Untitled Quiz

Bacterial & Fungal Infections - Oral & Maxillofacial Pathology Part 1

• Impetigo: A superficial skin infection caused by Streptococcus pyogenes or Staphylococcus aureus (separately or together).
• Very contagious, occurs in damaged skin (trauma, dermatitis, insect bites). Linear crusting if in scratched skin.
• Systemic risk factors include HIV+, diabetes type 2, and dialysis.
• Commonly affects children during summer or early fall with high humidity.
• Mimics angular cheilitis.
• Two types: Nonbullous (70%) and bullous (30%).
• Locations include legs, trunk, scalp, and face.
• Bacteria reside in the nose.
• Symptoms include red macules, papules, and vesicles covered in thick amber or honey-colored crusts (resembling attached cornflakes).
• Itching (pruritic) is a common symptom.
• Less common symptoms include lymphangitis, cellulitis, fever, and malaise.
• Mimics recurrent herpes simplex.

Lymphangitis

• Inflammation of lymphatic channels, usually from a microbial infection at a distal site.
• Red streaks extending from the wound to nearby lymph nodes are a characteristic sign.
• Potential complications include cellulitis and septicemia.
• Bacterial infection on the arm can spread to the axillary lymph nodes.

Impetigo: Diagnosis & Treatment

• Diagnosis is based on clinical presentation, and possibly culture.
• Treatment options involve topical antibiotics (mupirocin, retapamulin) or systemic antibiotics (cephalexin for MRSA, Bactrim for MRSA+).
• Possible complications include spread of infection, scarring, and acute glomerulonephritis.

Erysipelas

• Superficial skin infection caused by beta-hemolytic streptococci (especially S. pyogenes).
• Spreads via lymphatic vessels, which it plugs.
• Favors areas of previous scars, especially in young and elderly individuals, those who are debilitated, immune-compromised, obese, alcoholic, or have large surgical scars or lymphedema.
• Location: Legs >> face > upper arms.
• Symptoms include bright red, painful swelling or rash (Saint Anthony's fire).
• Possible orange peel texture or bullae and crusted lesions.
• Face lesions may show a butterfly rash appearance (like lupus).
• Associated symptoms may include high fever, lymphadenopathy, and nausea.
• Diagnosis aided by clinical presentation and culture.
• Treatment includes penicillin, cephalexin, or ciprofloxacin.
• Potential complications include abscesses, gangrene, toxic shock syndrome, organ failure, thrombophlebitis, acute glomerulonephritis, and endocarditis.

Streptococcal Tonsillitis & Pharyngitis

• Caused by Group A, beta-hemolytic streptococci.
• Accounts for up to 30% of cases in children and 15% in adults.
• Mimicked by adenoviruses, enteroviruses, influenza, Epstein-Barr virus, and coronaviruses (among others).
• Most prevalent in 5-15 year-olds.
• Transmission via respiratory droplets and saliva.
• Incubation period is 2-5 days.

Strep Throat: Clinical Features & Treatment

• Symptoms include fever, headache, malaise, vomiting, dysphagia (difficulty swallowing), tonsillar hyperplasia, yellowish tonsillar exudate, palatal petechiae, and swollen uvula.
• Cervical lymphadenopathy and scarlatiniform rash are possible.
• Treatment involves penicillin or amoxicillin.
• Potential complications include rheumatic fever and acute glomerulonephritis (AGN).

Scarlet Fever

• Caused by Group A, beta-hemolytic streptococci producing erythrogenic toxin.
• Toxin attacks blood vessels and causes rash.
• Begins as strep throat or tonsillitis.
• Problems arise in individuals lacking antitoxin antibodies.
• Incubation period: 1-7 days; fever lasts for 6 days.
• Commonly affects children (aged 3-12 years).
• Symptoms include enanthem (red mouth and throat; exudate), petechiae of soft palate, exanthem (red skin rash – goose bumps), scarlatina rash (desquamates for 3–8 weeks), white strawberry tongue (day 2), which changes to raspberry/strawberry tongue (day 5).
• Pastia's lines (red lines in skin folds; capillary fragility)
• Skin of face usually spared except for red cheeks and circumoral pallor.
• Mimics COVID-19.
• Diagnosis via culture and rapid antigen test.
• Complications include pharyngeal abscess, sinusitis, pneumonia, acute rheumatic fever, glomerulonephritis, arthralgia, meningitis, and hepatitis.
• Treatment: antibiotics (e.g., penicillin, amoxicillin)

Tonsillar Concretions & Tonsillolithiasis

• Range from keratin calcification to sloughed debris in crypts.
• More prevalent in males (2:1).
• Usually presents as asymptomatic multiple concretions, sometimes not visible clinically.
• Can cause recurrent infections, dysphagia, cough, and halitosis.
• Mimics an oral lymphoepithelial cyst.

Tonsilliths

• Radiopaque, 2-4mm globular opacities in the ramus region on panoramic radiography.
• CBCT shows opacities medial to the ramus area; may spontaneously release and be swallowed.
• Treatment options include warm salt-water gargling, curettage, or tonsillectomy.
• Complications include tonsillar abscess and chronic tonsillitis.

Actinomycosis

• Filamentous, branching, gram-positive anaerobic bacteria.
• Commonly found in oral flora.
• Colonizes periodontal pockets, oral biofilm, and calculus; gingiva (frequent in tonsils; 100% in gingival pockets).
• Usually caused by Actinomyces israelii or A.viscosus with coinfection by strep or staph, often causing acute or chronic infections and draining fistulas lasting for weeks or months.
• Characterized by a lumpy jaw or healed neck scars.
• Colonies may form yellow sulfur granules.
• Typically found in the cervicofacial region, frequently in the submandibular, submental, or mandibular regions.

Lumpy Jaw with Multiple Sinus Tracts

• Condition characterized by healed face and neck scars (lumpy jaw).
• Potential for osteomyelitis and salivary gland disease.
• Diagnosis via culture and biopsy.
• Treatment focuses on debridement and antibiotic therapy (penicillin, amoxicillin, tetracycline).

Cat-Scratch Disease

• Caused by Bartonella henselae infection.
• Spreads via damaged skin, resulting in adjacent lymph node infection.
• Gram-negative bacilli.
• Chronic regional lymphadenopathy in children - most common cause.
• Transmission occurs by saliva or scratch from cats or kittens.
• No human-to-human transmission.
• Incubation period: 3–14 days.
• Scratch often heals before swollen lymph nodes appear. Location can be facial/submandibular; causing diffuse enlargement, and is often painful.
• Massive necrosis is a frequent outcome.
• Sites include head, neck, axillary, and groin regions.
• Papule at scratch site, evolving to swollen lymph nodes, fever, malaise.
• Diagnosis based on positive history, serology, histopathology (lymph node hyperplasia, band of histiocytes and neutrophils, stellate suppurative necrosis), and special stains for bacterial identification.
• Treatment: Often self-limiting. Azithromycin if needed.

Noma (Cancrum Oris)

• Orofacial gangrene (necrotizing stomatitis).
• Rapidly progressive, polymicrobial, opportunistic infection involving normal oral flora.
• Predominantly affects children.
• Often linked with malnutrition, poverty, sanitation issues, and/or infections.
• May begin as NUG (Necrotizing Ulcerative Gingivitis).
• Spreads to destroy portions of face, jaws, and lips, resulting in black gangrenous necrosis.
• Symptoms include fetid odor, pain, fever, malaise, tachycardia, increased respiratory rate, anemia, leukocytosis, and regional lymphadenopathy.
• Diagnosis is clinical.
• Treatment involves antibiotics (penicillin, metronidazole), nutritional support, and local debridement.
• Mortality rate is high (95%) without treatment.

Syphilis

• Caused by Treponema pallidum.
• Pathogenic, mobile, gram-negative spirochete.
• Spread via sexual contact; congenitally transmitted.
• Anyone with oral, genital, or anal sex is at risk.
• Presents in 4 stages: Primary, secondary, tertiary, congenital.
• Highly contagious in primary and secondary stages.
• Oral presentation is uncommon and occurs at all stages.

Primary Syphilis

• Characteristic chancre lesion at inoculation site.
• Develops in 3-90 days.
• Often in genital areas, with 10% in oral areas and 1% in extragenital areas.
• Oral lesion locations primarily on lips, then buccal mucosa, tongue, and palate/gingival tissues.
• Painless ulcer with clean or amber base; characterized by bilateral lymphadenopathy.
• Heals in 3–8 weeks if untreated.

Secondary Syphilis

• Disseminated syphilis; occurs 4-6 weeks after primary stage.
• Systemic and oral signs/symptoms.
• Oral signs: Mucous patches (30%), split papules, condyloma lata.

Syphilitic Rash

• Painless maculopapular rash; widespread, including face, mouth, palms, and soles.
• Other systemic symptoms like fever, headache, muscle aches, and malaise.
• Lymphadenopathy (swollen lymph nodes).

Tertiary Syphilis (Latent Syphilis)

• Occurs 1-30 years after initial infection, impacting cardiovascular and central nervous system in 30% of cases.
• Oral lesions (glossitis, gumma) are painless, destroying areas of cartilage, bone, and soft tissue, often resulting in a perforated palate.
• Leutic glossitis (red and white or smooth with burning sensation on the dorsum).
• Typically localized to the tongue and palate.

Congenital Syphilis

• Hutchinson triad: Hutchinson teeth, ocular interstitial keratitis, and 8th nerve deafness.
• Other associated findings: frontal bossing, saddle nose, mandibular prognathism, and rhagades.

Diagnosis & Treatment (for syphilis)

• Serology: VDRL (nonspecific), RPR (nonspecific), FTA-ABS (specific for life), MHA-TP (specific for life).
• Biopsy and special stains.
• Treatment: Penicillin G (first line), doxycycline (second-line).
• Prognosis: Neurosyphilis may develop despite treatment.

Histopathology (for syphilis)

• Ulcerated or hyperplastic surface.
• Abundance of plasma cells and lymphocytes in lamina propria and surrounding blood vessels.
• Special stains reveal corkscrew microorganisms.

Gonorrhea

• Sexually transmitted disease (STD) caused by Neisseria gonorrhoeae (gram-negative diplococci).
• Incubation period: 2–5 days.
• Signs: Often purulent discharge but also 10% of men and 80% of women are asymptomatic.
• Diagnosed via gram stain, culture, and NAAT.
• Complication: Pelvic inflammatory disease (PID) and disseminated infection (possible oral findings).
• Oral findings: painful pharyngitis; erythema and pustules; palatal erosions, ulcers, and necrotizing (ulcerative) gingivitis; submandibular and cervical lymphadenopathy.
• Treatment: Ceftriaxone IM with oral azithromycin or doxycycline (second line).

Tuberculosis

• Infection by Mycobacterium tuberculosis.
• Infection is not the same as active disease.
• Primary TB commonly targets lungs (tubercles or Ghon nodules).
• Organisms live in nodules for years and may spread in 5–10% of cases.
• Particularly prevalent in cases of immunosuppression.
• Systemic spread is termed miliary TB via vascular system.
• Oral TB (0.5–5% of cases) is extrapulmonary.
• Oral symptoms include enlarged cervical lymph nodes, calcification of lymph nodes, chronic ulcers, swelling on tongue and gingiva, and osteomyelitis.
• Microscopic appearance includes caseating granulomas; epithelioid histiocytes and lymphocytes with multinucleated giant cells.
• Special stain for acid-fast bacilli (mycobacteria).
• Fluorescence microscopy may be helpful.
• Diagnosis via tuberculin skin test, sputum or tissue samples/cultures, PCR.
• Treatment for active disease: Multiagent therapy (6-9 months) with isoniazid (INH), rifampin (RIF), ethambutol (EMB), and pyrazinamide (PZA).

Histoplasmosis

• Most common systemic opportunistic fungal infection in the US.
• Caused by Histoplasma capsulatum.
• Transmission: Inhaled spores.
• Risk factors include immunosuppression and debilitation.
• Locations commonly include lungs and extrapulmonary sites.
• Oral lesions represent disseminated disease, presenting on the tongue, palate, and gingiva.
• Persistent, solitary, painful ulcers with firm rolled edges and granular surface are diagnostic.
• Mimics malignancy.
• Microscopy and Treatment: Granulomas, histiocytes, multinucleated giant cells, 1–3 µm oval yeast forms.
• Tissue ID (PAS, GMS).
• TX: Systemic antifungals (itraconazole, amphotericin).
• Mortality rate: 7-23%.

Mucormycosis (Zygomycosis)

• Serious, systemic opportunistic fungal infection caused by genera Absidia, Mucor, Rhizomucor, and Rhizopus.
• Commonly arises from decaying organic matter.
• Multiple forms, including rhinocerebral form.
• High risk factors include uncontrolled diabetes mellitus (ketoacidosis), AIDS, bone marrow transplant, and immunocompromised individuals (including those with COVID-19).
• Symptoms frequently localized to the nasal, sinuses, orbit, maxilla, and palate regions.
• Common finding: nasal obstruction; bloody nasal discharge; facial pain; headache; cellulitis; vision problems, even blindness; often necrotic ulcer, black surface of the lesion; and palatal perforations.
• Extensive tissue necrosis; large (6–30 µm), branching, nonseptate hyphae with branching at 90° angles.
• Fungus invades blood vessels causing tissue infarction and necrosis.
• Treatment: Aggressive debridement and intravenous amphotericin.
• Mortality: approximately 50%.

Aspergillosis

• Fungus disease with invasive and non-invasive forms.
• Noninvasive forms often present as allergic reactions or sinus infections (often called 'fungus ball').
• Invasive forms disseminate the disease, particularly in the lungs.
• Associated risk factors include leukemia, high dose steroids (particularly in immunocompromised).
• Oral findings include painful gingival or palatal swellings and ulcers, sometimes with bluish gray swelling or yellow or black surfaces.
• Fungus may enter the gingival sulcus or result from endodontic treatment or infection of the sinus.
• Microscopic examination reveals branching, septate hyphae; size 3-4 µm; tendency to invade blood vessels, and the presence of a "fruiting body" in the sinus.
• Treatment: Debridement and antifungal medications.
• Prognosis: Poor, especially in immunocompromised patients. Mortality rates around 60%.

Other Deep Mycotic Diseases

• Includes Cryptococcus, Coccidioidomycosis, Paracoccidioidomycosis, and Blastomycosis.
• Primarily presents as pulmonary disease but can involve granular ulcers or masses mimicking oral cancer.

Rhinosinusitis (Sinusitis)

• Inflammation of the paranasal sinuses.
• Commonly caused by bacteria (S. pneumoniae, H. influenza, Moraxella catarrhalis), viruses, fungi, allergies, pollutants or mechanical obstructions (like nasal polyps).
• May result from endodontic, periodontal, or dental implant infections.
• Acute forms are often viral, and chronic forms can be bacterial.
• Up to 40% of maxillary sinus diseases are of dental origin.
• Symptoms may involve headache, fever, facial pain or pressure, drainage, sore throat, halitosis (bad breath), fatigue, nasal congestion, and multiple toothaches.
• Diagnostic radiographs may show cloudy maxillary sinuses, possibly with thickening of the lining and calcified stone (antrolith).
• Treatment depends on the cause and may include antibiotics (amoxicillin, doxycycline, azithromycin), and/or surgical intervention.

Candidiasis

• Fungal infection from Candida albicans (most common), or other Candida species.
• Candida albicans is a dimorphic fungus (two forms). The "yeast" form is normal in 30-50% of humans, the "hyphal" form invades tissues if it takes over in populations over 60 years of age.
• Most common oral fungal infection.
• Many forms and clinical presentations exist.
• Risk factors include decreased immunity, antibiotic treatment (most common), or some other serious health issues (like leukemia, AIDS, or Diabetes).
• Microscopic features include a tangled hyphal and spore appearance, hyphal cells within the parakeratin layer of the epithelium, and chronic inflammation and microabscesses. Appropriate stain: PAS.
• Treatment uses antifungal medications like Nystatin, Clotrimazole, Fluconazole, and Itraconazole.
• Prognosis: Often annoying and recurrent; may become invasive in immune-compromised patients.