Download - Fungal Infection IIK
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Fungal Infection in the
Oral Cavity
Herlambang Prehananto, drg
Dept. Oral Medicine
FKG Institut Ilmu Kesehatan Kediri
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= MIKOSIS RONGGA MULUT= ORAL MYCOSES
CANDIDOSIS Candida albicansHISTOPLASMOSIS Histoplasma capsulatum
- Histoplasma duboisiiBLASTOMYCOSIS Blastomyces dermatitidis
INFEKSI JAMUR PADA MUKOSA RONGGA MULUT
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CANDIDOSIS
Penyebab : Candida albicans mikroorganisme komensal di tubuh manusia + 50% dari populasi (Individu normal 20-62%).
Sejak tahun 1980, Σ penderita pengidap infeksi kandidiasis ↑ hampir 500%
= candidiasis
= moniliasis
= thrush
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Candida albicans
• Yeast-like cell Blastophore– Kumpulan sel berbentuk bulat / oval
– Ukuran lebar : 2 – 8 μm
panjang : 3 – 14 μm
diameter : 1,5 – 5 μm
• Pseudohyphae / Hyphae– Sel membentuk ekor panjang
pada pembiakan dengan media serum
• Chlamidospora– Dinding sel bulat Ø 8 – 12 μm
– Medium kurang nutrient (corn meal agar)
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Dari golongan Jamur,genus Candida di dalam rongga mulut
paling banyak / sering flora normal
Terdapat 7 spesies :
1. C. albicans
2. C. stelatoidea
3. C. tropicalis
4. C. pseudotropicalis
5. C. krusei
6. C. parapsilosis
7. G. guillermondii
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Faktor predisposisi
Fisik Umur tua, bayi, kehamilan
Trauma lokal Iritasi mukosa, piranti orto/denture
yg tidak baik, OH jelek
Terapi antibiotik Broad spectrum (lokal & sistemik)
Terapi kortikosteroid Topikal, sistemik & inhaler
Malnutrisi Haematinic deficiency, high
carbohydrate diet
Immune defect AIDS
Gangguan endokrin DM, hypothyroidism, Addison’s
disease
Keganasan Leukemia, agranulocytosis
Salivary gland Hyp. Radiasi, Sjogren’s S, xerogenic
drugs
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Pathogenesis
• Change in Candida pathogenity– From commensal to pathogen
• Change in Candida morphology– From budding yeast
(blastospore) to filamentous hyphae
• Producing protein to attack host’s mucosal protein
• Colonization
• Adherence
• Infiltration
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JAMUR
Mikroorganisme KOMENSAL
Patogen / Kepadatan
Infeksi Opportunistik
Faktor predisposisi
atau pencetus
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Oral Candidosis• Acute Pseudomembranous Candidosis
= thrush
• Acute Erythematous (atrophic) Candidosis= antibiotic stomatitis
• Chronic Erythematous (atrophic) Candidosis= denture sore mouth
• Chronic Hyperplastic Candidosis= candidal leukoplakia
• Chronic Mucocutaneous Candidosis
• Candida-associated lesions :– Median rhomboid glossitis– Angular cheilitis
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• Nama lain : thrush
• Sifat : superfisial, & paling sering terjadi
• Banyak ditemukan pada
– Bayi yang baru lahir
– Penderita yang daya tahan tubuhnya
Acute Pseudomembranous Candidosis
Klinis Plak atau bercak putih seperti cotton wool yang dikelilingi
warna kemerahan Lokasi : mukosa bukal (paling sering), mukosa labial, gingiva
dan lidah Dapat dikerok, meninggalkan daerah lecet kemerahan, terasa
perih dan mudah berdarah
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ACUTE PSEUDOMEMBRANEOUS CANDIDOSIS (Trush)
• Terjadi pada bayi & org dewasa
• Gejala klinis :
– plak putih, spt cotton wool
– lunak
– melekat pd muk.mulut
– dapat dikerok meninggalkan perm yg kasar, sakit & b’darah.
– beradang, eritema
– Tdpt pd mukosa bukal, lidah, palatum.
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ACUTE PSEUDOMEMBRANEOUS CANDIDOSIS(Trush)
• Plak putih hifa, yeast, deskuamasi epitel & debris
• Simptom: sakit, rasa terbakar/kering & perubahan rasa
• Penyebab antibiotik yang lama, steroid sistemik, infeksi HIV, serostomia kronis radiasi, kemoterapi/ pengobatan, sindrom Sjogren, & DM
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Acute Erythematous (atrophic) Candidosis
• Nama lain : antibiotic stomatitis
• Kelanjutan dari acute pseudomembranous candidosis
• Berhubungan dengan pengobatan broad-spectrum candidosis
• Menimbulkan antibiotic sore tongue
• Satu-satunya candidosis yang menimbulkan keluhan sakit
Klinis
Bercak merah yang halus pada lidah
Sering disertai angular cheilitis
Selain pada lidah, inflamasi dapat terjadi pada bibir dan mukosa pipi
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(Antibiotic Sore Mouth)
• ok tx antibiotika spektrum luas
• Gx klinis :
– Tdpt pd dorsal lidah bag tengah
– Bercak kemerahan
– Atrofik
– Menetap
– Selalu meberi keluhan sakit
– Kadang tampak adanya inflamasi pada bibir, disertai angular cheilitis
Acute Erythematous (atrophic) Candidosis
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• Bercak eritematus/ merah atrofik & sakit
• Antibiotic sore mouthmulut terbakar, rasa tidak enak/sakit tenggorokan selama/setelah terapi antibiotik spektrum luas
• Sensasi terbakar dengan kehilangan difus papila filiformis dorsal lidah kemerahan & “botak”
Acute Erythematous (atrophic) Candidosis
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• Nama lain : denture stomatitis• Faktor predisposisi : gigi tiruan yang menutupi mukosa
proliferasi C. albicans inflamasi
Klinis• Eritema difus pada palatum atau mukosa penyangga gigi
tiruan• Biasanya tidak terasa sakit• Sering disertai Angular cheilitis• Bila disertai hiperplasi palatal terbentuk lesi halus atau
mungkin timbul permukaan seperti buah beri yang mudah berdarah
Chronic Erythematous (atrophic) Candidosis
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(Denture Sore mouth)
• ok organisme di bwh GT, terutama RA.
• 3 tahap perubahan Mukosa– Hiperaemie sebesar ujung
jarum, di muara kel liur minor palatal
– Eritema difus, disertai pengelupasan epitel palatum / mukosa penyangga GT
– Hiperplasia papiler
• Tidak sakit, sering disertai angular cheilitis
Chronic Erythematous (atrophic) Candidosis
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• Denture stomatitis (denture sore mouth)
• 3 tahap klinis :
• 1. Petekie palatal
• 2. Eritema difus sebagian besar/seluruh
• 3. Granulasi/nodul (hiperplasia papila) area sentral palatum keras & ridge alveolar
Chronic Erythematous (atrophic) Candidosis
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CHRONIC ATHROPIC CANDIDOSISAngular Cheilitis
• Gx klinis– Merah dan pecah2
– Tepi lesi kurang merah dibanding tengahnya
– Keropeng & nodula granulomatosa kecoklatan dpt menyertainya
– Inflamasi sudut mulut, dengan/tanpa fisur dengan simptom rasa sakit dan/atau rasa terbakar
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Median Rhomboid Glossitis
• Atrofi papila simetris, elips/jajaran genjang
• Lokasi : sentral lidah, anterior papila sirkumvalata
• Jika menjadi lebih nodular median rhomboid glositis hiperplastik
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CHRONIC HYPERPLASTIC CANDIDOSIS
• Nama lain : Candidal leukoplakia
• Paling jarang terjadi
Klinis
• Lesi putih cekat
• Tidak dapat dikerok invasi hyphae sampai lebih dalam dari permukaan mukosa atau kulit
• Lokasi tersering : lidah, pipi, bibir
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Chronic Hyperplastic Candidosis
• Etiologi :
– iritasi kronis
– OH ↓
– xerostomia
• Gx klinis :
– Plak putih,Keras,Kasar
– Mukosa bukal kiri / kanan terutama bag anterior, bibir, lidah
– Tidak dapat dikerok
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Kriteria penegakan diagnosis oral candidosisberdasarkan klinis dan laboratoris
• Bercak putih (white plaque) atau eritema yang meluas
• Kultur candida positif
• Terdapat bentuk hyphae pada epitel pada pemeriksaan biopsi
• Perubahan histologik yang khas
• Peningkatan titer antibodi terhadap Candida dalam serum dan saliva
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PENEGAKAN DIAGNOSA
• Bercak putih / eritema yang meluas
• Titer antibodi ↑ thd Candida dlm serum & saliva
• Kultur candida positif
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Pemeriksaan kerokan lesi miselium
Perubahan histologik yang khas
Pemeriksaan biopsi hyphae pada epitel
Penetrasi hifa pada permukaan tapi tidak sampai pada bagian spongiosa
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Swab Smear Oral
Rinse
Biopsy
Pseudome
mbranous + ± + -
Erythema
tous. +±
+ -
Hyperplas
tic± ±
- +
Angular
Cheilitis + + - -
Denture
stomatitis + + + -
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Direct smearSwabbed specimen
smeared onto glass slides
Gram-stained or KOH-stained
Viewed by microscope
Presence of hyphae Oral Candidiasis (+)
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•Culture• Swabbed specimen
streaked onto specific growth medium Sabouraud dextrose agar
• incubated in 37 C 2x24 hours
• Colony growth species identification
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Species Identification #1 Sugar fermentation test
• Specimen incubated in Urea, Lactose, Dextrose, Sucrose, Maltose & Trehalose
• Color change in each sugar type indicates a certain species
C. albicans C. glabrata C. albicans / tropicalis ???
C. albicans / krusei ???
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Species Identification #2 Germ tube test
• Specimen incubated in serum
• Microorganism forming sprout-like appearance = Candida albicans
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Species Identification #3 Chlamydospore test
• Specimen grown on cornmeal agar
• Each species grows in each characterized morphology C. albicans
C. krusei C. glabrata C. tropicalis
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Specific growth medium for
species identification
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Anti Fungal
azole
topical systemic
polyene
topical systemic
clotrimazolecream & troches
miconazolecream
p.o.& i.v.
ketoconazole
fluconazole
voriconazole amphotericin B
not absorbed effectively
nystatin
creams, ointment, supp., susp.,
powder
p.o.
ampho-B
not absorbed
effectively
i.v.
nystatintoo toxic
amphotericin B
high toxicity many SEs
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35
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Localized lesion
Topical7 days
Lesion persistent
Widespread lesion
Topical & systemic7 days
Liver function
test
Lesion persistent
Check for other systemic
predisposing factors
Continue treatment7 days
Switch to more potential systemic
7 days
Lesion reducing
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Prognosis
Before After
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Not a self-limiting disease
Risk of infection spreading along the
gastrointestinal tract
Risk of Candidemia
Oesophageal Candidiasis
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Suggested readings
• Greenberg, et al. 2008. Burket’s Oral Medicine.
• Field, et al. 2005. Tyldesley’s Oral Medicine.
• Scully, et al. 2008. Oral & Maxillofacial Medicine.
• Anaissie, et al. 2009. Clinical Mycology.