Thrush

Aka: Thrush, Oral Candidiasis, Candida Albicans Pharyngitis, Oral Erythematous Candidiasis, Pseudomembranous Candidiasis, Atrophic Candidiasis, Hyperplastic Candidiasis, Neonatal Thrush

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II. Epidemiology

  1. Candida colonizes 30-60% of healthy mouths
    1. Opportunistic infection occurs in the immunosuppressed or immature Immune Systems
  2. Common in infants, especially Breast fed
    1. Rare in first week of life
    2. Peaks at 4 weeks of age

III. Risk Factors: Adults with Thrush (Immunodeficiency)

  1. Human Immunodeficiency Virus
  2. Corticosteroid exposure
    1. Prolonged systemic steroids
    2. Inhaled Corticosteroids
  3. Dentures
  4. Xerostomia
  5. Leukemia
  6. Malnutrition
  7. Radiation Therapy
  8. Systemic Chemotherapy
  9. Broad-spectrum Antibiotics
  10. Diabetes Mellitus

IV. Risk Factors: Children with chronic Thrush

  1. Hypoparathyroidism
  2. Addison's Disease
  3. Hypothyroidism
  4. Diabetes Mellitus

V. Risk Factors: Systemic Candidiasis

  1. Acquired ImmunodeficiencyVirus
  2. Diabetes Mellitus
  3. Immunosuppressive Therapy
  4. Malignancy
  5. Neutropenia
  6. Organ Transplantation
  7. Prematurity

VI. Types

  1. Pseudomembranous Candidiasis (most common, Neonatal Thrush, typical erythematous Candidiasis)
    1. White Plaque adherent to erythematous mucosa over Palate, Buccal mucosa, Tongue
    2. Adherent, but does rub off with scraping to reveal an underlying erythematous mucosa
  2. Atrophic Candidiasis
    1. Generalized Oral Mucosa erythema
  3. Denture Stomatitis
    1. Localized form of Atrophic Candidiasis, limited to region of denture contact
    2. Dental prosthesis interferes with Saliva contact with mucosa (loss of antimicrobial protection)
    3. Remove dentures overnight and soak in 0.1% sodium Hypochlorite or 4% Chlorhexidine
  4. Hyperplastic Candidiasis (less common)
    1. See Angular Cheilitis
    2. Hyperplastic Plaques on lateral Tongue or oral commisures (angle between upper and lower lip)
    3. Hyperplastic Plaques are difficult to wipe off
    4. Differentiate from Leukoplakia (biopsy lesions that do not resolve)
  5. Median Rhomboid Glossitis
    1. Dorsal Tongue erythema and depillation

VII. Symptoms

  1. Pharyngitis
    1. Oral burning Sensation
    2. Mild Pharyngitis compared with Streptococcal Pharyngitis
  2. Dysphagia
  3. Nausea
  4. Vomiting
  5. Dysgeusia (Metallic Taste)

VIII. Signs: General

  1. See types above for specific findings
  2. White, curd-like or cottony patches or Plaques
  3. Alternative presentations
    1. Median Rhomboid Glossitis (Tongue)
    2. Perleche (Angular Cheilitis)

IX. Differential Diagnosis

  1. See Pharyngitis Causes
  2. Other opportunistic fungus (e.g. Aspergillus) in Immunocompromised patients
  3. Leukoplakia
    1. Does not rub off with scraping
  4. Esophageal Candidiasis (Immunocompromised patients)
    1. Consider if Dysphagia or odynophagia

X. Management: First-Line Agents

  1. Nystatin
    1. Adults
      1. Pastilles: 200,000 unit lozenge four times daily for 14 days
      2. Swish and swallow: 500,000 units (5 ml) four times daily for 14 days
      3. Tablets: Two 500,000 unit tablets three times daily for 14 days
    2. Child
      1. Swish and swallow 500,000 units (5 ml) orally four times daily for 14 days
    3. Infant
      1. Suspension (100,000 u/ml): Swab 1 ml on each cheek four times daily for 14 days
      2. Decrease dose in Preterm or low-birth weight infants to 0.5 ml/cheek
      3. Avoid feeding infant for 5 to 10 minutes after dose
  2. Clotrimazole troche (Mycelex)
    1. Adults
      1. Troche: 10 mg five times daily for 14 days
      2. Vaginal Suppository: 100 mg qd to bid for 14 days
    2. Adverse Effects
      1. May raise Liver Function Tests
      2. Gastrointestinal Side effects
  3. Fluconazole
    1. Adults
      1. Initial: 200 mg orally for 1 dose
      2. Later: 100 mg daily for 5-7 days (up to 10-14 days)
      3. Suppression in Immunocompromised patients: Fluconazole 100 mg orally three times weekly
    2. Children
      1. Protocol 1: 5 mg/kg orally daily for 5 days
      2. Protocol 2: 6-12 mg/kg day 1, then 3-6 mg/kg for 10 days
        1. Chetwynd (2002) J Hum Lact 18:168-71 [PubMed]

XI. Management: Alternative Agents

  1. Itraconazole
    1. Indicated in Immunocompromised adults with concurrent esophageal involvement (also covers Aspergillus)
    2. Adults: 200 mg orally daily for 10-14 days
  2. Amphotericin B Oral Suspension
    1. Adults with HIV: 3-5 ml PO qid
    2. Indicated for refractory oropharyngeal Candidiasis
  3. Other Antifungal agents
    1. Posaconazole
    2. Voriconazole
    3. Capsofungin, Micafungin or Anidulafungin
  4. Miconazole gel
    1. Not currently available in U.S.
  5. Other treatments used historically
    1. Gentian Violet?
    2. Homemade Recipe
      1. 2 drops of dish soap
      2. 1/4 tsp Baking Soda
      3. Glass of warm water
      4. Apply to roof of mouth w/ cotton applicator qid

XII. Prevention

  1. See types above for specific measures
  2. In HIV patients, Antiretroviral therapy is typically used to prevent recurrence

XIII. Reference

  1. Anderson (2019) Crit Dec Emerg Med 33(9): 3-10
  2. Hoppe (1997) Pediatr Infect Dis J 16:885-94 [PubMed]
  3. Pappas (2016) Clin Infect Dis 62(4):409-17 +PMID:26810419 [PubMed]
  4. Randall (2022) Am Fam Physician 105(4): 369-76 [PubMed]

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Related Studies

Ontology: Candidiasis (C0006840)

Definition (NCI_NCI-GLOSS) A condition in which Candida albicans, a type of yeast, grows out of control in moist skin areas of the body. It is usually a result of a weakened immune system, but can be a side effect of chemotherapy or treatment with antibiotics. Thrush usually affects the mouth (oral thrush); however, rarely, it spreads throughout the entire body.
Definition (MSH) Infection with a fungus of the genus CANDIDA. It is usually a superficial infection of the moist areas of the body and is generally caused by CANDIDA ALBICANS. (Dorland, 27th ed)
Definition (CSP) infection with a fungus of the genus Candida; usually a superficial infection of the moist areas of the body and is generally caused by Candida albicans; includes chronic mucocutaneous candidiasis, cutaneous candidiasis, oral candidiasis (thrush), and monilial vaginitis.
Concepts Disease or Syndrome (T047)
MSH D002177
ICD9 112.9, 112
ICD10 B37 , B37.9
SnomedCT 187005005, 187024008, 187478002, 154403005, 370520002, 78048006
English Candidiases, Candidiasis, Moniliases, Moniliasis, CANDIDIASIS, MONILIASIS, Candidiasis, unspecified, [X]Candidiasis, unspecified, candidiasis, candidiasis (diagnosis), Candida infections, Candidiasis site NOS, candidosis, Candidiasis [Disease/Finding], candidal infection, candidal infections, monilial infection, thrush, candida infections, candidiases, candida infection, muguet, monilia infection, Candidiasis NOS (disorder), [X]Candidiasis, unspecified (disorder), Candida NOS, Monilial infection, Moniliasis monilia, Moniliasis NOS, Candidiasis of unspecified site, Monilia NOS, Candidal infection NOS, Candidiasis NOS, Thrush, Candidosis, Infection by Candida species, Candida infection, Monilia infection, Candidiasis (disorder), moniliasis, candida; infection, Muguet, infection; candidal, infection; monilia, monilia; infection, Candidiasis, NOS, Candidosis, NOS, Moniliasis, NOS
French CANDIDOSE, MONILIASE, Infection candidosique, Infection à Candida, Candidiase SAI, Candidose SAI, Candida SAI, Infection à Candida SAI, Moniliase SAI, Candidose de site non précisé, Moniliase à Candida, Candidoses, Candidiase, Candidose, Moniliase, Moniliose
Portuguese CANDIDIASE, MONILIASE, Candidíase NE, Candidiase, Monilia NE, Candida NE, Monilia de monilíase, Infecção por Candida, Infecção por cândida NE, Candidíase de local NE, Infecção por monilia, Monilíase NE, Infecções a Candida, Candidíase, Monilíase
Spanish CANDIDIASIS, MONILIASIS, [X]candidiasis, no especificada (trastorno), moliniasis, SAI, candidiasis, SAI, candidiasis, SAI (trastorno), [X]candidiasis, no especificada, Infección por Candida NEOM, Infección por Cándida, Cándida NEOM, Candidiasis NEOM, Moniliasis NEOM, Candidiasis de localización no especificada, Monilia NEOM, Infección monilial, candidiasis (trastorno), candidiasis, candidosis, infección por especies de Candida, moniliasis, Infecciones por cándida, Candidiasis, Moniliasis
Italian Infezioni da candida, Moniliasi, Infezione da Candida, Candidiasi / Candida, Candidiasi NAS, Candida NAS, Candidiasi, Candidiasi di sede non specificata, Infezione da Candida NAS, Candidosi
Swedish Kandidos
Czech kandidóza, Kandidové infekce, moniliáza, Kandidy NOS, Kandidóza, Moniliáza, Kandidóza na blíže neurčeném místě, Kandidová infekce, Kandidová infekce NOS, Infekce způsobená Candida, Kandida NOS, Kandidóza NOS, Moniliáza NOS
Finnish Kandidiaasi
Russian KANDIDOZ, MONILIAZ, КАНДИДОЗ, МОНИЛИАЗ
German CANDIDIASIS, Kandidose, nicht naeher bezeichnet, MONILIASIS, Candidiasis unspezifischer Stelle, Candida NNB, Moniliasis NNB, Candidainfektion NNB, Candida-Infektion, Candidiasis NNB, Monilioseinfektion, Moniliasis durch Monilia, Candida-Infektionen, Candida-Mykosen, Candidose, Kandidose, Moniliasis, Soor, Candidiasis
Korean 상세불명의 칸디다증, 칸디다증
Croatian KANDIDIJAZA
Polish Kandidiaza, Zakażenie Candida albicans, Moniliaza, Oidiomikoza, Bielnica, Kandydoza
Hungarian Candida fertőzések, moniliasis k.m.n., Moniliazisos fertőzés, candidiasis, moniliasis, Moniliasis monilia, candidiasis k.m.n., Candida k.m.n., Nem meghatározott elhelyezkedésű candidiasis, Candida fertőzés, Monilia k.m.n., Candidás fertőzés k.m.n.
Japanese カンジダ症, カンジダ感染症, ｶﾝｼﾞﾀﾞｶﾝｾﾝ, ｶﾝｼﾞﾀﾞｼｮｳ, ｶﾝｼﾞﾀﾞｼｮｳNOS, モニリアＮＯＳ, カンジダ感染, カンジダ症ＮＯＳ, モニリア感染, ｶﾝｼﾞﾀﾞNOS, ﾌﾞｲﾌﾒｲﾉｶﾝｼﾞﾀﾞｼｮｳ, カンジダ感染ＮＯＳ, ﾓﾆﾘｱｶﾝｾﾝ, カンジダＮＯＳ, ﾓﾆﾘｱNOS, ｶﾝｼﾞﾀﾞｶﾝｾﾝNOS, ﾓﾆﾘｱｼｮｳ, 部位不明のカンジダ症, モニリア症ＮＯＳ, ﾓﾆﾘｱｼｮｳNOS, モニリア症
Norwegian Candidainfeksjoner, Candidose, Kandidose, Candidiasis, Moniliase, Moniliasis
Dutch Monilia NAO, candidiasis NAO, moniliasis Monilia, moniliasis NAO, Candida-infectie NAO, candidiasis op niet-gespecificeerde plaats, Monilia-infectie, moniliasis, Candida-infectie, candidiasis, Candida NAO, Monilia; infectie, candida; infectie, infectie; Monilia, infectie; candida, Candidiasis, niet gespecificeerd, Candida-infecties, Candidiasis, Moniliasis
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Oral candidiasis (C0006849)

Definition (MSH) Infection of the mucous membranes of the mouth by a fungus of the genus CANDIDA. (Dorland, 27th ed)
Concepts Disease or Syndrome (T047)
MSH D002180
ICD9 112.0
ICD10 B37.0 , B37.9
SnomedCT 79740000, 187006006, 187005005, 367093001, 78048006
English Candidiases, Oral, Candidiasis, Oral, Moniliases, Oral, Moniliasis, Oral, Oral Candidiases, Oral Moniliases, Thrush, MONILIASIS ORAL, Oral Moniliasis, THRUSH, Oral candidiasis, Candidal stomatitis, thrush (disorder), mycotic stomatitis, oral candidiasis (diagnosis), oral thrush, oral candidiasis, candidiasis oral thrush, Oral candida, Candida stomatitis, Stomatitis monilial, Moniliasis oral, Thrush oral, Candidiasis, Oral [Disease/Finding], Candidiasis;oral, Thrush;oral, Candida of mouth, Oral candidiasis (disorder), Thrush NOS, Candidiasis of mouth, Mycotic stomatitis, Candida infection of mouth, Candidosis of mouth, Moniliasis of mouth, Oral candidosis, Oral moniliasis, Oral thrush, Candidiasis of mouth (disorder), candida; thrush, oral, candidiasis; mouth, candidiasis; stomatitis, candidiasis; thrush, monilia; stomatitis, mouth; candidiasis, mycosis; stomatitis, mycotic; stomatitis, sprue; candidal, oral, stomatitis; candidal, stomatitis; monilia, stomatitis; mycosis, stomatitis; mycotic, Oral Candidiasis, Thrush, oral, thrush
French MUGUET, Moniliase buccale, Candida oral, Infection buccale à Candida, Stomatite candidosique, Stomatite à Candida, Candidose de la bouche, Muguet buccal, Muguet oral, MONILIASES ORALE, Muguet (maladie), Muguet SAI, Muguet, Blanchet, Candidose buccale, Moniliase orale, Stomatite à candida, Candidose orale
Italian Candidiasi orale, Mughetto orale, Stomatite da candida, Candidiasi della bocca, Candida orale, Candidiasi dela bocca, Mughetto, Moniliasi orale, Candidiasi, Candidiasi NAS, Candidosi orale
Dutch moniliasis oraal, orale moniliasis, spruw oraal, orale Candida, Candida van de mond, orale spruw, Monilia-stomatitis, candidiasis van de mond, thrush, spruw NAO, Monilia; stomatitis, candida; spruw, oraal, candidiasis; mond, candidiasis; spruw, candidiasis; stomatitis, mond; candidiasis, mycose; stomatitis, mycotisch; stomatitis, spruw; candida, oraal, stomatitis; Monilia, stomatitis; candida, stomatitis; mycose, stomatitis; mycotisch, orale candidiasis, Candida-stomatitis, Candidiasis, orale, Moniliasis, orale, Orale candidiasis, Spruw
German Candidose des Mundes, orale Candida, candida-bedingte Stomatitis, orale Moniliose, Moniliose oral, Candida des Mundes, Stomatitis durch Candida, CANDIDIASIS MUND, Candida-Stomatitis, SOOR, Soor NNB, Soor, orale Candidose, Candidose, orale, Kandidose, orale, Moniliasis, orale, Mundsoor
Portuguese Candidíase da boca, Estomatite por monilia, Candida oral, Sapinhos da boca, Monilíase oral, Estomatite por Candida, AFTA, MONILIASE ORAL, Candidíase, Candidíase NE, Candidíase Oral, Candidíase oral, Candidíase Bucal, Monilíase Bucal, Sapinho
Spanish Candidiasis de boca, Moniliasis oral, Cándida oral, Estomatitis moniliásica, Estomatitis por cándida, Cándida de boca, CANDIDIASIS ORAL, candidosis oral, Candidiasis NEOM, Candidiasis, Candidiasis Oral, candidiasis de la boca (trastorno), candidiasis de la boca, candidiasis oral, candidiosis oral, estomatitis micótica, moniliasis oral, muguet, Candidiasis oral, Muguet, Candidiasis Bucal, Moniliasis Oral
Japanese 口腔カンジダ, モニリア性口内炎, カンジダ性口内炎, ｺｳｸｳｶﾝｼﾞﾀﾞｼｮｳ, ｶﾝｼﾞﾀﾞｾｲｺｳﾅｲｴﾝ, ｺｳｸｳｶﾝｼﾞﾀﾞ, ｶﾞｺｳｿｳ, ｺｳｸｳﾓﾆﾘｱｼｮｳ, ﾓﾆﾘｱｾｲｺｳﾅｲｴﾝ, カンジダ症-口腔, ｺｳｺｳﾓﾆﾘｱｼｮｳ, ｶﾝｼﾞﾀﾞｼｮｳNOS, ｶﾝｼﾞﾀﾞｼｮｳ, カンジダ症, カンジダ症ＮＯＳ, がこう瘡, 口腔カンジダ症, 口腔モニリア症, 鵞口瘡, モニリア症-口腔, 口腔内カンジダ症
Swedish Kandidos, oral
Finnish Sammas
Russian MOLOCHNITSA, KANDIDOZ POLOSTI RTA, MONILIAZ POLOSTI RTA, KANDIDOZNYI STOMATIT, КАНДИДОЗНЫЙ СТОМАТИТ, КАНДИДОЗ ПОЛОСТИ РТА, МОЛОЧНИЦА, МОНИЛИАЗ ПОЛОСТИ РТА
Czech Moučnivka dutiny ústní, Ustní kandidóza, Kandidová stomatitida, Orální kandidóza, Orální moniláza, Orální moniliáza, Kandidová infekce úst, Kandidová infekce dutiny ústní, Orální moučnivka, orální kandidóza, kandidóza orální, moučnivka, orální moniliáza, soor, Moučnivka NOS, Moučnivka
Korean 칸디다 입안염
Croatian KANDIDIJAZA, ORALNA, MONILIJAZA, ORALNA
Polish Kandydoza jamy ustnej
Hungarian Candidás stomatitis, Száj candidiasisa, szájpenész, moniliasis oris, Oralis moniliasis, oralis candidiasis, Oralis candida, szájüregi candidiasis, Stomatitis moniliazisos, Penész, Penész k.m.n.
Norwegian Candidastomatitt, Oral candidose, Oral kandidose, Oral moniliase, Oral candidainfeksjon, Oral candidiasis, Munntrøske, Oral moniliasis
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Oral erythematous candidiasis (C0341021)

Concepts Disease or Syndrome (T047)
SnomedCT 235071003
English Acute erythematous candidosis, Erythematous candidosis, Erythematous candidiasis, Oral erythematous candidiasis, Oral erythematous candidiasis (disorder)
Spanish candidiasis eritematosa aguda, candidiasis eritematosa bucal (trastorno), candidiasis eritematosa bucal, candidiosis eritematosa oral
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Pseudomembranous thrush (C0521840)

Concepts Disease or Syndrome (T047)
SnomedCT 95893008
Dutch pseudo-membraan-candidiasis
French Candidose pseudomembraneuse
German pseudomembranoese Candidose
Italian Candidiasi pseudomembranosa
Portuguese Candidíase pseudomembranosa
Spanish Candidiasis pseudomembranosa, muguet pseudomembranoso, muguet seudomembranoso (trastorno), muguet seudomembranoso
Japanese 偽膜性カンジダ症, ｷﾞﾏｸｾｲｶﾝｼﾞﾀﾞｼｮｳ
Czech Pseudomembranózní kandidóza
English pseudomembranous candidiasis, candidiasis pseudomembranous, Pseudomembranous candidiasis, Pseudomembranous thrush, Pseudomembranous thrush (disorder)
Hungarian Pseudomembranosus candidiasis
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Atrophic thrush (C0521841)

Concepts Disease or Syndrome (T047)
SnomedCT 95894002
English Atrophic thrush, Atrophic candidiasis, Atrophic thrush (disorder)
Spanish candidiasis atrófica, muguet atrófico (trastorno), muguet atrófico
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Neonatal thrush (C1261284)

Concepts Disease or Syndrome (T047)
SnomedCT 30799000, 206355000
English Neonatal candidiasis of mouth, Neonatal trush, oral thrush of newborn (diagnosis), oral thrush of newborn, Neonatal candidiasis of mouth (disorder), Neonatal thrush, Neonatal thrush (disorder), Neonatal oral candidiasis, Thrush in newborn
Spanish muguet neonatal (trastorno), muguet neonatal, candidiasis oral neonatal
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Hyperplastic thrush (C1290820)

Concepts Disease or Syndrome (T047)
SnomedCT 110277001
English hyperplastic thrush, hyperplastic candidiasis, Hyperplastic candidiasis, Hyperplastic thrush (disorder), Hyperplastic thrush
Spanish candidiasis hiperplásica (trastorno), candidiasis hiperplásica, muguet hiperplásico
Derived from the NIH UMLS (Unified Medical Language System)

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