Oral Lesions Flashcards
What are corticosteroids and what are they used for?
a class of drugs that includes steroid hormones naturally produced by the adrenal cortex; used for things like asthma, COPD, allergic reactions, and autoimmune disease
What are some side effects of corticosteroids (especially with long term use)?
adrenal insufficiency, high blood glucose, dementia, and osteoporosis
What causes oropharyngeal candidiasis, more commonly known as thrush?
caused by normally occuring fungus (in most people) called Candida albicans; local infection occurs when conditions are right for overgrowth (opportunistic)
What are some predisposing factors for thrush?
immunucompromised (like HIV and AIDS), infancy, older people with dentures, diabetic, those undergoing chemo or radiation, those taking antibiotics or corticosteroids (topical and systemic)
clinical presentation of thrush
sore throat or mouth, oral erythema with OR without white plaques
Will thrush brush?
YES! It will brush when compared to leukoplakia (not necessarily when compared to milk)
How is thrush diagnosed?
usually diagnosed based on clinical presentation but can be confirmed by a KOH prep – will see budding yeasts with or without pseudohyphae
true hyphae vs. psuedohyphae
true = have septa (internal cross walls) pseudo = not fully septate and are fragile; associated with yeast
What are three medications used to treat thrush?
nystatin suspension (topical), clotrimazole (topical), or oral fluconazole (Diflucan)
What is some important patient education for the treatment of thrush?
Clean dentures carefully and rinse the mouth after using steroid inhalers!
When would a case of thrush warrant investigation for an underlying disease like diabetes or HIV?
if it involves the esophagus, if it is recurrent, or if it occurs without note of predisposing factors
What are some non-infectious causes of pharyngitis/tonsilitis?
allergies, smoking, GERD
Is most acute infectious pharyngitis bacterial or viral?
viral
What bacteria and viruses can cause acute infectious pharyngitis?
viruses = adenovirus, enteroviruses like coxackie A, HSV bacteria = Strept pyrogenes (a Group A) or GAS, Mycoplasma pneumoniae, Neisseria gonorrhea, Fusobacterium necrophorum, non-group A Strept, Corynebacterium diptheriae, Tularemia
Which is the most common organism involved in bacterial pharyngitis/tonsilitis? What group of people is particularly targeted?
Group A Strept
particularly in kids under 3 years old and in adolescents (15-30% of all cases in kids 3-15 years old)
The incidence of GAS pharyngitis peaks in what time of the year?
winter and early spring
clinical presentation of GAS pharyngitis
- pharynx with edema, erythema, and/or exudates
- tender anterior cervical nodes
- middle grade fever (between 101-103)
- absence of usual signs of viral URIs (so no cough or coryza)
may also see palatal petechiae and/or scarlatiniform rash; may be indistinguishable from infectious pharyngitis due to other causes!
What is coryza?
cold symptoms, nasal mucous membrane inflammation, congestion
What is scarlet fever and what causes it?
illness caused by group A strep; rash starts on torso – moves to arm creases, blanches; illness also associated with sore throat and fever
Centor criteria for GAS pharyngitis (4 things!)
- tonsillar exudates
- tender anterior cervical adenopathy
- fever by history
- absence of cough
How can we diagnose GAS pharyngitis?
throat culture (gold standard) – may take 48 hours; rapid antigen detection test; test only those in whom bacterial pharyngitis is likely (if they have signs and symptoms of bacterial and no signs and symptoms suggestive of viral)
What would you do if you suspected GAS pharyngitis but the rapid strep test was negative?
perform a throat culture to confirm, along with any other indicated testing
Do rapid strep tests and throat culture tell us anything about distinguishing between acute infection and colonization?
Nope!
What does the IDSA recommend when deciding to treat or test adults for GAS pharyngitis?
advises against testing or treating adults with less than 2 Centor criteria
How is GAS pharyngitis treated?
Pen V PO x 10 days, OR benzathine Pen 1.2 million units IM (a big shot!); can also used cefdinir, clindamycin, azithromycin (zithromax)
three complications of GAS pharyngitis
acute rheumatic fever
post-strep glomerulonephritis (<7 years old)
peritonsillar abscess
What are two signs of a peritonsillar abscess?
patient’s voice may be muffled; uvula displaced away from the abscess
How do we treat a peritonsillar abscess and why is it so important to treat?
can be a medical emergency because it can obstruct the airways; treat with incision and drainage plus antibiotics
What organism causes most cases of Lemierre’s Syndrome?
Fusobacterium necrophorum
What is Lemierre’s Syndrome and what are its main complications?
a necrotizing tonsillopharyngitis followed by a Fusobacterium bacteremia; leads to septic thrombophlebitis of the internal jugular vein and subsequent metastatic abscesses (often go to lung); serious and life threatening
What kind of bacteria is Fusobacterium necrophorum?
Gram negative anaerobe
symptoms of Lemierre’s Syndrome
high fever, rigors, respiratort symptoms, and unilateral neck swelling/pain; worsening pharyngitis
How do we diagnose Lemierre’s Syndrome?
no good test but we know the organism is a gram negative anaerobe
Lemierre’s Syndrome is resistant to what medications?
macrolides
What medications are used to treat Lemierre’s Syndrome?
PCN and metronidazole, or with Clindamycin
A patient presented one week ago with pharyngitis. A rapid strep was negative and a follow up throat culture was done. He was treated empirically with Zithromax. Throat culture came back positive for non-group A streptococci. The patient now returns 10 days later with fever, worsening pharyngitis, and neck swelling. What do we suspect?
Lemierre’s Syndrome, a type of bacterial pharyngitis that is very rare (1 in a million!)
What would a C. diphtheriae bacterial pharyngitis look like?
RARE; tightly adhering gray membrane in nares and throat
Is diptheria common in the United States?
NO!
How does a patient acquire Tularemia bacterial pharyngitis? This is rare, but when would we include it on our differential?
include on differential if the patient doesn’t respond to PCN; caused by ingestion of poorly cooked wild animal meat
What are the findings in a patient with the rare Neisseria gonorrhoae bacterial pharyngitis? How do we culture this?
no pathognomic findings but if a patient is at risk for STDs, this could be possible; requires a special media to culture
Mononucleosis usually occurs in what ages?
10 to 35 (but by age 20, most have antibodies)
What causes mono?
EBV - Epstein Barr Virus
transmitted via saliva (kissing disease!)
How long does saliva remain infectious with mono?
during convalescence (for six months or longer from the time of symptom onset)
clinical presentation of mono
like strep throat – myalgias and no cough
diagnosis of mono
throat culture or rapid strep (also a throat swab), mono spot test (blood test), EBV serology
treatment of mono
supportive only, and monitor for complications; advise kids to not play sports for at least four weeks
An acute HIV infection is also known as what?
acute retroviral syndrome or primary HIV, the initial period of infection
Why is an acute HIV infected patient very contagious?
viral load is high – has not made any antibodies
A disproportionate number of new infections are attributable to…
acute HIV
What would a routine HIV test show in a patient with acute HIV?
wouldn’t show infection so the diagnosis would be missed (as most are)
People in what age group account for HALF of HIV cases?
13-34
What is the clinical presentation of acute HIV similar to?
it varies but it can look like mono, Strep, or the flu
A viral syndrome associated with a rash and/or oral ulcers would be very suspicious for what condition?
acute HIV infection
symptoms of acute HIV infection
fever, malaise, RASH, myalgia/arthralgia, PHARYNGITIS, ORAL ULCERS, night sweats, weight loss
3 most common symptoms of acute HIV infection
fever, fatigue, rash
What tests do you order when suspecting acute HIV after taking a history?
HIV Ab test and a test to detect the virus like an HIV RNA test
Acute HIV illness usually subsides within…
14 days
Do we refer patients with acute HIV?
YES – right away, to HIV specialist
What does a qualitative DNA PCR do?
detects cell associated proviral DNA
What test confirms HIV?
HIV Ab
T/F. Most HIV-infected individuals will not substantially reduce sexual behaviors that transmit disease once diagnosed.
FALSE! They will.
What two things must happen in order for you to suspect HIV and order a test?
- patient has the signs of an acute HIV infection
2. history of potential HIV exposure in past six weeks
What happens if we test an HIV-suspect patient and the antibody comes back negative, and RNA is not detected?
Retest in three months.
What happens if we test an HIV-suspect patient and the antibody comes back negative/indeterminate, and the RNA IS detected?
Treat as acute HIV and refer to specialist.
What happens if we test an HIV-suspect patient and the antibody is detected and the RNA is detected?
Treat as established HIV and refer to specialist.
Other than mono and HIV, what other things can cause viral pharyngitis?
HSV, Cocksackie, Adenovirus, influenza
What is the most common clinical manifestation of primary HSV infection in childhood?
herpetic gingivostomatis
precipitating factors for HSV-1
sun, trauma, stress
How is HSV-1 transmitted?
direct contact during viral shedding
T/F. Viral shedding of HSV can occur with or without lesions.
T
What are three tests we could use to diagnose HSV?
Viral culture
Serology – HSV-1 antibodies
Tzanck smear - scraping ulcer base to look for Tzanck cells (multinucleated giant cells)
What are Tzank cells and when are they found?
multinucleated giant cells, found in HSV but also found in varicella, CMV, pemphigous
How is HSV treated?
ASAP, at the onset of prodrome! Topical aciclovir and oral meds like acyclovir, valacyclovir (Valtrex), famciclovir
