Superficial Fungal Infections (Kays) Flashcards
1
Q
Thrush involves infection of the ______________.
A
oral mucosa
2
Q
What bacteria is most commonly implicated in oropharyngeal and esophageal candidiasis?
A
C. albicans
3
Q
What is the most common opportunistic infection in HIV patients?
A
oropharyngeal candidiasis
4
Q
What is the primary line of host defenses against superficial Candida infections?
A
cell-mediated immunity (mediated by CD4 T-cells)
5
Q
What are the local risk factors for OPC and EC?
A
- steroid/antibiotic use
- dentures
- xerostomia due to drugs, chemotherapy, head/neck radiotherapy, BMT
- smoking
- disruption of oral mucosa from chemotherapy, radiotherapy, ulcers, endotracheal intubation, trauma, burns
6
Q
Why is steroid use considered a local risk factor for OPC and EC?
A
steroids suppress cellular immunity
7
Q
Why is antibiotic use considered a local risk factor for OPC and EC?
A
antibiotics can alter the endogenous oral flora
8
Q
What are the systemic risk factors for OPC and EC?
A
- drugs (cytotoxic agents, corticosteroids, immunosuppressants after organ transplant, PPIs)
- neonate or elderly
- HIV/AIDS
- diabetes
- malignancies (leukemia, head/neck cancers)
- nutritional deficiencies
9
Q
What about HIV/AIDS infections are risk factors for OPC and EC?
A
- they cause depletion of CD4 T-lymphocytes
- HIV viral load
10
Q
A patient presents with cottage cheese-like, yellowish-white, soft plaques overlying areas of erythema on the buccal mucosa, tongue, gums, and throat. What is the most likely diagnosis?
A
oropharyngeal candidiasis (OPC)
11
Q
OPC plaques are easily removed by _______________.
A
vigorous rubbing
12
Q
Although some patients may experience no OPC symptoms, which noticeable ones may occur?
A
- painful mouth
- burning tongue
- metallic taste
- dysphagia
- odynophagia
13
Q
What are the three most common symptoms that an esophageal candidiasis (EC) patient may present with?
A
- dysphagia
- odynophagia
- retrosternal chest pain
14
Q
True or false: esophageal candidiasis patients can present with fever.
A
true
15
Q
Esophageal candidiasis plaques can be _________ or _________ with ulceration in severe cases.
A
hyperemic; edematous
16
Q
How do we diagnose esophageal candidiasis?
A
upper GI endoscopy with biopsy
17
Q
What is the recommended treatment duration for oropharyngeal candidiasis?
A
7-14 days
18
Q
What are the recommended topical therapies for mild OPC?
A
- clotrimazole troche 5x day
- nystatin suspension (5 mL swish and swallow) QID
- miconazole mucoadhesive buccal tablet (applied to upper gum region) daily x 7-14 days
19
Q
How long should a clotrimazole troche be held in the mouth for slow dissolution?
A
15-20 minutes
20
Q
What counseling points would you give a patient taking miconazole buccal tablets for OPC?
A
- apply in the morning after brushing teeth, and hold in place for 30 seconds to ensure adhesion; will gradually dissolve
- don’t chew gum
- if the tablet falls off and is swallowed within the first 6 hours, apply a new tablet
21
Q
In which OPC patients may systemic therapy be required?
A
- refractory OPC
- unable to tolerate topicals
- moderate-to-severe disease
- high risk for disseminated systemic disease (neutropenia)
22
Q
What are the systemic treatment options for OPC?
A
- fluconazole QD (preferred)
- itraconazole solution daily
- posaconazole suspension BID on day 1, then QD x 14 days
23
Q
Which systemic OPC agent should be taken on an empty stomach?
A
itraconazole solution
24
Q
Which systemic OPC agent should be taken with food?
A
posaconazole suspension
25
What is the recommended treatment duration for fluconazole-refractory OPC?
≥ 14 days (up to 28 days)
26
What treatment regimens are recommended for fluconazole-refractory OPC?
* **itraconazole** solution QD
* **posaconazole** suspension BID x 3 days, then QD for 28 days
* **voriconazole** BID (\> 40 kg)
* **amphotericin B deoxycholate suspension** 1-5 mL swish & swallow QID
* **amphotericin B deoxycholate** 0.3-0.7 mg/kg/day
* **caspofungin** LD, then IV daily
* **micafungin** IV daily
* **anidulafungin** IV daily
27
What is the recommended treatment duration for esophageal candidiasis?
14-21 days
28
True or false: topical therapies are an option for treating esophageal candidiasis.
false; systemic therapy is ALWAYS required
29
What treatment regimens are recommended for esophageal candidiasis?
* **fluconazole** PO/IV daily
* **itraconazole** solution PO daily
* **voriconazole** PO/IV BID (\> 40 kg)
* **posaconazole** suspension BID or delayed release tablets daily
* **echinocandin** (micafungin daily; caspofungin LD, then daily; anidulafungin daily)
* **amphotericin B deoxycholate** 0.3-0.7 mg/kg/day
30
What is the recommended duration of treatment for fluconazole-refractory esophageal candidiasis?
21-28 days
31
What are the recommended treatment regimens for fluconazole-refractory esophageal candidiasis?
* **posaconazole suspension** PO BID (with food)
* **voriconazole** PO/IV BID (\> 40 kg)
* **amphotericin B deoxycholate** 0.3-0.7 mg/kg/day or lipid-based formulation 3-5 mg/kg/day
* **caspofungin** IV daily
* **micafungin** IV daily
* **anidulafungin** IV on day 1, then IV daily
32
Vulvovaginal candidiasis can be classified as ________ or _______ depending on frequency.
sporadic; recurrent
33
Define uncomplicated vulvovaginal candidiasis.
sporadic infection that is susceptible to all forms of antifungal therapy regardless of treatment duration
34
Define complicated vulvovaginal candidiasis.
recurrent VVC; severe disease; non-*Candida albicans* infection; host factors (DM, immunosuppression, pregnancy)
35
What organism is responsible for 80-92% of symptomatic VVC?
*C. albicans*
36
What is the most common non-*C. albicans* organism for VVC?
*C. glabrata*
37
\_\_\_\_\_\_\_\_\_ species are dimorphic.
*Candida*
38
\_\_\_\_\_\_\_\_\_\_\_\_ are responsible for *Candida* colonization (transmission and spread).
blastospores
39
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ *Candida* forms are associated with tissue invasion and symptomatic infection.
germinated
40
What the risk factors for vulvovaginal candidiasis?
* sexual activity
* oral-genital contact
* contraceptive agents (diaphragm with spermicide, sponge, IUD)
* high-dose oral contraceptives
* antibiotic use
* post-menopausal women taking HRT
41
What symptoms are associated with vulvovaginal candidiasis?
* intense vulvar itching
* soreness
* irritation
* burning on urination
* dyspareunia
42
What signs are associated with vulvovaginal candidiasis?
* erythema
* fissuring
* curdy cheese-like discharge
* satellite lesions
* edema
43
Someone with VVC will have a _______ vaginal pH.
normal
44
In VVC patients, saline and KOH microscopy will reveal what two results?
blastospores or pseudohyphae
45
In VVC, cultures for *Candida* are not recommended…except in which two cases?
* classic signs/symptoms with normal vaginal pH and microscopy are inconclusive
* suspected recurrence
46
What patient education can you give for VVC?
* avoid harsh soaps/perfumes that can cause or worsen vulvar irritation
* keep genitals clean and dry
* cool baths can soothe the skin
* douching is not recommended for prevention or treatment
* oral lactobacillus (controversial)
47
What is one of the major disadvantages of using topical azoles for uncomplicated VVC?
topical preparations can decrease efficacy of latex condoms and diaphragms
48
Which has the higher cure rate in uncomplicated VVC: topical/oral azoles, or nystatin?
topical/oral azoles (80-95%)
49
True or false: topical therapy is therapeutically superior to oral therapy for VVC.
false; oral and topical therapy are therapeutically equivalent
50
What OTC topicals can be used for uncomplicated VVC?
* **butoconazole** 2% cream x 3 days
* **clotrimazole** 1/2/10% cream x 1 day
* clotrimazole tablet x 1, 3, or 7 days
* **miconazole** 2% cream x 1 day
* miconazole suppository x 3, 7 days
* miconazole ovule x 1 day
* **ticonazole** 6.5% cream x 1 day
51
What prescription topicals can be used for uncomplicated VVC?
* **nystatin** x 14 days
* **terconazole** cream x 3, 7 days
* terconazole suppository x 3 days
52
What prescription oral medications can be used for uncomplicated VVC?
* **fluconazole** x 1 day
* **ibrexafungerp** x 1 day
53
What is the recommended duration of therapy for complicated VVC?
10-14 days (regardless of route of administration)
54
How far apart should fluconazole doses be spaced in complicated VVC?
72 hours
55
What treatment options are contraindicated for complicated VVC in pregnancy?
oral agents; concern for fetal complications
56
What is the preferred treatment regimen for complicated VVC in pregnancy?
topical azole x 7 days
57
What would qualify a patient as having recurrent VVC?
\> 4 episodes within a 12-month period
58
What is the recommended treatment regimen for recurrent VVC?
topical/oral azole x 10-14 days, then fluconazole PO once a week x 6 months
59
When should you consider whether a patient's VVC may be antifungal-resistant?
if persistently positive yeast cultures and/or failure to respond to therapy despite adherence
60
What are the recommended treatment regimens for antifungal-resistant VVC?
* **boric acid capsule** intravaginally daily x 14 days, then twice a week
* **flucytosine cream** intravaginally nightly x 7 days
61
What are superficial mycotic infections of the skin called?
dermatophytoses
62
What are the risk factors for superficial mycotic infections?
* prolonged exposure to sweaty clothes
* failure to regularly bathe
* many skin folds
* sedentary
* confined to bed
63
What is preferred for treating mild tinea pedis: topical or oral therapy?
topical
64
What is the preferred duration of therapy for mild tinea pedis infection?
2-4 weeks
65
Why is prolonged therapy required to treat tinea pedis?
because recurrence is so common
66
What does tinea manuum involve?
palmar surfaces
67
Tinea manuum treatment is similar to __________ treatment.
tinea pedis
68
What area of the body does tinea cruris involve?
proximal thighs and buttocks ("jock itch")
69
What is the the recommended duration of therapy for tinea cruris?
1-2 weeks after symptoms resolve
70
Which is generally preferred for tinea cruris: topical or oral therapy?
topical (severe infections may require oral)
71
Tinea corporis is an infection of the _______ and \_\_\_\_\_\_\_\_\_\_\_.
trunk; extremities
72
Treatment of tinea corporis is similar to treatment of \_\_\_\_\_\_\_\_\_\_\_\_.
tinea pedis
73
Tine capitis is an infection involving \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
the scalp, hair follicles, and adjacent skin
74
What is preferred in the treatment of tinea capitis: oral or topical therapy?
oral
75
What is the preferred treatment regimen for tinea capitis?
terbinafine daily x 4-8 weeks
76
What counseling point would you give to a tinea capitis patient?
use clean combs and brushes
77
Tinea barbae is an infection of the \_\_\_\_\_\_\_\_\_\_\_\_\_\_.
hairs and follicles of the beard and mustache
78
Tinea barbae treatment is the same as \_\_\_\_\_\_\_\_\_\_\_.
tinea capitis
79
If someone has tinea barbae, what non-pharmacologic recommendation would you make?
shave the beard/mustache
80
What is tinea (pityriasis) versicolor?
hyper- or hypopigmented scaly patches on the trunk and extremities
81
Tinea versicolor is most common in adults and which environment?
tropical
82
In tinea versicolor, ___________ therapy is adequate unless there is an extensive skin area or recurrent infection.
topical
83
Tinea unguium is also known as \_\_\_\_\_\_\_\_\_.
onychomycosis
84
Tinea unguium is an infection of the \_\_\_\_\_\_\_\_\_.
nails
85
What are the risk factors for onychomycosis?
* increasing age (especially \> 40)
* family history/genetic factors
* immunodeficiency
* diabetes
* psoriasis
* PVD
* smoking
* tinea pedis
* frequent nail trauma
* sporting activities (swimming)
86
What are the recommended treatment regimens for tinea unguium of the fingernails?
* **terbinafine** x 6 weeks
* **itraconazole** x 1 week/month for 2 months
* **fluconazole** for x 6+ months
87
What are the recommended treatment regimens for tinea unguium of the toenails?
* **terbinafine** x 12 weeks
* **itraconazole** x 12 weeks
* **fluconazole** x 12 months
88
Terbinafine is fungicidal against \_\_\_\_\_\_\_\_\_\_\_.
dermatophytes
89
What are the GI side effects associated with terbinafine?
* diarrhea
* dyspepsia
* nausea
* abdominal pain
90
What dermatological side effects are associated with terbinafine?
* rash
* urticaria
* pruritus
91
True or false: terbinafine can cause headaches.
true
92
Why should we monitor CBCs in patients taking terbinafine?
terbinafine may cause a transient decrease in lymphocyte count
93
What rare side effect should be noted for terbinafine?
severe hepatotoxicity; AVOID IN LIVER DISEASE
94
Terbinafine is a potent inhibitor of \_\_\_\_\_\_\_.
CYP2D6
