Presence of Incipient Fungal Infection in Atypical Squamous Lesions of the Lip.

ABSTRACT: Epidermal barrier disruption caused by atypical squamous proliferations of the lip (SOL) creates an ideal environment for fungal growth. Histologic features of SOL include parakeratosis overlying partial- or full-thickness keratinocyte atypia with or without invasion of the dermis, dermal solar elastosis, and scattered inflammatory cells which are predominantly lymphocytes. Histologic features of SOL with fungal superinfections overlap those seen in primary fungal cheilitis with reactive atypia, creating a diagnostic challenge. One-hundred seventy SOL cases were examined for the presence of fungal elements, and the histological features associated with superinfection were identified. Cases diagnosed as actinic cheilitis with fungal superinfection were carefully examined to rule out the possibility of misdiagnosed primary fungal cheilitis with reactive atypia. Histopathological characteristics commonly present with fungal hyphae included intraepidermal or intradermal neutrophils, bacterial colonies, and erosion or ulceration. Medical record review of those patients treated conservatively with topical antifungals revealed persistent clinical neoplasm and histological evidence of residual SOL on repeat biopsy. Thus, when biopsies exhibit histological overlap between these 2 entities, clinicians should keep a high index of suspicion for underlying SOL and carefully follow these patients if conservative antifungal therapy is initially trialed.

Cheilitis associated with sensitization to penicillium notatum in a clarinetist

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Angular cheilitis: A clinical and microbial study.

AIMS: The aim of the present study was to examine clinical types and microbiological flora isolated from angular chelitis. MATERIALS AND METHODS: An eroded and/or erythematous, with or without fissure formation, nonvesicular lesion radiating from the angle of the mouth was considered to be angular chelitis. A sample of the present study comprised of 40 patients having unilateral or bilateral angular chelitis and 20 healthy individuals without any lip lesions. Clinical examination was done. In both test and control groups, the sample for microbial analysis was obtained from angle of the mouth. RESULTS: Clinically, four types of angular cheilitis lesions were found, Type I, II, III, and IV. The most common type of lesion found was Type I lesion. Microorganisms isolated from the lesion were Staphylococcus aureus, Candida or Streptococci in 33 (82.5%) cases either in pure culture or mixed culture. Among these 33 patients, S. aureus was found in 25 (75.5%) cases, Candida in 16 (48.4%) cases, and Streptococci in 5 (13.5%) cases, respectively. Out of 16 cases positive for Candida, in 13 cases further isolation of Candida was possible. Candida albicans was found in 6 cases and Candida stellastodia in 7 cases. In majority of the dentulous and edentulous patients, S. aureus showed profuse growth. CONCLUSIONS: There are microorganisms associated with angular cheilitis.

[Tuberculous cheilitis revealing pulmonary tuberculosis]. / Chéilite tuberculeuse révélant une tuberculose pulmonaire.

Tuberculosis of the oral cavity is rare. It is associated with clinical polymorphism and poses above all a diagnostic problem. We report the case of a 42-year-old male patient with tubercular cheilitis. This study aims to focus attention on tuberculosis that can be detected exceptionally in specific locations, such as the oral lip.

Candida infection in oral leukoplakia: an unperceived public health problem.

OBJECTIVES: The study aimed to determine the proportion, known risk factors and etiology for Candida infection in leukoplakia lesions among patients with oral leukoplakia attending the Oral and Maxillofacial Clinic at a Tertiary Care Hospital in Sri Lanka. MATERIALS AND METHODS: Eighty clinically suspected oral leukoplakia patients were included. Two oral swabs each, from leukoplakia patients: one swab from the lesion and the other one from the contralateral unaffected corresponding area (as a control) were collected. Direct microscopy and culture followed by colony count and phenotypic identification were performed to identify pathogenic Candida species. RESULTS: Candida infection was seen in 47% of patients with oral leukoplakia. Candida albicans (94.7%) was the most common Candida species followed by Candida tropicalis (5.3%). Majority of Candida-infected lesions were seen in the buccal mucosa region. Alteration of taste (p = 0.021), having other oral lesions (p = 0.008), angular cheilitis (p = 0.024) and periodontitis (p = 0.041) showed a significant association with Candida-associated leukoplakia. Increasing age showed a significant tendency for Candida infection (p = 0.020). Smoking (p = 0.026) and betel-quid chewing (p = 0.006) were also found to be significantly associated, although alcohol consumption alone did not show a significant association. Oral leukoplakia patients who had all three habits: alcohol consumption, smoking and betel-quid chewing had a significant association with Candida infection (p = 0.004). CONCLUSIONS: Patients who had a combination of risk factors: smoking, betel-quid chewing and alcohol consumption were seen to have a significant association with Candida infection. Further betel-quid chewing alone and smoking singly was also significantly associated with Candida infection in oral leukoplakia.

Oral candidiasis.

Oral candidiasis (OC) is a common fungal disease encountered in dermatology, most commonly caused by an overgrowth of Candida albicans in the mouth. Although thrush is a well-recognized presentation of OC, it behooves clinicians to be aware of the many other presentations of this disease and how to accurately diagnose and manage these cases. The clinical presentations of OC can be broadly classified as white or erythematous candidiasis, with various subtypes in each category. The treatments include appropriate oral hygiene, topical agents, and systemic medications. This review focuses on the various clinical presentations of OC and treatment options.

Clinical features, cytology and bacterial culture results in dogs with and without cheilitis and comparison of three sampling techniques.

BACKGROUND: Cheilitis is a common presentation in dogs associated with a variety of skin diseases and often complicated by microbial infections. OBJECTIVES: To describe and compare clinical and cytological features and bacterial culture results from the lower lips of dogs with cheilitis (as compared to healthy controls), and to evaluate three cytology sampling techniques for their abilities to differentiate between the groups. ANIMALS: Fifty six dogs with cheilitis and 54 controls. METHODS: Anatomy and clinical signs of the lower lip were recorded. Cytology samples taken by tape strip, direct impression and swabs rolled over skin were scored semiquantitatively for microorganisms, inflammatory cells and keratinocytes. Cytology scores were correlated with semiquantitative bacterial culture scores. RESULTS: Pure breeds, frequency of lip folds and all cytology scores except keratinocytes were higher in dogs with cheilitis than in controls, but a substantial overlap was seen in all microorganisms between the groups. Hypersensitivity disorders were diagnosed in 40 of 56 dogs with cheilitis. The tape strip technique yielded the greatest differences between groups. Bacterial growth was reported in 100% of dogs with cheilitis and in 93% of the controls. Pathogens such as Staphylococcus pseudintermedius, Escherichia coli and Pseudomonas spp were found more frequently in dogs with cheilitis. Cytology and bacterial culture were poorly correlated. CONCLUSION: Cheilitis was associated with primary hypersensitivity disorders and the presence of a lip fold was a predisposing factor. Results of aerobic culture were similar to prior studies on pyoderma of other body sites, except for higher rates of Pseudomonas spp. isolation.

Methicillin-resistant Staphylococcus Aureus Lip Infection Mimicking Angioedema.

BACKGROUND: It is rare for angioedema to be misidentified by the experienced clinician or for it to mimic another disease process. As an Emergency Physician, it is important to recognize and treat angioedema immediately. Of equal importance is the recognition and initiation of treatment of facial cellulitis. A case report follows that illustrates methicillin-resistant Staphylococcus aureus (MRSA) lip infection mimicking angioedema. CASE REPORT: Here, we describe a case of a 21-year-old man who presented with a swollen lower lip, initially diagnosed as angioedema. Further investigation revealed the cause of his lip swelling was actually a MRSA abscess and surrounding cellulitis, an unusual presentation for lip infection, which we discuss below. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Misidentifying MRSA lip infection for angioedema, with a delay in proper treatment, could result in serious morbidity or mortality.

The role of antifungal and antiviral agents in primary dental care.

In comparison to the range of antibiotics used in medicine, the spectrum of antifungal and antiviral drugs used in primary dental care is relatively limited. In practical terms, there are only three antifungal agents and two antiviral agents that have a role. This paper will describe the clinical presentation of orofacial candidal and viral infections and the use of antimicrobial drugs in their management.

[Bacterial lip abscess in an immunocompetent patient]. / Absceso bacteriano labial en paciente inmunocompetente.

Lip abscesses are a potentially serious condition rarely reported in the medical literature. This disease requires prompt diagnosis and treatment with hospitalization, intravenous antibiotics, and urgent surgical drainage. Clinical knowledge of this condition is essential to guide the differential diagnosis and correctly adapt the etiological treatment. The presence of necrotic and cavitated lesions requires ruling out immunosupression or methicillin-resistant agent. We report a necrotic and cavitated bacterial lip abscess caused by methicillin-sensitive Staphylococcus aureus in an immunocompetent male.

Angular cheilitis, part 1: local etiologies.

Angular cheilitis (AC) is a common condition characterized by erythema, moist maceration, ulceration, and crusting at the corners of the mouth. This article focuses on the common local factors that act alone and in combination to produce AC. These factors are categorized as irritant, allergic, and infectious causes. Identifying the underlying etiology of AC is a critical step in developing an effective treatment plan for this condition.

Oral candidiasis and angular cheilitis.

Candidiasis, an often encountered oral disease, has been increasing in frequency. Most commonly caused by the overgrowth of Candida albicans, oral candidiasis can be divided into several categories including acute and chronic forms, and angular cheilitis. Risk factors for the development of oral candidiasis include immunosuppression, wearing of dentures, pharmacotherapeutics, smoking, infancy and old age, endocrine dysfunction, and decreased salivation. Oral candidiasis may be asymptomatic. More frequently, however, it is physically uncomfortable, and the patient may complain of burning mouth, dysgeusia, dysphagia, anorexia, and weight loss, leading to nutritional deficiency and impaired quality of life. A plethora of antifungal treatments are available. The overall prognosis of oral candidiasis is good, and rarely is the condition life threatening with invasive or recalcitrant disease.

Oral fungal infections: an update for the general practitioner.

Oral candidosis is the most common fungal infection encountered in general dental practice. It manifests in a variety of clinical presentations which may mimic more sinister diseases, and can occasionally be refractory to treatment requiring the attention of an oral medicine specialist. Management of oral candidosis should always include a thorough investigation of underlying predisposing conditions, as the disease often presents when the patient is systemically compromised. This update highlights the pathogenesis, clinical presentation, and management strategies of oral Candidal lesions commonly encountered in dental practice.

[Baker Rosenbach erysipeloid appearing as a granulomatous cheilitis]. / Erysipéloïde de Baker-Rosenbach prenant l'aspect d'une chéilite granulomateuse.

BACKGROUND: Baker-Rosenbach's erysipeloid is a skin infection caused by Erysipelothrix rhusiopathiae. It occurs essentially in humans exposed to animals colonized with this germ such as swine. The typical skin lesion, an erythematous macule generally localized to inoculation site, frequently in the extremities, quickly resolves spontaneously. The lips are an atypical site of this infection. We describe a case of chronic granulomatosis cheilitis in a farmer caused by E. rhusiopathiae. CASE REPORT: A 40-year-old farmer, a wild-boar hunter and chronic smoker with no history of tuberculosis, injury or insect bites, presented at our dermatology unit with ulcerative macrocheilitis of the lower lip ongoing for 1 year. Its surface was purulent. A biopsy specimen showed non-caseating epithelioid granulomas. Laboratory and radiological screening for tuberculosis, sarcoidosis and Crohn's disease, and parasitological examination for Leishmaniasis proved negative. Bacteriological examination identified E. rhusiopathiae and labial Baker-Rosenbach's erysipeloid was diagnosed. The lesion healed after 15 days of treatment with parenteral penicillin G (12m IU/d), totally disappearing after 3 months. DISCUSSION: Swine erysipelas usually occurs in man as Baker-Rosenbach's erysipeloid. This localized form of infection with E. rhusiopathiae is the most frequent and the lesion typically observed is a violaceous plaque, less inflammatory with induration; spontaneous regression occurs after a mean 3 months. To our knowledge, this case is the first report of ulceration associated with macrocheilitis. Histologically, the granuloma directed our investigation towards the principal aetiologies of granulomatosis cheilitis, such as tuberculosis considering the epidemiological context, sarcoidosis or Crohn's disease. The diagnosis of erysipeloid was supported by epidemiological evidence (occupational exposure), isolation of the germ at the lesion and its regression on treatment with penicillin G. CONCLUSION: Diagnosis of E. rhusiopathiae infection was confirmed by bacteriology. However, the hypothesis concerning the pathogenesis of its chronic course in our patient remains a subject of discussion.

The Oral HIV/AIDS Research Alliance: updated case definitions of oral disease endpoints.

The Oral HIV/AIDS Research Alliance (OHARA) is part of the AIDS Clinical Trials Group (ACTG), the largest HIV clinical trials organization in the world. Its main objective is to investigate oral complications associated with HIV/AIDS as the epidemic is evolving, in particular, the effects of antiretrovirals on oral mucosal lesion development and associated fungal and viral pathogens. The OHARA infrastructure comprises: the Epidemiologic Research Unit (at the University of California San Francisco), the Medical Mycology Unit (at Case Western Reserve University) and the Virology/Specimen Banking Unit (at the University of North Carolina). The team includes dentists, physicians, virologists, mycologists, immunologists, epidemiologists and statisticians. Observational studies and clinical trials are being implemented at ACTG-affiliated sites in the US and resource-poor countries. Many studies have shared end-points, which include oral diseases known to be associated with HIV/AIDS measured by trained and calibrated ACTG study nurses. In preparation for future protocols, we have updated existing diagnostic criteria of the oral manifestations of HIV published in 1992 and 1993. The proposed case definitions are designed to be used in large-scale epidemiologic studies and clinical trials, in both US and resource-poor settings, where diagnoses may be made by non-dental healthcare providers. The objective of this article is to present updated case definitions for HIV-related oral diseases that will be used to measure standardized clinical end-points in OHARA studies, and that can be used by any investigator outside of OHARA/ACTG conducting clinical research that pertains to these end-points.

Estudo do papel de células T reguladoras e moléculas co-estimulatórias ma regulação da resposta imune em doenças infecciosas e tumor de cabeça e pescoço / The role of the regulatory T cells and PD-1 molecules in the modulation of the immune response in chronic infections and head and neck tumors

O sistema imune serve como uma barreira contra os patógenos e ao crescimento anormal de células. Para impedir as respostas imunes excessivas ou indiscriminadas que podem comprometer a sobrevivência do organismo, diversos mecanismos regulatórios são ativados visando manter o delicado balanço entre início e término de uma resposta imune. As celular T reguladoras (Treg) parecem desempenhar papel central na regulação da resposta imune em infecções crônicas e durante o desenvolvimento de tumores. Outro mecanismo importante no controle da resposta imune é desempenhado por moléculas co-estimulatórias, dentre as quais estão CTLA-4 e PD-1, todas associadas à função das células T reguladoras. Um aspecto importante é q a sobrevida de tecido tumoral e de transplantes tem sido associada à função das células T reguladoras. Assim, buscamos definir o envolvimento de células T reguladoras e PD-1 na modulação da resposta imune L. braziliensis, ao fungo P. brasiliensis, à doença periodontal e ao tumor de cabeça e pescoço. Baseado nos resultados já publicados e em dados preliminares, as hipóteses são que: (a) a interação do parasita (ou célula tumoral) com o hospedeiro leva à migração de linfócitos T e efetores e células T reguladoras para o local da lesão; (b) a dinâmica do acúmulo dessas células em tais sítios determina a eficiência da eliminação do patógeno ou tumor. No caso das parasitoses, há o desenvolvimento de imunidade concomitante; (c) as células T regulam a resposta imune local de forma contato dependente e modulando a função de APC através da liberação de IL-10 e/ou TGF-β; (d) infecção e progressão tumoral levam à modulação da expressão de PD-1 nos leucócitos e seus ligantes nos órgãos; (e) a interação PD-PDL-1 regula a resposta imune local de forma a favorecer a persistência do patógeno e os mecanismos de escape tumoral.

The immune system serves as a barrier against pathogens and abnormal cellular growth. To avoid tissue and organ damage during immune response several regulatory mechanisms are activated to limit, terminate and attenuate T-cells response. Regulatory T cells (Treg) play a central role in the regulation of the immune response in chronic infections and tumor-specific immunity. Programmed death-1 (PD-1) is a transmembrane protein that acts as a negative regulator in effector T cells, modulating the delicate balance between effective antimicrobial immune defenses and immune-mediated tissue damage. However, recent data suggest that the PD-1:PD-L1 pathway can also block antitumor immune responses even when tumor antigens can be recognized. An important aspect it that the survival of tumor and transplant tissues has been associated with the function or regulatory T cells. Thus, we discuss the role of Treg cells and PD-1 molecules in the modulation of the immune response to L. braziliensis, P. brasiliensis, periodontal disease and head and neck tumors. Based on published results and preliminary data, the hypotheses are that: (a) the interaction of the parasite (or tumoral cells) with the host leads to the migration of effector T lymphocytes and Treg cells to the local; (b) the dynamics of cells accumulation in such sites determinate the elimination efficiency of tumors. In infectious disease, there is the development of concomitant immunity; (c) Treg cells regulate the local immune response, modulating the APC function through the release of IL-10 and/or TGF-β; (d) infection and tumor progression leads to the modulation of PD-1 expression in the leukocytes and their ligands in the tissue; (e) PD-PDL-1 interactions regulate the immune response and may mediate the persistence of pathogen and contribute to immune evasion by cancers.T.

Cheilitis as a variation of Candida-associated lesions.

OBJECTIVE: Occasionally, the clinical diagnosis of Candida-associated lesion is difficult because of a variety of its clinical manifestations. There have been a few reports on Candida-associated lip lesion except angular cheilitis. In this paper, we investigate the relation of Candida in persistent lesions of the lip. SUBJECTS AND METHODS: The present study includes consecutive nine patients with persistent erosive lip lesion. For each patient the age at presentation, gender, duration of the disease, other symptoms or signs, complete medical history and prior treatment or medications for the symptom were obtained. Then, mycological examination and the direct cytologic examination were performed. RESULTS: The reported average duration of the disease was 7 months. Six of nine patients had received prior treatments with topical steroids at the other clinic, which failed to resolve their symptoms. Six of nine patients had a predisposing factor for candidiasis. In the culture examination, Candida albicans were isolated in seven patients (77.8%). Five of nine patients received the direct cytologic examination, and four of them revealed pseudohyphae of fungi. The anti-fungal treatment was miconazol gel 25 mg four times per day, and average duration of the treatment was 2 weeks. The outcome was as follows: complete remission in five, remarkable response in two and no response in two. CONCLUSION: Our results suggested that one form of the varieties of Candida-associated lesions might be considered in the case of lip lesion with unknown origin that was persistent and ineffective to the topical steroids treatment.