Rosen & Barkin's 5-Minute Emergency Medicine Consult (122 page)

• Candida organisms are normally present as oral flora from 65–88% of elderly or those in long-term care facilities
  
• Dentures can lead to Candida overgrowth
  
• Angular cheilitis more common in the elderly secondary to facial wrinkling
  

DIAGNOSIS

• Pseudomembranous candidiasis (thrush):
  
  • Painless white mucosal plaques
    
  • Adherent but removable plaques
    
  • Erythematous base
    
  • May become confluent and curdlike
    
  • Anorexia, dysphagia
    
• Acute atrophic candidiasis:
  
  • Also referred to as erythematous candidiasis
    
  • Burning sensation in mouth or on tongue
    
  • Erythematous with few, if any white patches usually on the palate or dorsum of tongue
    
  • Tongue may be bright red in color—similar to nutritional deficiency
    
• Chronic atrophic candidiasis:
  
  • Also referred as denture stomatitis
    
  • Irritation around denture-bearing mucosa
    
• Angular cheilitis:
  
  • Cracking or erythema at the corners of mouth
    
  • Lesion can be asymptomatic, pruritic, or painful
    
  • Superinfection with Staphylococcus or Streptococcus is common
    
• Hyperplastic candidiasis:
  
  • Chronic, invasive ulcers
    
  • Typically on lateral borders of tongue or buccal mucosa
    
  • High incidence of malignant degeneration in tobacco users
    

• Minimal workup needed in otherwise healthy infant. Diagnosis can be made clinically.
  
• Determine whether there is a cause for a breakdown of host factors
  
• If no reason is found, evaluate for possible HIV infection or diabetes
  
• Exclude a systemic infection
  

• Clinical diagnosis often sufficient
  
• CBC if suspect severe infection
  
• Glucose testing
  
• Periodic acid-Schiff stain/KOH/fungal culture:
  
  • Branching, thread-like hyphae, spores or pseudohyphae may be seen
    
  • Obtain culture and sensitivity if failed first line treatment or high-risk individuals (HIV/AIDs, neutropenic, AIDs, transplant, etc.)
    

• Hairy leukoplakia
  
• Lichen planus
  
• Squamous cell carcinoma
  
• Adherent food/milk
  

TREATMENT

• IV fluids if dehydration and/or unable to tolerate PO fluids
  
• Topical analgesia: “Magic mouthwash”:
  
  • Mixture of equal parts of 2% viscous lidocaine, Maalox, and diphenhydramine elixir
    
  • Swish for 1–2 min, then expectorate
    
• Topical antifungal medications:
  
  • Suspension, troches, lozenges
    
  • Ointments (angular cheilitis)
    
• Systemic agents reserved for those with severe disease or resistant to topical therapy
  
• Provide oral hygiene education:
  
  • Instruct those using steroid inhalers to rinse mouth immediately after use
    
  • Denture and orthodontic care
    

• Dissolve troche in bottle nipple
  
• Mix suspensions with fruit juice and freeze into popsicle
  
• Apply suspensions to affected areas with a cotton-tipped swab
  
• Instruct parents to disinfect or replace toothbrushes, pacifiers, bottle nipples
  

• Angular cheilitis: Treat with topical nystatin ointment
  
• Dentures: Remove, brush, and soak nightly. Consider overnight rinse with 2% chlorhexidine
  

• Nystatin: Oral suspension; neonates 100,000 U; older infants: 200,000 U; children/adults: 400,000–600,000 U. Swish and swallow QID for 7–14 days
  
• Nystatin pastilles: 200,000 U PO QID for 7–14 days
  
• Clotrimazole troches: 10 mg PO dissolved slowly 5 times per day for 7–14 days (children >3 yr)
  

• Oral fluconazole: Loading dose of 200 mg (peds: 6 mg/kg) on day 1, followed by 100 mg (peds: 3 mg/kg) PO daily for 7–14 days
  
• Itraconazole solution: 200 mg (peds: >5 yr, 2.5 mg/kg BID, not FDA approved) PO daily for 7–14 days
  
• Posaconazole 100 mg (peds: >13 yr refer to adult dosing) PO BID on day 1, then 100 mg PO daily for 13 days
  
• Systemic Amphotericin B (0.3 mg/kg) daily is the treatment of choice for candidiasis in pregnant women
  

FOLLOW-UP

• Inability to tolerate oral intake
  
• Newly diagnosed immunocompromised state
  
• Systemic infection
  

If the candidiasis does not threaten patient’s hydration status, discharge

Additional workup for immunodeficiency is warranted in older children and adults with unexplained candidiasis.

• Failure to recognize immunodeficiency
  
• Failure to recognize other intraoral pathology such as squamous cell carcinoma
  

• Gonsalves WC, Chi AC, Neville BW. Common oral lesions: Part I. Superficial mucosal lesions.
  Am Fam Physician
  . 2007;75:501–507.
  
• Krol DM, Keels MA. Oral conditions.
  Pediatr Rev
  . 2007;28:15–22.
  
• Kuyama, K, Sun Y, Taguchi C, et al. A clinico-pathological and cytological study of oral candidiasis.
  Open J Stomatology
  . 2011;1:212–217.
  
• Pappas PG, Kauffman CA, Andes D, et al. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America.
  Clin Infect Dis
  . 2009;48:503–535.
  

CODES

• 112.0 Candidiasis of mouth
  
• 771.7 Neonatal Candida infection
  

BASICS

• Therapeutic uses of carbamazepine:
  
  • Anticonvulsant
    
  • Treatment of chronic pain
    
  • Migraine prophylaxis
    
  • Mood stabilizer
    
• Mechanism:
  
  • Anticholinergic
    
  • Similarities to phenytoin and tricyclic antidepressants (TCAs)
    
  • Sodium channel blocker
    
  • Decreases synaptic transmission
    

Toxicity may occur from:

• Suicide attempt
  
• Accidental ingestion
  
• Supratherapeutic dosing
  
• Drug–drug interaction
  

DIAGNOSIS

• Neurologic manifestations common
  
• Cardiotoxicity rare, except in massive overdose
  
• CNS:
  
  • Ataxia
    
  • Dizziness
    
  • Drowsiness
    
  • Nystagmus
    
  • Hallucinations
    
  • Combativeness
    
  • Coma
    
  • Seizures
    
• Respiratory system:
  
  • Respiratory depression
    
  • Aspiration pneumonia
    
• Cardiovascular system:
  
  • Hypotension
    
  • Conduction disturbances (mostly in elderly)
    
  • Supraventricular tachycardia
    
  • Sinus tachycardia or bradycardia
    
  • ECG changes:
    
    • Prolongation of PR, QRS, and QTc intervals
      
    • T-wave changes