Mouth

Thrush

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Thrush, Oral Candidiasis, Candida Albicans Pharyngitis

  • Epidemiology
  • Common in infants, especially Breast fed
  1. Rare in first week of life
  2. Peaks at 4 weeks of age
  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
  • Risk Factors
  • Children with chronic Thrush
  1. Hypoparathyroidism
  2. Addison's Disease
  3. Hypothyroidism
  4. Diabetes Mellitus
  1. Acquired ImmunodeficiencyVirus
  2. Diabetes Mellitus
  3. Immunosuppressive Therapy
  4. Malignancy
  5. Neutropenia
  6. Organ transplantation
  7. Prematurity
  • Symptoms
  1. Pharyngitis
    1. Oral burning sensation
    2. Mild Pharyngitis compared with Streptococcal Pharyngitis
  2. Dysphagia
  3. Nausea
  4. Vomiting
  1. White, curd-like or cottony patches or Plaques
  2. Adherent to erythematous mucosa over Palate, Buccal mucosa, Tongue
    1. Adherent, but does rub off with scraping to reveal an underlying erythematous base
  • Signs
  • Alternative presentations
  1. Median Rhomboid Glossitis
  2. Perleche (Angular Cheilitis)
  • 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
  • Management
  • General Measures
  1. In HIV patients, Antiretroviral therapy is typically used to prevent recurrence
  • Management
  • First-Line Agents
  1. Nystatin
    1. Adults
      1. Pastilles: 200,000 u lozenge qid for 14 days
      2. Swish and swallow: 500,000 u qid for 14 days
      3. Tablets: Two 500,000 u tablets tid for 14 days
    2. Children
      1. Suspension (100,000 u/ml): Swab 1 ml on each cheek
  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]
  • 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
  • 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]