Deep Fungal Infections

Maxillofacial aspergillosis is most common following tooth extraction of: a. #9 b. #24 c. #18 d. #14

#14 (maxillary molars in contact with maxillary sinus!)

If a biopsy of aspergillosis related ulcer on palate was taken, what would you see microscopically?

*FRUITING BODY* very characteristic for aspergillosis under the microscope (very large so you can see them without a special stain!) fungal hyphae

Mucormycosis w/ GMS stain:

- L shaped

What kinds of patients will present with maxillofacial aspergillosis?

- immunocompromised - uncontrolled diabetics - maxillary sinus infection - may follow tooth extraction

What are the two most likely sites for oral manifestations of deep fungal infection in order?

1. palate 2. tongue

What is the second most common opportunistic fungal infection after candidiasis?

Aspergillosis

How do you diagnose oral lesions of deep fungal infections?

Biopsy and microscopic examination

What is the common variant of Blastomycosis?

Blastomyces dermatitidis

Skin plaques of _________ look like:

Blastomycosis elevations, rough surface, verrucous

Rank these from most to least common: histo blasto candidiasis aspergillosis

Candidiasis > aspergillosis > histo > blasto

What are some deep fungal infections? what is the most common fungal infection?

Candidiasis MOST COMMON deep fungal: aspergillosis histoplasmosis blastomycosis zygomycosis (mucormycosis) cryptococcosis coccidiomycosis paracoccidiomycosis

Oral lesions are manifestations of

DISSEMINATED DISEASE

How do you manage deep fungal infections? diagnose? treatment?

Diagnosis: - biopsy - look at granulomas for organisms - often need GMS special stain ID risk factors: immunosuppresion, HIV/AIDS, uncontrolled diabetes Systemic antifungal treatment - keto/itraconazole IN REALLY SEVERE CASES: - AmpB (polyene agent, IV formulation because poorly absorbed by GI tract)

If you see an oral lesion of histo it would be what type (acute, chronic, disseminated)?

Disseminated!

T/F it is common to have a primary fungal infection present orally

FALSE very very very rare normally its a manifestation of disseminated disease

What is GMS stain?

Grocott methenamine silver stain

Histoplasmosis is at least ___x more common than Blastomycosis

Histo 10x more common!!!

Of histoplasmosis what is the most common subtype that causes systemic fungal infections?

Histoplama capsulatum

What is the MOST common systemic fungal infection in the US?

Histoplasma capsulatum

Who does Blastomycosis affect? Cutaneous lesions present as?

Men > women men might be more likely to camp and be in those areas etc often cutaneous lesions are verrucous plaques

Disseminated form of Histoplasmosis is

RARE - in older debilitated pts - HIV pts w/ immune deficiency - immunosuppressed pts - most oral lesions - ulcerated lesions resemble SCC

Unlike the other deep fungal infections that present like ulcers, intraorally Blastomycosis looks like:

ROUGH surface verrucous nodules

Treatment for all deep fungal infections is:

SYSTEMIC ANTI FUNGAL must take tablets of very strong i.e. itra or keto if VERY severe: AmpB (but lots of side effects so reserved for very severe cases)

Where is coccidiomycosis most common?

San joaquin valley fever/valley fever/western US

Where is paracoccidiomycosis found? what is it called?

South America South American Blastomycosis

Fungal infections have a _____ mediated immune response

T CELL

T/F Oral manifestations of deep fungal infections are usually manifestations of disseminated infection

True i.e. fungus inhaled, primary infection in lung, not treated --> disseminates systemically and presents orally

Zygomycosis/Mucormycosis this is notable for being seen in

VERY uncontrolled diabetics (HBa1C of 12% or above)

What are AmpB adverse effects:

acute anaphylactic rxn severe kidney damage electrolyte imbalance cardiac failure severe skin reactions *this is why it's very rarely prescribed*

Histoplasma capsulatum typically found in? transmission? growth?

areas of ohio and Mississippi rivers, humid areas with soil enriched by bird or bat excrement INHALATION DIMORPHIC i.e. yeast at body temp, mold in soil (yeast in the heat mold in the cold)

Many deep fungal infections come from

bird, bat, pigeon droppings (allow for growth and proliferation of spores that can be inhaled) --> primary pulmonary infections histo, crypto, blasto, coccidio many spread to meninges of brain and spinal cord

Mucormycosis oral presentation:

can perforate the palate necrosis **associated with uncontrolled diabetes** CAN BE VERY DESTRUCTIVE - around nose, eyes, sinuses

Histoplasmosis oral manifestation describe image from class, what ?s do you ask, how do you diagnose?

chronic non healing ulcer on tongue fibrinoprurlent membrane dorsal surface of tongue take history, ask if its been present for a long time, history of burn? once you can't come up with a cause you do a biopsy *ALL deep fungal under the microscope present as granulomas: giant cells in granulomas is where you look for fungal organisms*

How do oral manifestations of deep fungal infections present?

chronic, non healing ulcers

Examples from class where histoplasmosis presented clinically?

dorsal tongue maxillary vestibule lateral border of tongue remember 99% of the time you biopsy this thinking its SCC!!! but under microscope you'll see granulomas and make the diagnosis and tx will be totally different than SCC

When a biopsy of mucormycosis is taken what will you see? Most of the time this MUST be treated with?

find organism in necrotic areas *L SHAPED ORGANISMS* non septate found in blood vessels! AMPHOTERICIN B ITS SEVERE!!!! high dose long term, debridement and reconstruction!!

In GMS stain the background is: the organism is:

green organism is black

Cryptococcosis Cryptococcus neoformans transmission? most common manifestation? most common in? histo?

inhalation of organisms in pigeon and bat droppings Cryptococcal meningitis most common systemic fungal infection in HIV/AIDs pts true capsulated yeast

How is Blastomycosis transmitted?

inhalation of spores --> pulmonary infection

Under the microscope Blastomycosis:

larger organisms with clear capsule and neutrophils around it in granuloma w/ chronic inflammatory cells

When prescribing systemic antifungals you MUST:

look at drug interactions and adverse effects

When you look at histoplasmosis under microscope you:

look for giant cells in the granulomas and notice a dot with a white halo of capsule <-- that is the histoplasmosis organism

Chronic form of histoplasmosis is:

lung infection appears similar to TB

India has a large proportion of uncontrolled diabetics which means:

mucormycosis susceptibility!! expensive txt with AmpB

In class example of severe oral manifestation of aspergillosis appeared:

on palate large, dark necrotic area, black tissue, ulceration

Mucor/Zygo are found in transmission? growth? who is at risk? more common presentation of mucormycosis?

organisms found throughout the world in soil and decaying vegetation spores are inhaled ENHANCED BY IRON uncontrolled diabetics, immunosuppressed or immunodeficient pts are at risk rhino orbital sino cerebral form

Where is Blastomyces dermatitidis found? Where does it grow?

same areas as histo but extends farther north grows as a mold in rich, moist soil

Acute form of histoplasmosis is:

self limited pulmonary infection - primary infection is not an opportunistic infection

Aspergillosis found in? transmission?

soil, water, decaying organic debris sores are released and inhaled can be spread nosocomially SECOND most common fungal infection after candidiasis

What is the clinical differential diagnosis of most oral manifestations of deep fungal infections?

squamous cell carcinoma

Histology of Blastomycosis:

thick cell wall B is a BIG ORGANISM

T/F most oral fungal infections are opportunistic infections

true

T/F B cell mediated immune response play very little role in protection against fungal infections

true! mostly Th1 response

T/F you rarely see oral manifestations of fungal infections

true! rarely seen, when you do its a severe case!

Cryptococcosis oral manifestation? under microscope?

ulceration/necrosis on palate as shown in class THICK CAPSULE - sometimes two organisms connected/budding

Why are uncontrolled diabetics particularly susceptible to mucor/zygomycosis?

uncontrolled diabetics who are ketoacidotic have HIGHER serum iron levels (*growth is enhanced by iron*)