4.08 Oral Candidiasis (Thrush)
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agk's Library of Common Simple Emergencies

Presentation
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An infant (usually with a concurrent diaper 
rash) will have white patches in his mouth, or 
an older patient (usually with poor oral 
hygiene, diabetes, a hematologic malignacy, 
some immunodeficiency or on antibiotic, 
cytotoxic or steroid therapy) will complain of 
a sore mouth and sensitivity to foods that are 
spicy or acidic. On physical examination, there 
are painless white patches in the mouth and and 
on the tongue which wipe off easily with a 
swab, leaving an erythematous base that may 
bleed. There may be intense dark red 
inflammation throughout the oral cavity.

What to do:
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- If there is any doubt about the etiology, 
   onfirm the diagnosis by smearing the 
   exudate, Gram staining, and examining under 
   a microscope for large, gram-positive 
   pseudohyphae and spores. A fungal culture 
   may also confirm the diagnosis.
- For topical treatment, prescribe an oral 
   suspension of nystatin 200,000 units for 
   infants and 400,000-600,000 u for children 
   and adults, gargled and swished in the mouth 
   as long as possible before swallowing, four 
   times a day, for at least two days beyond 
   resolution of symptoms. Nystatin is also 
   avilable in pastilles of 200,000 u: one or 
   two can be dissolved in the mouth 4-5 times 
   daily. Alternatively, prescribe clotrimazole 
   in 10mg troches to be dissolved slowly in 
   the mouth 5 times a day for 7-14 days.
- For adults, fluconazole 200mg once, then 
   100mg qd po x7-14d may be a better regimen. 
   Sometimes a single oral dose is effective, 
   but the longer course decreases the risk of 
   relapse.
- Look elsewhere for Candida: esophagitis, 
   intertrigo, vaginitis, diaper rash. All 
   should respond to topical treatment with 
   topical nystatin or clotrimazole.

Discussion
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In the healthy newborn, thrush is a self- 
limited infection, but it should be treated to 
avoid feeding problems. In adults, oral 
candidiasis is found in a variety of acute and 
chronic forms. Localized erythema and erosions 
with minimal white exudate may be caused by 
candidal colonies beneath dentures and is 
commonly called "denture sore mouth." 
Maintenance prophylaxis may be prequired in 
patients with AIDS. Nystatin suspension has a 
high sugar content.

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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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