Orofacial manifestations of the systemic mycoses

Orofacial Cryptococcosis: A Challenging Clinical Report and a Systematic Analysis of the Literature

Cryptococcosis is a neglected fungal disease. The scarcity of studies on oral cryptococcosis is certainly due to rarity and/or underreporting of the disease, especially in Brazil. We describe an example of orofacial cryptococcosis affecting a 57-year-old man after heart transplantation, who presented with multiple erythematous ulcers and erosions distributed in the chin, nasal cavity, labial mucosa, hard palate, and buccal vestibule. Computed tomography revealed opacities and micronodules in the lungs. Histopathological features of the oral and pulmonary lesions were compatible with Cryptococcus spp. Amphotericin B and fluconazole were used for treatment during hospitalization and itraconazole for prolonged therapy after hospital discharge. The patient has been under follow up for 6 months without signs of disease. According to a review conducted in PubMed, Web of Science, Scopus, Embase, and LILACS for data analysis of oral cryptococcosis, 26 reports were described in the literature. Predilection for men was observed (85%), with a male:female ratio of 5.5:1. The mean age of the individuals was 49 ± 15.3 years. Oral cryptococcosis mostly presented as an ulcer (n = 17). The palate and tongue were the most affected sites (n = 9 for each). Amphotericin B was the primary therapy utilized in most patients. Seventeen (65%) individuals survived. Knowledge of the clinicodemographic aspects of oral cryptococcosis is important for clinicians in decision making and surveillance.

A Rare Case of Mandibular Aspergillus Osteomyelitis in an Immunocompetent Patient

Aspergillosis is a fungal infection caused by Aspergillus species, which is contracted through spores that colonize the respiratory tract, causing rhinosinusitis and pulmonary infections. Oral aspergillosis is rare and, when present, may cause soft tissue and bone destruction, generally in immunodeficient patients. Mandibular Aspergillus osteomyelitis is even rarer, with few cases reported in the literature. A 57-year-old Caucasian woman was referred for the evaluation of painful recurrent swelling in the anterior mandibular alveolar ridge, with purulent drainage, previously treated with multiple surgical debridement procedures and antibiotics without success. The patient was otherwise systemically healthy. Surgical debridement was performed and histopathological examination showed osteomyelitis associated with Aspergillus species. Therapy with oral itraconazole (400 mg per day) was administered for 3 months, resulting in complete resolution. No recurrence was detected after 15 years of follow-up. The patient was rehabilitated with dental implants. In conclusion, non-bacterial microorganisms, such as Aspergillus, should be considered in cases of mandibular osteomyelitis that do not heal after surgical debridement and antibiotic therapy.

Oral Paracoccidioidomycosis affecting women: A systematic review

Paracoccidioidomycosis (PCM) is an infection caused by fungi of the genus Paracoccidioides and is marked by a strong predilection for men; nevertheless, some women have had developed PCM and have presented oral involvement by the disease.

OBJECTIVES

To review all published cases until August 2020 of oral PCM in women, with emphasis on the presence of systemic changes, deleterious habits (tobacco and alcohol) and oral manifestation features through a systematic review.

METHODS

Observational studies (both prospective and retrospective) and case reports indexed in the Embase, PubMed, Scopus, Web of Science and LIVIVO databases were selected by two reviewers in a two-phase process following the pre-established PICOS criteria.

RESULTS

Twenty-five studies met the eligibility criteria and were selected for qualitative synthesis, of which 72 participants were enrolled. Brazilian White women between 40 and 50 years were the most affected and social history revealed them to be housewives or rural workers. Fifteen women (33.3% of the informed cases) presented any systemic change at the time of PCM diagnosis, namely pregnancy, HIV infection and/or depression. Moriform stomatitis was predominant and affected preferentially the gingivae and alveolar processes in the form of a single painful lesion. Most patients were treated with sulfamethoxazole + trimethoprim or itraconazole.

CONCLUSIONS

Oral PCM in women is rare; some cases showed systemic changes at the time of PCM diagnosis, namely HIV infection, pregnancy and depression. New studies should be conducted to elucidate the influence of systemic alterations on the development of oral PCM in women.

Granulomatous Diseases Affecting Jaws

The common aspect of all granulomatous diseases is the typical form of chronic inflammatory response with distinct microscopic granulomas that are formed secondary to either definitive etiologic agents, like bacteria, fungal, or parasitic, or due to an unknown etiologic agent, such as trauma, autoimmune, or even neoplastic process. Although they can be histologically distinct, granulomatous diseases demonstrate a variety of clinical features that may not seem to be inflammatory. Two types of granulomas are typically encountered: foreign body granulomas and immune granulomas. The differences between the two types of granulomas lie in the pathogenesis.

Unusual Otolaryngologic Manifestations of Paracoccidioidomycosis: A Case Report and Review of Literature

AbstractParacoccidioidomycosis is a systemic mycosis caused by Paracoccidioides brasiliensis. It occurs more frequently in its chronic form, which particularly affects male adults from rural areas. These patients present with pulmonary involvement and systemic symptoms. Skin and mucosal lesions are rather typical and might suggest the diagnosis. The involvement of the upper airway mucosa is common and the patients usually complain of dysphagia and dysphonia. Nonetheless, in endemic areas, physicians should maintain a high level of suspicion even when faced with some atypical symptoms. We present the case of an adult diagnosed with nasopharyngeal paracoccidioidomycosis after presenting with an unusual otolaryngologic syndrome including unilateral soft palate paralysis with velopharyngeal insufficiency and hearing loss secondary to middle ear effusion.

Erratum: Paracoccidioidomycosis of the Mouth: an Emerging Deep Mycosis

Oral fungal infections (mycoses) have come into particular prominence since the advent of infection with Human Immunodeficiency Virus (HIV), and recognition of the Acquired Immune Deficiency Syndrome (AIDS), as well as the phenomenal increase in world travel with increased exposure to infections endemic in the tropics. Paracoccidioidomycosis is a rare mycosis worldwide but common in Brazil and some other areas in Latin America. It can be life-threatening and can manifest with a spectrum of clinical presentations, including frequent oral lesions. This paper reviews the more recent information on Paracoccidioidomycosis, emphasizing those areas most relevant in dental science.

Uncommon opportunistic fungal infections of oral cavity: A review

The majority of opportunistic oral mucosal fungal infections are due to Candida albicans and Aspergillus fumigatus species. Mucor and Cryptococcus also have a major role in causing oral infections, whereas Geotrichum, Fusarium, Rhodotorula, Saccharomyces and Penicillium marneffei are uncommon pathogens in the oral cavity. The broad spectrum of clinical presentation includes pseudo-membranes, abscesses, ulcers, pustules and extensive tissue necrosis involving bone. This review discusses various uncommon opportunistic fungal infections affecting the oral cavity including their morphology, clinical features and diagnostic methods.

Tropical Oral Health

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Oral health poses a major health burden for many countries, and some forms of oral disease are specific to tropical countries.

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Oral diseases are the most common non-communicable diseases and share risk factors with many other non-communicable diseases.

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Some 90% of the world's population is affected by tooth decay.

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A high proportion suffer from periodontal disease.

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Oral cancer rates are high among smokers and tobacco users.

Aspergillus petrous apicitis associated with cerebral and peritubular abscesses in an immunocompetent man

Background:

Petrous apex aspergillosis is an uncommon and dangerous condition, with only four previously reported cases. As with other forms of petrous apicitis, the clinical symptoms are often non-specific and this contributes to diagnostic delay. This paper presents the first reported case of Aspergillus petrous apicitis associated with an intracranial or nasopharyngeal abscess.

Case report:

A 72-year-old man with chronic otorrhoea developed neuralgic headaches and progressive lower cranial nerve palsies despite antibiotic therapy. Imaging revealed petrous apicitis, a temporal lobe abscess and nasopharyngeal abscess. Analysis of biopsy tissue indicated invasive aspergillosis. The patient recovered on a protracted course of voriconazole in addition to medium-term antibiotic therapy.

Conclusion:

Invasive fungal disease should be considered early in the course of skull base osteomyelitis that is clinically unresponsive to empirical broad spectrum antibiotics. This paper highlights the role of tissue biopsy in diagnosis, and the efficacy of voriconazole therapy without the need for radical surgery.

Aspergillosis of the cranial base

Aspergillus is an ubiquitous organism seldom pathogenic in normal hosts. Aspergillus osteomyelitis of the spine occurs rarely in immunocompromised patients as a result of hematogenous spread from distant foci. We present a case of Aspergillus osteomyelitis in the region of the jugular foramen in a previously healthy male with no antecedent event. He presented with dysphagia, hypophonia, and weight loss of several months duration. Diagnosis was delayed due to nonspecific results of various imaging tests. We review the clinical course of fungal osteomyelitis, including appearance on magnetic resonance imaging and computed tomography, culture characteristics, and gross appearance. Current treatment consists of surgical debridement and antifungal medications such as amphotericin B and itraconazole, and the efficacy of these are discussed.

Differential gene expression analysis of Paracoccidioides brasiliensis during keratinocyte infection

Paracoccidioides brasiliensis is the agent of paracoccidioidomycosis, one of the most important systemic fungal diseases in Latin America. This initiates in lung tissue and can subsequently disseminate to other tissues. Clinical manifestations range from localized forms to disseminated disease that can progress to lethality, probably depending on the relationships among the virulence of the fungus, the immune response and the ability to interact with the surface structures and invade epithelial cells and mononuclear cells of the host. It is generally regarded as a multifocal disease, with oral lesions as the prominent feature. The aim of this study was to evaluate P. brasiliensis yeast infection in normal oral keratinocytes (NOKs). The differential expression of mRNAs and proteins was also determined when the fungus was placed in contact with the cell in order to characterize differentially expressed genes and proteins during P. brasiliensis infection. After contact with NOKs, the fungus appeared to induce alterations in the cells, which showed cellular extensions and cavitations, probably resulting from changes in the actin cytoskeleton seen at 5 and 8 h after infection. Levels of protein expression were higher after reisolation of the fungus from infected NOK culture compared with culture of the fungus in medium. The analysis identified transcripts related to 19 proteins involved in different biological processes. Transcripts were found with multiple functions including induction of cytokines, protein metabolism, alternative carbon metabolism, zinc transport and the stress response during contact with NOKs. The proteins found suggested that the yeast was in a stress situation, as indicated by the presence of RDS1. Nevertheless, the yeast seemed to be proliferating and metabolically active, as shown by the presence of a proteasome, short-chain acetylator, glucosamine-6-phosphate isomerase and ADP/ATP carrier transcripts. Additionally, metabolic pathways may have been activated in order to eliminate toxic substances from the cell as a zinc transporter was detected, which is a potential target for the development of future drugs.

Disseminated histoplasmosis associated with hemophagocytic lymphohistiocytosis in kidney transplant recipients

Transplant patients are susceptible to infectious complications due to chronic immunosuppression. We present two cases of persistent fever, weight loss and pancytopenia in kidney transplant recipients (originally concerning for posttransplant lymphoproliferative disease) that were later diagnosed with disseminated histoplasmosis on bone marrow and lymph node biopsy. In both patients, pancytopenia was due to hemophagocytic lymphohistiocytosis (HLH) which has rarely been described in association with histoplasmosis and not previously reported in kidney transplant recipients with this fungal infection. The diagnosis of histoplasmosis can be complex due to nonspecific symptomatology, delays in isolating histoplasma by fungal culture and false-negative antibody titers in immunocompromised patients. A review of the literature including the clinical features of histoplasmosis in immunosuppressed patients (prevalence, current diagnostic testing and treatment options) as well as the association of HLH in immunocompromised states are discussed.

Treating oral histoplasmosis in an immunocompetent patient

BACKGROUND

Histoplasmosis is a deep fungus infection that occurs worldwide and is caused by Histoplasma capsulatum. Oral histoplasmosis has been of considerable importance in recent years because it occurs frequently in immunosuppressed patients, more often in those who test positive for the human immunodeficiency virus (HIV). However, the literature contains reports of histoplasmosis in immunocompetent patients, especially in endemic areas.

CASE DESCRIPTION

The authors describe a case of an HIV-negative, immunocompetent 60-year-old man with ulcerative and painful oral lesions. The clinician included squamous cell carcinoma and systemic mycosis in the differential diagnosis. After the patient underwent a biopsy and a definitive diagnosis was reached, his initial treatment regimen included itraconazole (200 milligrams per day for one month), nystatin and chlorhexidine mouthrinse (0.12 percent, 10 milliliters, two times a day). The itraconazole treatment was continued for three more months (100 mg daily) until the lesions had resolved completely.

CLINICAL IMPLICATIONS

Clinicians need to conduct a careful clinical evaluation and make an accurate diagnosis of ulcerated oral lesions. Knowledge of the oral manifestations of histoplasmosis may enable clinicians to reach a diagnosis earlier and initiate therapy more quickly.

Ulcerative lesions of the mouth: an update for the general medical practitioner

Oral ulceration is a common complaint of patients attending out-patient clinics. Because of the diversity in causes of oral ulceration, patients presenting with oral mucosal disease can be challenging to diagnose and manage. Patients with signs or symptoms of oral ulcers are sometimes referred to gastroenterology clinics; however, in most instances the ulcers do not result from gastrointestinal disease. The aim of the present article is to review aspects of the etiology, diagnosis and management of common ulcerative disorders of the oral mucosa. A search in the National Library of Medicine computerized bibliographic database MEDLINE was performed. Selection of publications, extraction of data, and validity assessment were then performed by the authors. Based upon the searched literature, it is concluded that there are several systemic disorders that can present with similar clinical signs and symptoms, and knowledge of each disease is necessary for the clinician to provide proper management.

Characterization of inflammatory cells in oral paracoccidioidomycosis

Paracoccidioidomycosis (Pmycosis) is one of the most common deep mycoses in many regions of Latin America, particularly in Brazil. Microscopically, it shows granulomatous inflammatory reaction with giant cells, macrophages, lymphocytes, plasma cells, polymorphonuclear neutrophilic leukocytes, and eosinophils. The purpose of this study was to assess the distribution of inflammatory cells in oral Pmycosis. Fifteen cases of oral Pmycosis were studied by immunohistochemistry for the presence of macrophages, CD4(+) and CD8(+) lymphocytes, CD20(+), CD15(+), and S100(+) cells. Macrophages were the main cells in well-organized granulomas and non-granulomatous areas. The CD4 phenotype was predominant in well-organized granulomas and a balance between CD4(+) and CD8(+) cells was observed in non-granulomatous areas. Dendritic, S100(+) cells were found mainly in the epithelium, in subepithelial connective tissue, and at the periphery of organized granulomas. CD15(+) cells were concentrated mainly in areas of intraepithelial microabscess and ulceration. Macrophages and T cells are the predominant cells in oral Pmycosis. Well-organized granulomas contain fewer yeast particles, indicating a more effective host immune response. Better understanding of the histopathological changes in oral Pmycosis might help determine treatment, severity and systemic involvement of the disease.

Cytokeratin expression in pseudoepitheliomatous hyperplasia of oral paracoccidioidomycosis

Paracoccidioidomycosis (Pmycosis) is one the most prevalent deep systemic mycoses in Latin America. It is characterized by granulomatous inflammation and pseudoepitheliomatous hyperplasia. Cytokeratins (CKs) are a group of intermediate filaments of epithelial cells and their expression varies according to the epithelium type, differentiation and pathological processes. This study describes cytokeratin expression as examined by immunohistochemistry, in 28 cases of oral Pmycosis involving the buccal mucosa, lip, gingiva and hard palate. Expression of CKs in the basal layer of the epithelium in pseudoepitheliomatous hyperplasia of Pmycosis was similar to that in normal oral mucosa (NOM), but in Pmycosis CK1 and CK10 were not expressed in the spinous and superficial layers of the lip, gingiva or hard palate, and, in the spinous and superficial layers of the lip and buccal mucosa, CK14 was positive in contrast to NOM where it was negative. In Pmycosis, CK6 was more frequently expressed in the spinous layer of the lip, gingiva and hard palate, but nevertheless CK16 expression was decreased in the spinous and superficial layers of the gingiva and hard palate. We conclude that pseudoepitheliomatous hyperplasia in oral Pmycosis shows a different pattern of CK expression, particularly CKs 1, 10 and 14, compared with NOM.

Mucormycosis in an immunocompetent patient: follow-up of 1 year after treatment

Mucormycosis is a rare acute fatal fungal infection. It is typically observed in diabetic or immunocompromised patients but not in systemically healthy individuals. Here, we describe an unusual mucormycosis case in an immunocompetent patient who had clinical signs of a maxillary sinusitis and associated osteomyelitis at the first examination. He was treated by surgery and removal of the necrotic bone and amphotericin B medication. At 1-year follow-up he shows complete recovery.

Unusual orofacial manifestations of histoplasmosis in renal transplanted patient

Histoplasmosis is a fungal infection caused by the Histoplasma capsulatum. Mucosal manifestations are uncommon, but, when present, they are usually associated with pulmonary or chronic disseminated infection. The course of the disease is often related to the host immune response. The purpose of this article is to describe the clinical and microscopic findings of unusual involvement of nasal cartilage and septal destruction, and oral lesions of histoplasmosis in an immunosuppressed patient who presented an unusual form of the disease.

Lichenoid and granulomatous stomatitis: an entity or a non-specific inflammatory process?

BACKGROUND

The presence of lichenoid or granulomatous inflammation in an oral mucosal biopsy usually suggests a distinct range of diagnostic possibilities. However, the presence of both patterns of inflammation in the same biopsy is uncommon.

METHODS

A clinico-pathological study of six patients.

RESULTS

All the patients in this study presented with similar mucosal lesions of the upper lip. Microscopically the lesions were characterized by the presence of lichenoid inflammation with concomitant granulomatous inflammation. The lesions were persistent and refractory to treatment with steroid medications, but remained localized and did not appear to herald the onset of systemic inflammatory or neoplastic disease.

CONCLUSION

We propose the designation 'lichenoid and granulomatous stomatitis' for the cases described in this study. The clinico-pathological features of a subset of these cases suggest an unusual drug eruption.

Oral histoplasmosis in an HIV-negative patient

Histoplasmosis is a deep mycosis caused by Histoplasma capsulatum, which has been found in soil with accumulated excreta of bats and birds. This disease has variable clinical findings with only pulmonary or systemic involvement. Upper aerodigestive lesions are found mainly associated with systemic disease, affecting particularly patients with immunosuppression conditions mainly caused by HIV. However, it is uncommon in immunocompetent patients. This report describes a case of oro-laryngeal-esophageal histoplasmosis in a HIV-seronegative patient without detectable systemic involvement.

Extensive maxillary sequestration resulting from mucormycosis

Mucormycosis is an invasive and potentially lethal infection caused primarily by fungi of the order mucorales. An ulcer or extraction in the mouth can be the port of fungal invasion, particularly when the patient is immunocompromised. Early recognition and aggressive treatment have reduced the mortality and morbidity. We present a case of oral mucormycosis with extensive maxillary osteonecrosis that is of interest because the patient ignored the initial warning signs and was rescued from the fulminating stage by thorough debridement and medical treatment.

Coccidioidomycosis of the tongue

A Spanish-speaking farm worker with type 2 diabetes mellitus presented to our institution with an ulcerating tongue lesion. He was initially evaluated for possible squamous cell carcinoma; however, histologic examination revealed coccidioidomycosis. Coccidioidal titers were elevated and consistent with disseminated disease, although the patient had no systemic symptoms and clinical evaluation was negative. He was ultimately treated with intravenous and oral antifungal medication, which was followed by improvement of his tongue lesion.

Sinus maxillaris mycetoma of odontogenic origin: case report

Fungal infections are on the increase and those of the jaw cavities with Aspergillus species may be connected with the root apices of teeth in the upper jaw. Diagnostic changes in the sinus maxillaris and certain types of facial pain may be indicative of fungal infection. The authors report a case of aspergillosis sinusitis and describe the diagnostic methods and treatment of this infection that may be associated with endodontic treatment.

Review article: oral ulcers and its relevance to systemic disorders

Oral ulceration is a common problem, and is sometimes a marker of gastroenterological disease. Patients with signs or symptoms of oral ulcers are sometimes referred to gastroenterology clinics, however, in most instances the ulcers does not reflect gastrointestinal disease. Indeed, a spectrum of disorders other than those of the gut can give rise to oral mucosal ulcers ranging from minor local trauma to significant local disease such as malignancy or systemic illness. This present article reviews aspects of the aetiology, diagnosis and management of common ulcerative disorders of the oral mucosa.

Oral Candida isolates in patients undergoing radiotherapy for head and neck cancer: prevalence, azole susceptibility profiles and response to antifungal treatment

Oral pseudomembranous candidiasis and mucositis were assessed in 39 patients receiving a total dose of 39-70 Gy radiotherapy for head and neck cancer. Mucositis was scored using the Radiation Therapy Oncology Group criteria, and oral candidiasis was diagnosed on the basis of clinical evaluation and quantitative laboratory findings. Radiation-induced mucositis was observed in 9/39 patients. Only 3/39 patients discontinued radiotherapy due to acute severe mucosal effects. Candidiasis (colony-forming units 35 to > or = 60/lesion) associated with mucositis was diagnosed in 30/39 patients: the most frequent aetiology of the infection was Candida albicans (n = 23), followed by Candida glabrata (n = 3), Candida krusei (n = 2), Candida tropicalis (n = 1) and Candida kefyr (n = 1). Patients with confirmed oral pseudomembranous candidiasis were treated with either fluconazole 200 mg/day or itraconazole 200 mg/day for 2 weeks. Clinical improvement and concomitant negative Candida cultures (mycologic cure) were the criteria determining a response to antifungal treatment. Etest revealed very low voriconazole MICs (0.004-0.125 microg/ml) for all isolates, and fluconazole resistance for eight C. albicans strains (MIC > 64 microg/ml) and for the C. krusei isolates (MIC > 32 microg/ml). The same strains showed itraconazole susceptibility dose dependence (MIC 0.5 microg/ml). Despite the itraconazole susceptible dose dependent MIC readings, all patients with oral pseudomembranous candidiasis caused by these strains responded to antifungal treatment with 200 mg/day itraconazole. Oral mycologic surveillance of patients undergoing radiotherapy for head and neck malignancies and susceptibility testing of isolates may be indicated in cases with mucositis-associated confirmed oral pseudomembranous candidiasis to ensure prompt administration of targeted antifungal treatment. On the basis of the low MIC values found, clinical evaluation of voriconazole is indicated for management of oral pseudomembranous candidiasis refractory to other azoles.

[Histoplasmosis of the oral cavity]

Histoplasmosis is an endemic mycosis. Histoplasma capsulatum, and duboisiï are the pathogenic agents in humans. The disease is reported as endemic in more than 30 countries. Three clinical forms are distinguished; acute, chronic and disseminated. Oral lesions may take on different clinical aspects which are often associated with disseminated histoplasmosis. Disseminated histoplasmosis is frequently diagnosed in immunocompromised hosts. High risk of mortality dictates rapid diagnosis and treatment.

Combined mucormycosis and aspergillosis of the oro-sinonasal region in a patient affected by Castleman disease

One case of aspergillosis and mucormycosis occurring in a patient with stage-IV Castleman disease was investigated. The patient, who had undergone polychemotherapy and was in otherwise good general condition, without lymphadenopathies or imbalance of the immune system, presented with a palatal ulceration that progressively involved the palatal mucosa and bone, the paranasal sinuses and the orbit. Repeated cultural examinations were always negative. He had undergone multiple cytological smears of the inflammatory infiltration and biopsies of both the oral and nasal mucosa, which resulted in extensive necrotic debris and suppurative inflammation, and, on the very last biopsy, fungal hyphae, spores and conidia were also detected. These were large, branching, mostly non-septate hyphae, associated with conidiophores and conidia, the latter appearing dark brown to black in the histological preparations. Following the diagnosis of combined mucormycosis and aspergillosis, the patient underwent prolonged topic and systemic antibiotic treatment that resulted curative. Mucormycosis usually is a fatal complication of head and neck or systemic disorders, leading to severe immune suppression. Nevertheless, early diagnosis may be achieved using a combination of special stains and may lead to effective antibiotic treatment and cure of the patient, even if associated with other opportunistic infections, such as aspergillosis.

Update on diabetes mellitus and related oral diseases

Diabetes mellitus (DM) is a group of complex multisystem metabolic disorders characterized by a relative or absolute insufficiency of insulin secretion and/or concomitant resistance to the metabolic action of insulin on target tissues. The chronic hyperglycaemia of diabetes is associated with long-term systemic dysfunction. The present article summarizes current knowledge of DM and details the oral and dental implications of this common endocrine disorder.

Paracoccidioidomycosis of the mouth: an emerging deep mycosis

Oral fungal infections (mycoses) have come into particular prominence since the advent of infection with Human Immunodeficiency Virus (HIV), and recognition of the Acquired Immune Deficiency Syndrome (AIDS), as well as the phenomenal increase in world travel with increased exposure to infections endemic in the tropics. Paracoccidioidomycosis is a rare mycosis worldwide but common in Brazil and some other areas in Latin America. It can be life-threatening and can manifest with a spectrum of clinical presentations, including frequent oral lesions. This paper reviews the more recent information on Paracoccidioidomycosis, emphasizing those areas most relevant in dental science.

Eradication of invasive mucormycosis--effectiveness of the Echinocandin FK463

BACKGROUND

Invasive rhinocerebral mucormycosis is a rare and often fatal opportunistic fungal infection. It is encountered in immunocompromised hosts exemplified by those with diabetes, human immunodeficiency viruses and particularly haematologic malignancies typically after high-dose chemotherapy and stem cell transplantation. In contrast to the more usual outcome with rapid progression and death. We now describe a successful eradication attributable to the use of a newly available antifungal agent.

SETTING

Haematology department and bone marrow transplantation unit.

MATERIAL AND METHOD

Two patients are contrasted. The first with acute leukaemia developed rapidly progressive facial swelling with mucormycosis proven on biopsy. Treatment over 2 months with maximally tolerated doses of amphotericin failed to halt intracranial extension and death resulted. The second, presented with acute lymphoblastic leukaemia in August 1997, underwent successful autologous bone marrow transplantation in February 1998. Relapse followed in March 1999 and after reinduction and consolidation receive a matched unrelated volunteer allograft in September 1999. A second recurrence was documented in April 2000 and in spite of achieving remission he developed a fever that was managed empirically with intravenous amphotericin and, on discharge, oral itraconazole. Left-sided facial swelling expanded rapidly and biopsy showed extensive invasion of the maxillary sinus with mucormycosis. FK463 was added on 5 June 2000 with gradual reduction in facial pain and within 1 month all clinical signs and resolved. Serial biopsies that included histopathologic investigation and microbiologic cultures confirmed eradication of the invasive mucor. In view of the potential danger of recrudescence this treatment regimen was continued through further chemotherapy and, once again disease-free, a second matched unrelated volunteer allograft took place in August 2000. Full reassessment at the time failed to demonstration any residual fungus. Engraftment was confirmed but neutropenic sepsis resulted in severe inflammatory response syndrome with progression to multiple organ dysfunction to which he succumbed without any evidence of leukaemic or systemic mycosis.

CONCLUSION

Echinocandin FK463 is of documented value in managing invasive candidiasis and aspergillosis. This is believed to be the first case of successful outcome with one of the angiotrophic zygomycetes.

Oral histoplasmosis in Brazil

OBJECTIVE

We report 10 cases of histoplasmosis with oral manifestations seen in a teaching hospital in Brazil.

STUDY DESIGN

This is a retrospective study of the sociodemographic, clinicopathologic, and treatment data of these cases.

RESULTS

Overall, 8 of 10 cases were seropositive for human immunodeficiency virus (HIV), whereas 2 were negative. The predominant oral manifestations found in HIV-seropositive patients were ulcers, oral pain, and odynophagia; both of the HIV-seronegative patients were symptom-free. HIV infection was suspected in 7 cases because of the presence of oral lesions of histoplasmosis. Asthenia, fever, weight loss, lymphadenopathy, and hepatosplenomegaly were found only in HIV-seropositive patients. Radiographs in 3 out of 10 patients suggested pulmonary involvement. Amphotericin B was the antifungal therapy chosen, and clinical remission of oral lesions occurred in an average of 30 days (accumulated doses: 500-1500 mg). Itraconazole was very effective as a follow-up treatment in terms of prevention of recurrence.

CONCLUSION

Histoplasmosis only rarely affects HIV-seronegative patients; however, the possibility of hidden immunodepression should be considered when oral manifestations of histoplasmosis are present.

Paracoccidioidomycosis in an HIV-positive patient: a case report with gingival aspects

Paracoccidioidomycosis is an important deep mycosis, endemic in some areas of the South American countryside, with great incidence in males bearing rural activities, being unusual in urban developed centres. Cell-mediated immunity is the main host defence against the P. brasiliensis, and HIV-positive patients have been increasingly affected by the disease, although only a few reports are available in the literature. We present a case of paracoccidiodomicosis in an HIV-positive female, with unusual clinical history and histopathological aspects.

Oral manifestations of systemic disease

Many systemic diseases have associated oral symptoms. Occasionally, patients with these diseases present with lesions that occur primarily in the mouth. Although few systemic diseases have strictly pathognomonic lesions of the oral mucosa, a careful examination of the oral cavity can often lend important clues to making a diagnosis.