Bacterial & Fungal Infections Oral Path PPT 9-2024 PDF

Bacterial & Fungal Infections Oral & Maxillofacial Pathology Part 1 CATHERINE M. FLAITZ, DDS, MS NOVEMBER 2024 Bacterial Infections ORAL PATHOLOGY I Impetigo  Superficial skin infection caused by: Streptococcus pyogenes Staphylococcus aureus Separately or together  Very contagiou...

Bacterial & Fungal Infections Oral & Maxillofacial Pathology Part 1 CATHERINE M. FLAITZ, DDS, MS NOVEMBER 2024 Bacterial Infections ORAL PATHOLOGY I Impetigo  Superficial skin infection caused by: Streptococcus pyogenes Staphylococcus aureus Separately or together  Very contagious  Occurs in damaged skin: trauma, dermatitis, Mimics: Angular cheilitis insect bites  If in scratched skin: linear crusting  Systemic risk: ↑ HIV+, diabetes type 2, dialysis  Usually children, in summer or early fall, high humidity Impetigo: Clinical Features  2 Types: Nonbullous (70%), bullous (30%)  Site: Legs, trunk, scalp, face  Bacteria harbored in nose  S/S: Red macules, papules and Mimics: Recurrent herpes simplex vesicles; covered by thick amber or honey crust, resemble attached cornflakes; pruritic  Uncommon S/S: Lymphangitis, cellulitis, fever, malaise  Lymphangitis  Lymphangitis: Inflammation of lymphatic channels that occurs as a result of infection at a site distal to the channel.  Cause: Usually microbial infection  Red streaks from wound to the nearest lymph nodes.  Complication: Cellulitis, septicemia Bacterial infection on arm spreading to axillary lymph nodes Impetigo: Diagnosis & Treatment  Diagnosis: Clinical presentation, +/- culture  Treatment options:  Topical antibiotics: mupirocin, retapamulin  Systemic antibiotics: selection depends on if MRSA – (cephalexin) or MRSA+ (Bactrim)  Complication: Spread, scars, acute glomerulonephritis Bullous type with cellulitis Erysipelas  Superficial skin infection by beta- hemolytic streptococci, esp. S. pyogenes  Spreads via lymphatics, plugs them  Favors sites of previous scar  Young & elderly, especially if:  Debilitated  Immunosuppressed  Obese  Alcoholic  Have large surgical scars  Areas of lymphedema Erysipelas: Clinical Features  Site: Legs >> face > upper arms  Bright red, painful swelling or rash (Saint Anthony’s fire)  May have orange peel texture or bullae and crusted lesions  If on face: cheek, eyes; may have a butterfly rash appearance (like lupus)  High fever, lymphadenopathy, nausea  Leukocytosis Erysipelas: Diagnosis & Treatment  Diagnosis: Clinical, +/- cultures  Treatment: Penicillin, cephalexin, ciprofloxin  May recur due to lymphatic damage  Complication: Abscess, gangrene, toxic shock syndrome, organ failure, thrombophlebitis, acute glomerulonephritis, endocarditis  Streptococcal Tonsillitis & Pharyngitis  Group A, beta-hemolytic streptococci  Up to 30% of cases in children  Up to 15% of cases in adults  Mimickers: adenoviruses, enteroviruses, influenza, Epstein- Barr virus, coronavirus, many others  Most common in 5-15 year-olds  Spreads: respiratory droplets, saliva  Incubation period: 2-5 days Strep Throat: Clinical Features & Treatment  Fever, headache, malaise, vomiting  Dysphagia (difficulty swallowing)  Tonsillar hyperplasia  Yellowish tonsillar exudate  Palatal petechiae  Swollen uvula  Cervical lymphadenopathy  May have scarlatiniform rash  Rx: Penicillin, amoxicillin  Complication: Rheumatic fever, AGN  Scarlet Fever  Group A, beta-hemolytic streptococci  Produces erythrogenic toxin  Toxin attacks vessels >>> rash  Begins as strep throat/tonsillitis  Problem for persons with no antitoxin antibodies  Incubation period = 1-7 days  Fever for 6 days  Childhood (3-12 years of age) Scarlet Fever  Enanthem (red mouth & throat; exudate)  Petechiae of soft palate  Exanthem (red skin rash - goose bumps)  Scarlatina rash (desquamates for 3-8 weeks after redness is gone)  White strawberry tongue (day 2), then raspberry/strawberry tongue (day 5)  Pastia’s lines: red lines in skin folds (capillary fragility)  Skin of face usually spared, except red cheeks, circumoral pallor Mimics COVID-19 Scarlet Fever  Diagnosis: Culture, rapid antigen test  Complications:  Pharyngeal abscess  Sinusitis  Pneumonia  Late complications:  Otitis media  Acute rheumatic fever  Glomerulonephritis  Arthralgia  Meningitis Peritonsillar abscess  Hepatitis  Rx: antibiotics (penicillin, amoxicillin) Tonsillar Concretions & Tonsillolithiasis  Range from calcification of keratin plugs or sloughed debris in crypts  Males>females (2:1); any age  Usually multiple, asymptomatic  Usually not seen clinically  May cause recurrent infection, dysphagia, cough, halitosis  Mimics: Oral lymphoepithelial cyst Tonsilliths  Some are radiopaque  2-4 mm globular opacities of ramus region on panoramic radiograph  CBCT shows opacities medial to ramus  May spontaneously release, and swallowed  No tx needed unless pain or swelling or purulence  If tx: gargling with warm salt water, curettage or tonsillectomy  Complication: tonsillar abscess, chronic tonsillitis  Microscopy Lymphoid hyperplasia Actinomycotic aggregates (sulfur granules) Actinomycosis  Filamentous, branching, gram-positive anaerobic bacteria  Normal saprophytic oral bacteria  Colonization in periodontal pockets, oral Operculitis biofilm and calculus, gingival sulcus (40% in tonsil; 100% in gingival pockets)  Usually Actinomyces israelii followed by A. viscosus -- coinfection with strep, staph  Causes an acute or chronic infection  Draining facial fistula, lasts for wks or months  Neck may heal with scars (lumpy jaw)  Yellow sulfur granules (colonies) Plugged tonsillar crypts  Actinomycosis  Types: acute or chronic infection  Location: 55% of infection occur in cervicofacial region, esp. submandibular, submental, angle of mandible regions  Enters at previous diseased oral sites  Facial cellulitis, draining facial sinus tract, indurated swelling, single or multiple tracts, lasts for weeks or months  May occur as a focal abscess intraorally  Neck may heal with scars (lumpy jaw)  Yellow sulfur granules (colonies) Extraoral drainage from odontogenic infection Lumpy Jaw with Multiple Sinus Tracts Face and neck may heal with scars (lumpy jaw) May develop osteomyelitis or salivary gland disease DX: Culture (50% +), biopsy TX: Debridement; penicillin, amoxicillin, tetracycline May be associated with periapical infection, but most remain localized Histopathology  Evaluate for sulfur granules  Chronically inflamed granulation tissue and fibrosis  Focus of neutrophils that surround microbial colonies  Club-shaped filamentous bacteria Cat-Scratch Disease  Bartonella henselae infection of damaged skin, spreads to adjacent lymph nodes  Gram-negative bacilli  Most common cause of chronic regional lymphadenopathy in children  Contact with cat/kitten – saliva or scratch  No human-to-human transmission  Incubation period: 3-14 days  Scratch is healed before nodes enlarge  Facial scratch >> submandibular diffuse enlargement, usually painful  Often: massive necrosis of node  Cat-Scratch Disease  Sites: Head & neck, axillary, epitrochlear, groin regions  Papule develops at scratch line  Papule resolves in 1-3 weeks  Lymph node enlargement, fever, malaise follow healing of skin  Single (50%) or multiple nodes  Site: Axillary and epitrochlear – 46%; head & neck nodes in 26%  Suppuration in 10%  Multiple organs affected in immunocompromised Diagnosis & Treatment  Positive history and serology  Histopathology  Lymphoid hyperplasia  Band of histiocytes, neutrophils  Stellate suppurative necrosis  Special stains for bacterial identification  Treatment: most are self-limiting  If needed, azithromycin  Noma (Cancrum Oris) OROFACIAL GANGRENE; NECROTIZING STOMATITIS ▪ Greek nomein = “to devour” ▪ Rapidly progressive, polymicrobial, opportunistic infection - normal flora ▪ Fusobacterium necrophorum, Prevotella intermedia, others ▪ Age: usually children ▪ Risk: malnutrition, poverty, sanitation, infection (HIV), malignancy ▪ May begin as NUG and spread ▪ Black gangrenous necrosis of face, jaws, destroys lips NUG  Noma (Cancrum Oris) ▪ Fetid odor ▪ Pain ▪ Fever, malaise ▪ Tachycardia, ↑ respiratory rate ▪ Anemia, leukocytosis ▪ Regional lymphadenopathy ▪ Rx: Penicillin, metronidazole, nutrition, local debridement ▪ No treatment: 95% risk of death https://www.thelancet.com/journals/laninf/article/PII S1473309903006704/fulltext Noma is rare in U.S. unless associated with HIV ✓ May be associated with secondary fungal or viral infection ✓ Very painful ✓ Loss of teeth and alveolar bone 80% increase from 2018-2022 Note: 1 in 5 people have STI on any given day in U.S.  Syphilis  Caused by Treponema pallidum, pathogenic, mobile, gram negative spirochetes  Transmission: Sexual contact, congenital infection  Risk: Anyone who has oral, genital or anal sex  Stages of disease: Primary, secondary, tertiary and congenital  Highly contagious in first 2 forms  Oral presentation are uncommon and occur at all stages  Primary Syphilis  Chancre is the characteristic lesion  Develops at site of inoculation  Develops 3 – 90 days after infection  Sites: 85% in genital area, 10% in anal, 4% in oral and 1% in extragenital areas  Oral site: most on lips, then buccal mucosa, tongue, palate, gingiva  S/S: Painless ulcer with clean or amber base; bilateral lymphadenopathy  Heals in 3-8 weeks, if untreated Secondary Syphilis  Sign of disseminated syphilis  Occurs 4-6 weeks after primary  Systemic & oral signs/symptoms  Oral signs: Mucous patches (30%), split papules, Split papule Condyloma lata condyloma lata Mucous patches  Syphilitic Rash  Painless maculopapular rash  Widespread, including face, mouth, and palmar and plantar areas  Other systemic signs:  Lymphadenopathy  Fever  Headache  Muscle ache  Sore throat  Malaise Tertiary Syphilis (Latent Syphilis)  Period: 1-30 years  Occurs in 30%  Cardiovascular and central nervous systems affected  Oral lesion: Gumma, leutic glossitis  Gumma: Painless destruction of cartilage, bone, soft tissue; perforated palate may be site  Leutic glossitis: Red and white, smooth, dorsum; burning sensation  Site: Usually tongue and palate  Congenital Syphilis  Hutchinson triad  Hutchinson teeth  Ocular interstitial keratitis  8th nerve deafness  Other H&N findings  Frontal bossing  Saddle nose  Mandibular prognathism  Rhagades Diagnosis & Treatment Serology  VDRL: Venereal Disease Research Laboratory (nonspecfic)  RPR: Rapid Plasma Reagin (nonspecific)  FTA-ABS: Fluorescent treponemal AB absorption (specific for life)  MHA-TP: Microhemagglutination for T. pallidum (specific for life) Biopsy and special stains Treatment Penicillin G parenteral (first line) Doxycycline (second-line) Prognosis: Despite treatment, neurosyphilis may develop Histopathology  Ulcerated or hyperplastic surface  Abundant plasma cells and lymphocytes in lamina propria and around blood vessels  Special stains show corkscrew microorganisms (silver stains) Gonorrhea  Cause: STD by Neisseria gonorrhoeae; gram-negative diplococci  Incubation period: 2-5 days  Sign: Purulent discharge but 10% of men and 80% of women are asymptomatic  Diagnosis: Gram stain, culture and NAAT  Complication: Pelvic inflammatory disease and disseminated infection Gonorrhea Oral findings  Painful pharyngitis with erythema and pustules  Palatal erosions and ulcers  Necrotizing (ulcerative) gingivitis  Submandibular & cervical lymphadenopathy Treatment  Ceftriaxone IM with oral azithromycin  Doxycycline (second-line)  Oropharyngeal is harder to resolve  Tuberculosis  Infection by Mycobacterium tuberculosis  >2 billion people worldwide  Infection ≠ active disease  Primary tuberculosis: usually involves lungs (tubercles; Ghon nodules)  Organisms present in nodules for years  5%-10% progress to secondary tuberculosis:  Especially with immunosuppression  Miliary TB – disseminated disease via vascular system  Consumption (lungs); lupus vulgaris (skin) Tuberculosis  Primary TB is usually asymptomatic  Secondary TB: fever, anorexia, weight loss, night sweats, productive cough  Oral (extrapulmonary TB) in 0.5%-5%  Enlarged cervical lymph nodes  Calcification of lymph nodes  Chronic ulcers, granularity and swellings of tongue, gingiva, others  Osteomyelitis Oral Tuberculosis Chronic ulcers mimic: ✓ Squamous cell carcinoma ✓ Chancre ✓ Deep mycotic infections  TB: Microscopy  Caseating granulomas  Epithelioid histiocytes, and lymphocytes  Langhans multinucleated giant cells  Special stain for acid-fast bacilli (mycobacteria) – only 27-60% positive  Fluorescence microscopy TB: Diagnosis & Treatment  Tuberculin skin test – positive means exposure to TB  Sputum, tissue samples, cultures, PCR needed for active disease  TX: Multiagent therapy – 6-9 months  Drug protocol:  isoniazid (INH)  rifampin (RIF)  ethambutol (EMB)  pyrazinamide (PZA)  Rhinosinusitis (Sinusitis)  Inflammation of paranasal sinuses – common disease  Cause: Bacterial (S. pneumoniae, H. influenza, Moraxella catarrhalis), viral, fungal, allergies, pollutants, mechanical obstruction (nasal polyps)  May develop from endodontic or periodontal infection, extraction, implant  Triggers: acute: viral - viral URI; chronic: bacteria – viral URI, allergies, dental  Up to 40% of maxillary sinus disease is dental origin  Sinusitis  Signs: headache, fever, facial pain/pressure, drainage, sore throat, halitosis, fatigue, nasal congestion, multiple toothaches  Radiographic: Cloudy of maxillary sinus, thickening of Cobblestone pattern of pharyngeal sinus lining +/- antrolith (calcified wall with mucus or purulence stone)  Treatment depends on cause  Antibiotics?: amoxicillin, doxycycline, azithromycin  +/- Surgical intervention Cloudy right maxilla with antroliths Fungal Infections ORAL PATHOLOGY I Candidiasis  Fungal infection from Candida albicans US = candidiasis; British = candidosis  Sometimes infection from other genus: C. tropicalis, C. krusei, C. parapsilosis  Dimorphism (two forms):  Yeast: normal in 30-50% of humans; >60% if > 60 YO  Hyphal: disease form; invades tissues  Most common oral fungal infection  Many clinical manifestations  Red flag disease: ↑ risk with ↓ immunity Pseudomembrane partially wiped off  Oral Candidiasis Clinical Subtypes – what a world of differences! ▪ Pseudomembranous (thrush) ▪ Erythematous (atrophic) ▪ Central papillary atrophy (median rhomboid glossitis) ▪ Chronic multifocal candidiasis ▪ Angular cheilitis Pseudomembranous candidiasis under denture ▪ Cheilocandidiasis (candida cheilitis) ▪ Juvenile juxtavermilion candidiasis ▪ Denture stomatitis ▪ Hyperplastic candidiasis ▪ Mucocutaneous candidiasis ▪ Endocrine-candidiasis syndrome ▪ Ulcerative (invasive) candidiasis Pseudomembranous Candidiasis ▪ In newborns, it is called thrush ▪ White plaques, like cottage cheese Tangled masses of hyphae (yeasts) Desquamated epithelial cells Rubs off: underlying mucosa is normal or erythematous No bleeding, unless another problem ▪ Triggered by: Broad-spectrum antibiotics (fast onset) Compromised immunity (slow onset) [leukemia, AIDS, diabetes, autoimmune] Xerostomia (dry mouth) Corticosteroid therapy Poor denture hygiene, loose denture Pseudomembranous Candidiasis ▪ Location: Buccal mucosa, tongue, palate ▪ Symptoms are usually mild ▪ Mild burning sensation ▪ Unpleasant taste (salty, bitter) ▪ Feels thickened or fuzzy ▪ Mimics: Oral biofilm (dental plaque), coated tongue Erythematous Candidiasis  More common than pseudomembranous  Associated factors: Antibiotics, xerostomia, immunosuppression  Location: Dorsal tongue, palate, buccal mucosa  Signs: Red macules or diffuse red patches; atrophy of tongue papillae; burning sensation Erythematous Candidiasis  Median rhomboid glossitis (central papillary atrophy): well demarcated, red patch on posterior midline dorsal tongue  Kissing lesion involves the midline hard palate  Not a developmental defect Kissing Lesion: Candidiasis on dorsal tongue and palate Risk factor: steroid inhaler use for asthma and COPD Erythematous Candidiasis  Angular cheilitis: redness, fissures, scaly, and crusting in corners of mouth  Microbiology: Candida (20%) and/or S. aureus (20%) – 60% are combined,  Contributing factors:  Loss of vertical dimension  Vitamin deficiency  Local irritation  Some medications  May be sore, burn or pruritic  Often recurs Erythematous Candidiasis  Denture stomatitis  Redness of the denture bearing areas, especially palate  Microbiology: Candida and/or oral bacteria  Contributing factors:  Persistent wearing of denture  Poor fitting of prosthesis  Poor cleaning  Usually nontender  Mimics: trauma or allergic reaction Chronic Hyperplastic Candidaisis  Also know as Candidal leukoplakia  Least common form; > smokers  Location: anterior buccal mucosa and tongue  Signs: Adherent white or speckled plaques; usually nontender  May be associated with epithelial dysplasia Mucocutaneous Candidasis  Rarest form of candidiasis  May be genetic disease or immune dysfunction  Location: tongue, buccal mucosa, palate; +/- nails, skin eyes  Signs: White plaques with redness  May be associated with endocrine and autoimmune disorders and genetic disease  Increased risk for oral and esophageal carcinoma (10%) with autoimmune type Microscopy  Cytology: tangled hyphal and spores, epithelial cells, bacteria (PAS+)  Tubular hyphae in parakeratin layer of epithelium  Also chronic inflammation, and microabscesses  Special stains needed for identification – Periodic acid- Schiff (PAS) Treatment and Prognosis  Treatment  Nystatin  Clotrimazole  Fluconazole  Itraconazole  Prognosis: Annoying & recurrent Necrotic ulcer in a poorly controlled diabetic  If immunocompromised, it may become invasive Antifungal Treatment Response: Clotrimazole Troches Pre-treatment Post-treatment Histoplasmosis  Most common systemic, opportunistic, fungal infection in US  Cause: Histoplasma capsulatum  Transmission: Inhaled sores  Risk: Debilitated, immunosuppressed  Location: Lung and extrapulmonary sites, including mouth  Oral lesions: Represent disseminated disease on tongue, palate Histoplasmosis  Oral lesions: Represent disseminated disease on tongue, palate, gingiva  Signs: Persistent, solitary, painful ulcer with firm rolled margins and granular surface  Mimics: Malignancy Microscopy & Treatment  Granulomas with epithelioid histiocytes & multinucleated giant cells  1-3 um oval yeast forms  Special stains for tissue ID: PAS, GMS  TX: Systemic antifungals, itraconazole, amphotericin  Mortality rate: 7-23% Grocott-Gomori methenamine silver stain  Mucormycosis (Zygomycosis)  Serious, systemic opportunistic fungal infection  Caused by genera Absidia, Mucor, Rhizomucor, Rhizopus from decaying organic matter  Multiple forms, including rhinocerebral form  Risk: Uncontrolled diabetes (ketoacidosis), AIDS, bone marrow transplant, immunocompromised, rarely in COVID-19 Rhinocerbral Mucormycosis ▪ Site: nasal, sinuses, orbit, maxilla, palate ▪ Signs: Nasal obstruction, bloody nasal discharge, facial pain, headache, cellulitis, vision problems, blindness ▪ Oral: Destructive necrotic ulcer, black surface, palatal perforation  Microscopy & Treatment  Extensive necrosis with numerous large (6 to 30 µm in diameter), branching, nonseptate hyphae  Hyphae branch at 90° angles  Fungus invades blood vessels causing infarction, necrosis  Treatment: Aggressive debridement, IV amphotericin  Palatal obturator  Mortality: 50% Aspergillosis  Fungus disease that has invasive & noninvasive forms  Noninvasvie presents often as an allergic reaction or sinus infection (fungus ball) in normal host  Invasive causes disseminated disease, especially lungs  Risk: Leukemia, high-dose Fungus ball in maxillary sinus steroids  Aspergillosis  Oral findings include painful gingival or palatal swellings and ulcers  Often bluish-grey swelling followed by necrotic ulcers with yellow or black surface  Fungus may enter gingival sulcus or following tooth extraction of endodontic treatment resulting in Painful purplish-black swelling of sinus infection hard palate in woman with leukemia Microscopy & Treatment  Branching, septate hyphae, 3 - 4µm in diameter  Tendency to invade blood vessels  Fruiting body in sinus  Treatment: Debridement and antifungal meds  Prognosis: Poor especially for immunocompromised  60% mortality rate Other Deep Mycotic Diseases  Cryptococcus  Coccidioidomycosis  Paracoccidioidomycosis  Blastomycosis  Most present as pulmonary disease  Most present as granular ulcers or Blastomycosis indurated mass that mimic oral cancer