4.08 Oral Candidiasis (Thrush)

agk’s Library of Common Simple Emergencies

Presentation

An infant (usually with a concurrent diaper rash) will have white patches in his mouth, or an older patient (usually with poor oral hygiene, diabetes, a hematologic malignacy, some immunodeficiency or on antibiotic, cytotoxic or steroid therapy) will complain of a sore mouth and sensitivity to foods that are spicy or acidic. On physical examination, there are painless white patches in the mouth and and on the tongue which wipe off easily with a swab, leaving an erythematous base that may bleed. There may be intense dark red inflammation throughout the oral cavity.

What to do:

• If there is any doubt about the etiology, onfirm the diagnosis by smearing the exudate, Gram staining, and examining under a microscope for large, gram-positive pseudohyphae and spores. A fungal culture may also confirm the diagnosis.
• For topical treatment, prescribe an oral suspension of nystatin 200,000 units for infants and 400,000- 600,000 u for children and adults, gargled and swished in the mouth as long as possible before swallowing, four times a day, for at least two days beyond resolution of symptoms. Nystatin is also avilable in pastilles of 200,000 u: one or two can be dissolved in the mouth 4-5 times daily. Alternatively, prescribe clotrimazole in 10mg troches to be dissolved slowly in the mouth 5 times
  a day for 7-14 days.
• For adults, fluconazole 200mg once, then 100mg qd po x7-14d may be a better regimen. Sometimes a single oral dose is effective, but the longer course decreases the risk of relapse.
• Look elsewhere for Candida: esophagitis, intertrigo, vaginitis, diaper rash. All should respond to topical treatment with topical nystatin or clotrimazole.

Discussion

In the healthy newborn, thrush is a self-limited infection, but it should be treated to avoid feeding problems. In adults, oral candidiasis is found in a variety of acute and chronic forms. Localized erythema and erosions with minimal white exudate may be caused by candidal colonies beneath dentures and is commonly called “denture sore mouth.” Maintenance prophylaxis may be prequired in patients with AIDS. Nystatin suspension has a high sugar content.

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