oral Disease (42 decks)

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