Noncandidal Fungal Infections of the Mouth Clinical Presentation
- Author: Crispian Scully, MD, PhD, MDS, CBE, MRCS, FDSRCS, FDSRCPS, FFDRCSI, FDSRCSE, FRCPath, FMedSci, FHEA, FUCL, DSc, DChD, DMed(HC), Dr(HC), ; Chief Editor: William D James, MD more...
History
The following conditions may predispose individuals to infection. These conditions require an evaluation to determine whenever a deep fungal infection is established.
- Drug use - Corticosteroids, cytotoxic agents, immunosuppressants
- Immunodeficiency - HIV, AIDS
- Endocrinologic condition - Poorly controlled diabetes mellitus, ketoacidosis
- Malignancy - Leukemia, lymphoma, others
- Other conditions - Neutropenia, malnutrition, old age
Physical
Patients with deep mycoses may present with a primary infection of the oral mucosa, but, more commonly, they present with an extension of an established paranasal infection. Therefore, by the time oral lesions are present, considerable destruction of the maxilla and maxillary sinus may have occurred.
In healthy individuals, the disease is usually self-limiting, but in individuals who are immunocompromised, extensive local destruction, fungemia, visceral and cerebral invasion, and death are substantial risks.
The most common presentation of oral deep fungal infection is a chronic, solitary ulcer or nodule. When infection involves the palate, this finding may be only the initial indication of considerable antecedent destruction of the maxilla and maxillary sinus. Extension and/or invasion into the orbital and cranial cavity are not uncommon. The condition may be indistinguishable from other causes of chronic oral ulcers (eg, tuberculosis, malignancy).
Aspergillosis
Orofacial lesions caused by Aspergillus species include antral aspergilloma, invasive aspergillosis of the antrum, indolent chronic sinusitis, allergic sinusitis, and oral lesions.[7, 8, 9] Aspergilloma of the maxillary antrum is uncommon and typically occurs in a healthy host as a hyphal ball in a chronically obstructed sinus.
Invasive sinus aspergillosis is rare and affects mainly immunocompromised hosts, although it is also seen in some apparently healthy individuals, predominantly in subtropical countries with a warm climate (eg, Sudan, Saudi Arabia, India). Patients with leukemia, lymphoma, HIV disease, or iatrogenic immunosuppression (eg, those undergoing bone marrow or renal transplantation) are at particular risk from such invasive sinus aspergillosis. Although A fumigatus is the usual cause of invasive sinus aspergillosis, A flavus appears to predominate in immunocompromised individuals. Rarely, other species (eg, A repens) are encountered, sometimes with other mycoses such as Microascus cinereus.
In invasive sinus aspergillosis, the antral wall is destroyed; this damage may be characterized by antral pain, swelling, sequelae from orbital invasion (eg, impaired ocular motility, exophthalmos, or impaired vision), or intracranial extension (eg, headaches, meningism).
Chronic sinus aspergillosis is uncommon, and patients present with a diffusely opaque antrum radiographically, sometimes with dense punctate radiopacities. This disease is unresponsive to treatment used for bacterial sinusitis. Allergic fungal sinusitis is also uncommon and is usually due to fungi other than Aspergillus organisms.
Interestingly, subclinical defects in cell-mediated immune responses to Aspergillus species have been observed in patients with sinus aspergillosis. Occasional cases of sinus aspergillosis arise as a result of metastasis from pulmonary aspergillosis or iatrogenic factors following dental procedures such as extractions, endodontics, or implants in the maxilla.[10]
Oral lesions of aspergillosis are seen predominantly in some immunocompromised patients with invasive aspergillosis. Yellow or black necrotic ulcers typically appear on the palate or occasionally on the posterior tongue.
Note the image below.
Aspergillosis. Note deep mucosal ulceration and nodular expansion of the hard palate. Courtesy of David Sirois, DMD, PhD. Blastomycosis
Blastomycosis[11] may become disseminated to produce ulcerating lesions that affect the oral mucosa. Mandibular involvement is rare. Cutaneous blastomycosis may spread to affect the lips.
Note the image below.
Blastomycosis. Top image shows nonspecific papillary nodular lesion on the hard palate. Bottom image shows extensive ulceration involving the skin of the face and neck. Courtesy of David Sirois, DMD, PhD. Coccidioidomycosis
Oral lesions from coccidioidomycosis are rare, but when they occur, they typically are reported secondary to lung involvement. They are usually verrucous lesions, sometimes occurring with infection of the jaw. Parotid involvement has been recorded. Oral lesions have yet to be reported in a patient with HIV disease.
Cryptococcosis
Oral cryptococcal infection manifests mainly as nonhealing extraction wounds or chronic ulceration on the palate or tongue.[12] Several cases of cryptococcal oral lesions have been reported, mainly in persons infected with HIV. In the past, rare cases have been reported mainly in individuals with leukemia.
Histoplasmosis
Oral lesions of H capsulatum infection have been recorded mainly in persons with pulmonary or disseminated histoplasmosis, especially in patients with HIV infection.[13] Oral lesions are sometimes isolated and have also been recorded in apparently healthy persons. Oral lesions are usually ulcerative or nodular; have been found on the tongue, palate, buccal mucosa, or gingiva; and rarely invade the mandible or maxilla.[14, 15] Oral lesions in African histoplasmosis are generally localized, affecting the tongue, buccal mucosa, or jaws.
Note the image below.
Histoplasmosis. Top image shows periodontal recession and deep ulceration with exposed necrotic alveolar bone (arrow). Bottom image shows solitary, deep ulceration of the gingivae also associated with necrotic bone (arrow). Courtesy of David Sirois, DMD, PhD. Paracoccidioidomycosis
Oral lesions of paracoccidioidomycosis are chronic, often granular or exophytic, and ulcerated.[16] Antral lesions are rare. Oral lesions of paracoccidioidomycosis appear to be uncommon in persons with HIV disease, although involvement of the submandibular lymph nodes and the presence of lesions outside the head and neck have been reported.
Rhinosporidiosis
Oral lesions of rhinosporidiosis are usually proliferative lumps, especially affecting the soft palate.
Zygomycosis
Rhinocerebral zygomycosis is usually caused by Rhizopus oryzae or Rhizopus arrhizus. The disease typically commences in the nasal cavity or paranasal sinuses and causes pain, nasal discharge, and fever; the organisms may then invade the palate to produce black, necrotic oral ulcers. Orbital invasion may produce orbital cellulitis, impaired ocular movements, proptosis, and ptosis. Intracranial invasion follows penetration of ophthalmic vessels or the cribriform plate. Zygomycosis occasionally commences in the palate.
Causes
- Aspergillosis -A flavus, A terreus, and A fumigatus
- Cryptococcosis -C neoformans
- Histoplasmosis -H capsulatum
- Blastomycosis -B dermatitidis
- Zygomycosis -Mucor species and Rhizopus species
- Paracoccidioidomycosis -P brasiliensis
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