Noncandidal Fungal Infections of the Mouth Clinical Presentation

Updated: Mar 01, 2018
  • Author: Manuel Valdebran, MD; Chief Editor: William D James, MD  more...
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Presentation

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 (transplant patients)

  • Immunodeficiency - HIV infection, AIDS, others

  • Endocrinologic condition - Poorly controlled diabetes mellitus, ketoacidosis

  • Malignancy - Leukemia, lymphoma, others

  • Other conditions - Neutropenia, malnutrition, old age

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Physical Examination

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. [26, 27, 28] 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, with 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 treatments 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. [6, 29]

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 no Aspergillosis. Note deep mucosal ulceration and nodular expansion of the hard palate. Courtesy of David Sirois, DMD, PhD.

Blastomycosis

Blastomycosis [30] 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 papilla 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.

Cryptococcosis

Oral cryptococcal infection manifests mainly as nonhealing extraction wounds or chronic ulceration on the palate or tongue. [31] Several cases of cryptococcal oral lesions have been reported, mainly in persons infected with HIV. 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. [32] 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. [33, 34] Oral lesions in African histoplasmosis are generally localized, affecting the tongue, buccal mucosa, or jaws.

Note the image below.

Histoplasmosis. Top image shows periodontal recess 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. [35] 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.

The most frequent manifestation in the oral cavity is the development of white or black palatal ulcers, which become necrotic with well-defined borders. They may form rapidly when associated with diabetic decompensation or neutropenia. It is usually an acute condition during which palatal ulcers develop within the first 10 days; therefore, it is important to make an early diagnosis of the disease. The cure rate in the series reported by Bonifaz et al was 19%. [36]

Geotrichosis

Oral geotrichosis presents as pseudomembranous plaques with an underlying chronic inflammatory reaction, which can resemble oral candidiasis. Ulcerative and hyperplastic variants have also been described. [5]  See the image below.

Pseudomembranous form affecting the tongue. Courte Pseudomembranous form affecting the tongue. Courtesy of Dr. Alexandro Bonifaz.

Rhodotorula infection

Oral presentations include nonhealing ulcers and white plaques, which may resemble those of candidiasis. [37]

Fusariosis

Oral lesions occur as secondary lesions derived from blood-borne organisms in disseminated disease. Risk factors include low count of T lymphocytes, neutropenia, and previous fungal infections. It presents as necrotic ulcerations of the gingiva, palate, or tongue. [38]

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Complications

Complications can include the following:

  • Drug resistance

  • Drug interactions and adverse effects

  • Structural defects or loss of function (eg, resulting from fungal destruction of the maxilla, orbit, and/or cranial base)

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