The Effect of Treatment of Denture-related Stomatitis on Peripheral T Cells and Monocytes.

PURPOSE: Systemic immune activation has been recently linked to chronic inflammatory disorders of the oral cavity, particularly to periodontitis. The purpose of this study was to determine whether treatment of a fungus-induced oral inflammation, namely denture-related stomatitis (DRS), can affect the activation of the systemic immune response. MATERIALS AND METHODS: Peripheral blood from patients with denture-related stomatitis caused by Candida albicans infection (n = 15) was collected at three time points: before treatment with nystatin, at the end of therapy and 2 months after finishing therapy. Activation of T cells and monocytes was assessed by flow cytometry. RESULTS: The percentages of peripheral lymphocytes, T cells and their subpopulations, as well as monocytes were similar before, immediately following and two months after nystatin treatment. Cells expressing early activation marker CD69 and RANTES C-C chemokine receptor type 5 significantly increased immediately after treatment and returned to baseline levels after two months. Th17 cells, which have been implicated in the pathogenesis of DRS, remained unchanged. Central memory CD4+ subset and intermediate subset of monocytes were lower after therapy and this effect was sustained for two months. CONCLUSION: Treatment of denture-related stomatitis does not seem to affect the general state of the cellular components of the immune system. The results suggest a potential proinflammatory effect of the antifungal agent, nystatin. Although transient and not intense, this effect might be of particular clinical importance, because of relationships between inflammation and certain diseases. Further studies are required to clarify this aspect.

Topical Antimycotics for Oral Candidiasis in Warfarin Users.

Treatment for oral candidiasis in warfarin users may be complicated by drug-drug interactions (DDIs) between warfarin and topically applied antimycotics. However, current knowledge of these putative DDIs is merely based on case series. We therefore performed a cohort cross-over study with the objective to evaluate the potential DDIs between warfarin and miconazole oral gel or nystatin oral solution. The cohort consisted of individuals using warfarin in the period of 1998-2012 (n ≈ 7400). We collected data on cohort members' measurements of the international normalized ratio (INR) from a clinical database, and obtained information on their use of topically applied miconazole and nystatin from a regional prescription register. Potential DDIs were assessed by comparing INR values before and after initiation of an antimycotic drug. Among 17 warfarin users exposed to miconazole oral gel, the mean INR increased from 2.5 (95% CI: 2.1-2.8) to 3.8 (95% CI: 2.8-4.8) after exposure, corresponding to a mean INR increase of 1.4 (95% CI: 0.3-2.4). Among 30 warfarin users exposed to nystatin oral solution, the mean INR was 2.7 (95% CI: 2.3-3.1) before and 2.5 (95% CI: 2.2-2.9) after exposure. In conclusion, we found evidence supporting a clinically relevant drug-drug interaction between warfarin and miconazole oral gel. In contrast, we did not find any indication of an interaction between warfarin and nystatin oral solution. Nystatin rather than miconazole should be preferred when treating warfarin users for oral candidiasis.

Isolation and identification of Candida species in patients with orogastric cancer: susceptibility to antifungal drugs, attributes of virulence in vitro and immune response phenotype.

BACKGROUND: Because of the inherent immunosuppression of cancer patients opportunistic infections by Candida spp, occur frequently. This study aimed to identify Candida species in the oral mucosa of 59 patients with orogastric cancer (OGC) and to analyze the immunological phenotype of these patients. METHODS: The yeasts were identified by MALDI-TOF mass spectrometry (MS). For all isolates, we performed phospholipases and proteinases assays, in vitro adherence to buccal epithelial cells (BEC), minimum inhibitory concentration of antifungal drugs and determined the cytokine profile by Cytometric Bead Array flow citometry assay. RESULTS: C. albicans was the most prevalent species in OGC patients (51.6 %) and control group (66.7 %). Candida spp. strains isolated from OGC patients exhibited better adherence to BEC (p = 0.05) than did the control group. Phospholipases production by Candida strains from OGC patients was lower (51.6 %) than in the control group (61.9 %). Proteinases were detected in 41.9 % and 4.8 % of the yeasts from OGC patients and control group, respectively. Significant differences were found in the serum of OGC patients compared to the control group for IL-2, IL-10, TNF-α, IFN-γ and IL-17. CONCLUSIONS: The results of this work suggest increased virulence of yeasts isolated from OGC patients and, that this may interfere with the immune phenotype.

Simultaneous detection of four common oral Candida species from blood samples by the fluorescence polarization assay.

The genus Candida is both the commensal microbe and the opportunistic pathogen, containing approximately 200 species inhabiting in oral cavity of 53 % of the general population. Candida species can cause the diseases from local mucosal infections to systemic mycoses, even life-threatening infections in immunocompromised individuals. The timely differentiation of Candida species is important for the guidance of clinical medication. Four common Candida species in Chinese population (Candida albicans, Candida tropicalis, Candida glabrata, Candida krusei) were chosen as the targets to develop the rapid screening method in this work. Combined with amplification by asymmetric PCR, this parallel fluorescence polarization (FP) immunoassay is carried out in homogeneous solution phase. The limit of detection of the assay was shown to be 50 copies/mL in blood samples. The evaluation in multicenter manner showed excellent reproducibility and stability. The comparison between DNA sequencing and the FP immunoassay indicated that there was no significant difference between these methods. This molecular strategy-based method is simple, rapid, and feasible for identifying common Candida species and thereby holding great potential in the application of clinical laboratories.

Factors associated with esophageal candidiasis and its endoscopic severity in the era of antiretroviral therapy.

BACKGROUND: Candidia esophagitis (CE) is an AIDS-defining condition, usually occurring in individuals with low CD4 counts of <200 cells/µL. Endoscopy is a valuable definitive diagnostic method for CE but may not be indicated for asymptomatic patients or for those with high CD4 counts or without oral candidiasis. This study assessed such patients to clarify the factors associated with CE and its severity on endoscopy in the highly active antiretroviral therapy (HAART) era. METHODOLOGY PRINCIPAL FINDINGS: A total of 733 HIV-infected patients who underwent upper gastrointestinal (GI) endoscopy were analyzed. Sexual behavior, CD4(+) count, HIV-RNA viral load (VL), history of HAART, GI symptoms, GI diseases, and oral candidiasis were assessed. Endoscopic severity of CE was classified as mild (Kodsi's grade I/II) or severe (grade III/IV). Of the 733 subjects, 62 (8.46%) were diagnosed with CE (mild, n = 33; severe, n = 29). Of them, 56.5% (35/62) had no GI symptoms, 30.6% (19/62) had CD4 + ≥200 cells/µL, and 55.3% (21/38) had no oral candidiasis. Univariate analysis found lower CD4+ counts, higher HIV VL, and no history of HAART to be significantly associated with CE. With lower CD4(+) counts and higher HIV VL, CE occurrence increased significantly (P<0.01 for trend in odds). Multivariate analysis showed low CD4+ counts and high HIV VL to be independently associated with CE. Of the severe CE patients, 55.2% (16/29) had no GI symptoms and 44.4% (8/18) had no oral candidiasis. Median CD4(+) counts in severe cases were significantly lower than in mild cases (27 vs. 80; P = 0.04). CONCLUSIONS: Low CD4+ counts and high HIV VL were found to be factors associated with CE, and advanced immunosuppression was associated with the development of severity. Endoscopy is useful as it can detect CE, even severe CE, in patients without GI symptoms, those with high CD4 counts, and those without oral candidiasis.

Vitamin D status and its association with morbidity including wasting and opportunistic illnesses in HIV-infected women in Tanzania.

Vitamin D has a potential role in preventing HIV-related complications, based on its extensive involvement in immune and metabolic function, including preventing osteoporosis and premature cardiovascular disease. However, this association has not been examined in large studies or in resource-limited settings. Vitamin D levels were assessed in 884 HIV-infected pregnant women at enrollment in a trial of multivitamin supplementation (excluding vitamin D) in Tanzania. Information on HIV related complications was recorded during follow-up (median, 70 months). Proportional hazards models and generalized estimating equations were used to assess the relationship of vitamin D status with these outcomes. Women with low vitamin D status (serum 25-hydroxyvitamin D<32 ng/mL) had 43% higher risk of reaching a body mass index (BMI) less than 18 kg/m(2) during the first 2 years of follow-up, compared to women with adequate vitamin D levels (hazard ratio [HR]: 1.43; 95% confidence intervals: [1.03-1.99]). The relationship between continuous vitamin D levels and risk of BMI less than 18 kg/m(2) during follow-up was inverse and linear (p=0.03). Women with low vitamin D levels had significantly higher incidence of acute upper respiratory infections (HR: 1.27 [1.04-1.54]) and thrush (HR: 2.74 [1.29-5.83]) diagnosed during the first 2 years of follow-up. Low vitamin D status was a significant risk factor for wasting and HIV-related complications such as thrush during follow-up in this prospective cohort in Tanzania. If these protective associations are confirmed in randomized trials, vitamin D supplementation could represent a simple and inexpensive method to improve health and quality of life of HIV-infected patients, particularly in resource-limited settings.

Oral manifestations of HIV infection and their correlation with CD4 count.

Human Immunodeficiency Virus (HIV)-related oral lesions can be used as markers of the immune status. The present cross-sectional study was conducted to identify the oral manifestations in HIV-infected individuals and their association with reduced Cluster of Differentiation 4 (CD4) count. The study population included known HIV-positive patients. A detailed case history of 399 HIV-positive patients was obtained and general examination was carried out. Diagnosis of oral lesions was done based on presumptive criteria of EEC Clearinghouse, 1993. The CD4 count was determined in 369 patients and correlated with oral manifestations. The prevalence of oral lesions was found to be 76.70% (n = 306). Oral candidiasis (157 (39.3%)) was the most common oral lesion associated with HIV infection. Amongst various forms of oral candidiasis, erythematous candidiasis (122 (39.3%)) outnumbered the other forms. The mean CD4 count of patients with oral lesions (207 cells/mm(3)) was less than in patients without oral lesions (291 cells/mm(3)) (P = 0.002). Oral candidiasis was found to be significantly correlated to a reduced CD4 cell count below 200 cells/mm(3) (P = 0.000; Odds ratio = 3.1; 95% Confidence interval 1.9-4.9) with good sensitivity, best specificity and positive predictive value. Oral manifestations may be used as an alternative to CD4 count at field-based settings to diagnose the immune compromised status of HIV-infected individuals.

Candida albicans HWP1 gene expression and host antibody responses in colonization and disease.

In vivo expression of the developmentally regulated Candida albicans hyphal wall protein 1 (HWP1) gene was analysed in human subjects who were culture positive for C. albicans and had oral symptoms (n=40) or were asymptomatic (n=29), or had vaginal symptoms (n=40) or were asymptomatic (n=29). HWP1 mRNA was present regardless of symptoms, implicating hyphal and possibly pseudohyphal forms in mucosal carriage as well as disease. As expected, in control subjects without oral symptoms (n=10) and without vaginal symptoms (n=10) who were culture negative in oral and vaginal samples, HWP1 mRNA was not detected. However, exposure to Hwp1 in healthy culture-negative controls, as well as in oral candidiasis and asymptomatic mucosal infections, was shown by the existence of local salivary and systemic adaptive antibody responses to Hwp1. The results are consistent with a role for Hwp1 in gastrointestinal colonization as well as in mucosal symptomatic and asymptomatic infections. Overall, Hwp1 and hyphal growth forms appear to be important factors in benign and invasive interactions of C. albicans with human hosts.

Diabetes mellitus as a contributory factor in oral candidosis.

It has been reported that poor glycaemic control predisposes to oral candidal infection in diabetic patients. For instance, the carriage of Candida species and the density of candidal growth in the oral cavity is frequently claimed to be increased in patients with diabetes mellitus. However, the validity of these observations remains controversial. Hence, we review and discuss here the clinical data in the literature on the relationship between diabetes and oral candidal carriage and infection, and possible mechanisms associated with its pathogenicity.

Effect of orally administered bovine lactoferrin on the immune response in the oral candidiasis murine model.

Therapeutic activity against oral candidiasis of orally administered bovine lactoferrin (LF), a multifunctional milk protein, was shown in a previous report using an immunosuppressed murine model. In the present study, the influence of orally administered LF on immune responses relevant to this therapeutic effect was examined. Because mice were immunosuppressed with prednisolone 1 day before and 3 days after the infection with Candida, the numbers of peripheral blood leukocytes (PBL) and cervical lymph node (CLN) cells were reduced. LF feeding prevented the reduction in the numbers of PBL on day 1 and CLN cells on days 1, 5 and 6 in the Candida-infected mice. The number of CLN cells of individual mice on days 5 and 6 was inversely correlated with the Candida c.f.u. in the oral cavity. Increased production of IFN-gamma and TNF-alpha by CLN cells stimulated with heat-killed Candida albicans on day 6 was observed in LF-treated mice compared with non-treated mice. Concanavalin A (ConA)-stimulated CLN cells from LF-treated mice also showed a significant increase in the production of IFN-gamma and IL12 on day 5 and a tendency for increased production of IFN-gamma and TNF-alpha on day 6. The levels of cytokine production by ConA-stimulated CLN cells on day 6 were inversely correlated with the Candida c.f.u. in the oral cavity. In conclusion, the alleviation of oral candidiasis by LF feeding in this model may correlate with the enhancement of the number of leukocytes and their cytokine responses in regional lymph nodes against Candida infection.

Chronic hyperplastic candidosis/candidiasis (candidal leukoplakia).

Chronic hyperplastic candidosis/candidiasis (CHC; syn. candidal leukoplakia) is a variant of oral candidosis that typically presents as a white patch on the commissures of the oral mucosa. The major etiologic agent of the disease is the oral fungal pathogen Candida predominantly belonging to Candida albicans, although other systemic co-factors, such as vitamin deficiency and generalized immune suppression, may play a contributory role. Clinically, the lesions are symptomless and regress after appropriate antifungal therapy and correction of underlying nutritional or other deficiencies. If the lesions are untreated, a minor proportion may demonstrate dysplasia and develop into carcinomas. This review outlines the demographic features, etiopathogenesis, immunological features, histopathology, and the role of Candida in the disease process. In the final part of the review, newer molecular biological aspects of the disease are considered together with the management protocols that are currently available, and directions for future research.

Oral candidosis in patients with removable dentures.

The prevalence of Candida species with and without denture-related stomatitis were evaluated in 167 Jordanian patients. The study revealed that 47 (28%) of the patients with denture-related stomatitis were colonized with Candida species (clinical group). Candida albicans was responsible for most cases of denture-related stomatitis (72%), and it was the only species capable of secreting aspartic proteinases. The study also indicated that candidal colonization was not influenced by predisposing haematological deficiencies, as both the clinical and control patient groups showed comparable haematological parameters and the differences were not significant (P > 0.05). All Candida species isolates were 100% susceptible to amphotericin B, while these isolates were less susceptible (25-75%) to fluconazole.

Nonspecific secretory immunity in HIV-infected patients with oral candidiasis.

Buccal and digestive tract opportunistic infections occur frequently in patients infected by HIV. In this study, we measured lysozyme (Lz), lactoferrin (Lf), total IgA (T-IgA), and secretory IgA (S-IgA) levels to investigate nonspecific secretory immunity in HIV-infected patients with oral candidiasis. Serum, saliva, and stool samples were analyzed by time-resolved immunofluorometric assay for Lz and Lf levels and by enzyme-linked immunosorbent assay for T-IgA and S-IgA levels. Mean salivary Lf and T-IgA levels (66.50 mg/L and 0.10 g/L, respectively) and mean fecal Lf, T-IgA, and S-IgA outputs (0.87, 54.0, and 43.6 mg/d, respectively) were significantly higher in HIV-infected patients with oropharyngeal candidiasis than in HIV-infected patients without oropharyngeal candidiasis and healthy subjects. There was a modification in the molecular form rate, with a high increase in S-IgA and monomeric IgA transudation from the plasmatic compartment into salivary and digestive fluids and an increase in salivary Lf local synthesis by polymorphonuclear neutrophils. HIV infection appears to be associated with dysregulation of some of the nonspecific immune factors at the mucosal surface. Despite high saliva concentrations and high intestinal output, innate immunity was not able to stop yeast expansion in HIV-infected patients.

Prognostic factors for the clinical effectiveness of fluconazole in the treatment of oral candidiasis in HIV-1-infected individuals.

OBJECTIVE: To identify prognostic factors for the clinical effectiveness of fluconazole in HIV-1-infected patients with oropharyngeal candidiasis. DESIGN AND SETTING: The study was designed as a prospective, open label, non-comparative, dose escalating, single centre trial. PATIENTS AND METHODS: Thirty-four HIV-1-infected patients with oropharyngeal Candida infection were treated with 50 or 100mg fluconazoleday(-1), depending on the clinical manifestation (erythematous or pseudomembranous). The dose was doubled weekly until clinical cure. The predictive value of potential prognostic factors for the duration of treatment and cumulative fluconazole dose until cure was studied: exposure to fluconazole, previous use of fluconazole, the use of antiretroviral drugs, the CD4(+) cell count, erythematous or pseudomembranous appearance, the minimum inhibitory concentration (MIC) for fluconazole of the isolated Candida strain, and xerostomia. RESULTS: Twenty-eight patients (with 30 episodes of oropharyngeal candidiasis) were evaluated. Twenty-five episodes were cured within 1-week of treatment, the remaining five episodes were cured within 2 weeks. No predictive value for any of the studied factors on the duration of fluconazole treatment or the cumulative fluconazole dose until cure was demonstrated. CONCLUSION: Because of the high susceptibility to fluconazole and the positive clinical outcome, the variation in outcome measurements was too modest to establish a significant relationship between any of the investigated potentially prognostic factors and the cumulative fluconazole dose and the duration of treatment to reach cure. On the other hand it can be concluded, that fluconazole is very effective in patients with advanced HIV infection and low CD4(+) cell counts, even if they are not using antiretroviral agents.

Serum and salivary antibodies to a mycobacterial 65-kDa stress protein are elevated in HIV-positive patients and modified by oral candidiasis.

Serum immunoglobulin G (IgG) and IgA, and salivary IgA antibodies to a mycobacterial stress protein (mSP65) were determined in human immunodeficiency virus (HIV)-positive patients, acquired immunodeficiency syndrome (AIDS) patients and HIV-negative controls with or without oral candidiasis. Serum IgG antibodies were elevated in patients with HIV infection and AIDS and especially in subjects with candidiasis compared with controls (P < 0.02, P < 0.005). This was not apparent with serum IgA. In the absence of candidiasis, salivary IgA antibodies were elevated in HIV-positive patients compared with AIDS (P < 0.005) patients and healthy controls (P = 0.001). The relative avidity of serum IgG antibodies to mSP65 in controls with candidiasis was lower than healthy controls (P < 0.0001). In saliva there was a decrease in the relative avidity of IgA antibodies in AIDS patients with candidiasis compared with HIV patients (P < 0.03). In patients without candidiasis, the relative avidity was higher in HIV patients than healthy controls (P = 0.02). The results suggest that HIV infection leads to raised serum and salivary antibodies to heat shock proteins. Concurrent Candida infection may modify both the titer and relative avidity differently for serum and saliva.

Synergistic immunosuppression by candida in HIV infection: a cytokine based analysis.

Candida is a common opportunistic pathogen in HIV infection and is regarded a signal infection for progression to AIDS. Cytokine imbalances between Th1/Th2 groups have been described in both candida and HIV infections. A study was undertaken to assess the role of candida in furthering immunosuppression in HIV infection based on cytokine levels and CD4 cell counts. 30 Indian subjects were enrolled; 10 HIV positive patients with and 10 without mucosal candidiasis and 10 age matched controls. Th1 cytokines; interleukin (IL) 2, IL 12 and interferon (IFN) gamma, Th2 cytokines; IL 4, IL 6, IL 10 and tumor necrosis factor (TNF) alpha with CD 4 cell counts were estimated using ELISA in all subjects. CD4 cell counts were reduced in both patient groups as compared to controls; significantly more in patients with both HIV and candida infections. There was a decrease in Th1 cytokine levels in all patients; lower levels of Th1 cytokines were seen in patients with both infections. Among the Th2 cytokines, there was a significant increase in the levels of IL 6, IL 10 and TNF alpha in both patient groups; IL 10 and TNF alpha values were significantly raised in patients with dual HIV and candida infections as compared to the other patients. There was no difference in IL 4 values across the subject groups. A positive correlation between CD4 cell counts and Th1 cytokine levels and a negative correlation with Th2 cytokines were noted; these were stronger in patients with both HIV and candidiasis. Thus, there was a Th1/Th2 cytokine imbalance with CD4 cell count reduction in all HIV infected patients, which was more pronounced in patients with both infections. It can be concluded that, owing to the depressed CD4 cell count and Th1 response and increased Th2 cytokines in patients with both candidiasis and HIV as compared to patients with only HIV candidiasis may have a synergistic immunosuppressive effect with HIV in patients with dual infections.

Association of HIV viral load with oral diseases.

OBJECTIVE: The measurement of HIV viral load as a predictor of disease progression has revolutionized the medical management of HIV patients. In this study, oral diseases as measured by DMFT (decayed, missing and filled teeth), periodontal assessment and oral Candidacolonization, were related to HIV viral load. Also correlated was HIV status assessments, including CD4+ count, a history of intravenous drug abuse (IVDA) and the use of protease inhibitor drugs. MATERIALS AND METHODS: Oral and periodontal examination, dental radiographs, and tongue swab for fungal culture was accomplished over a 2-month period on 39 HIV positive patients attending the University of Maryland Dental School. Twenty-eight (71. 8%) of these patients had a history of IVDA. Viral load was measured by a quantitative RT-PCR. RESULTS: Among the patients with high viral load (>10 000 copies ml-1), 92.3% were found to have a history of IVDA. Also, patients with high viral load demonstrated average CD4+ counts of 136 mm-3 while moderate viral load (400-10 000 copies ml-1) corresponded to average counts of 271 mm-3. Periodontal pocket depths (PPD) of >5 mm at a minimum of two oral sites were found in 76.9% of the patients with high viral load. Among the high viral load patients, 69.2% had DMFT >20, 69.2% were culture positive for Candida and 81.5% of patients on protease inhibitors demonstrated moderate or low viral loads. CONCLUSION: These data demonstrated that elevated viral load levels correlate well with oral disease prevalence in this predominantly IVDA population of HIV-infected dental patients.

Fungi of Candida species in the pharynx and some parameters of humoral and cellular immunity in patients.

BACKGROUND: The pharynx is one of the open spaces where fungi can settle easily. The purpose of the investigation was to estimate an overall prevalence of fungal colonization and some parameters of humoral and cell immunity. METHODS: The study consisted of 167 patients, from whom swabs of the posterior and lateral part of the pharynx were taken for mycological examinations, during which tests based on morphological and biochemical (zymogram, auxanogram) characteristics were used. In all cases, the leukocyte count, overall protein level, and protein individual fractions were determined. Also determined were the levels of IgA, IgM and IgG immunoglobulin in blood serum, and IgA immunoglobulin (S-IgA) in saliva. At the same time, blastic transformation test and rosette tests: E (ER) to determine lymphocytes T count, as well as EA (EAR) and EAC (EACR) to detect lymphocytes B, were performed. RESULTS: Fungal infection was found in 2/3 of patients. Fungi were classified as belonging to six species of Candida, which are considered to be important etiological factors of mycoses; the most common fungus was Candida albicans (in 86 cases). All cases of candidosis showed a decreased count of lymphocytes T, with their function deficient, and most of them a low S-IgA level in saliva (over three times lower than the norm) and high mean values for sedimentation rate. CONCLUSIONS: In patients in our study the IgA level in serum remained within normal limits, yet the ratio fo this fraction to other immunoglobulins deviated from that in healthy individuals.