Case Report DOI: 10.

17354/cr/2016/223

Drug-induced Oral Candidiasis: A Case Report

Archana Patil1, H R Susmitha2, Srisha Basappa3, M S Mahesh4
1
Senior Lecturer, Department of Oral Medicine and Radiology, Farooqia Dental College and Hospital, Mysuru, Karnataka, India, 2Post-graduate,
Department of Oral Medicine and Radiology, Farooqia Dental College and Hospital, Mysuru, Karnataka, India, 3Head and Professor, Department of
Oral Medicine and Radiology, Farooqia Dental College and Hospital, Mysuru, Karnataka, India, 4Reader, Department of Oral Medicine and Radiology,
Farooqia Dental College and Hospital, Mysuru, Karnataka, India

Oral candidiasis is a broad term which describes the fungal infections mainly caused by the yeasts belonging to the genus Candida. In
developing countries, it is the third most common presenting compliant of the HIV-infected patients. Varied incidences have been observed
depending on age and predisposing factors. Oropharyngeal candidiasis and dysphonia are among the local side effects of the use of several
different topical steroids for the treatment of asthma. Long-term use of inhaled steroids renders oropharyngeal mucosa to opportunistic
fungal infections by their local immunosuppressive actions. Here, we report a case of a 55-year-old male chronic asthmatic patient, who was
on a steroid inhaler and presented with oral candidiasis.

Keywords: Bronchial asthma, Inhaled corticosteroids, Oral thrush

INTRODUCTION in both the genders worldwide, except in places where males

An opportunistic fungal infection of the oral cavity by
an increased growth of Candida species is termed oral
candidiasis. The most common species being Candida albicans
and the other species include Candida tropicalis, Candida
glabrata, Candida pseudotropicalis, Candida guilliermondii,
Candida parapsilosis, and Candida krusei.1 Oral candidiasis
is also known as oral candidosis, oral thrush, moniliasis,
oral mycosis, oral yeast infection, or Candidal stomatitis.
Candidal species are relatively common inhabitant of the
oral cavity, gastrointestinal tract, and vagina of clinically
normal persons. The mere presence of the fungus is
not sufficient to produce disease. There must be actual
penetration of the tissues, although such invasion is usually
superficial and occurs only under certain circumstances.
Conventionally, oral candidiasis is divided into acute or
chronic candidiasis. The modified classification was given
by Samarnayake and Yacoob, Holmstrup and Axel in 1990
as primary oral candidiasis (the condition is confined to the
mouth) and secondary oral candidiasis (occurs secondary to
thymic aplasia and candidosis endocrinopathy syndrome).2
Incidence of mucosal candidiasis is high in patients with
immunocompromised state. This lesion is reported equally
Access this article online
Month of Submission : 03-2016
Month of Peer Review : 04-2016
Month of Acceptance : 04-2016
Month of Publishing : 05-2016
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with HIV infection outnumber females. Predominantly, it
is seen in the middle or older age group people.3 Inhaled
corticosteroids (ICS) being one of the predisposing factors
for oral candidiasis, causes disturbed oral ecology, or
marked changes in the oral microbial flora resulting in oral
thrush. The management of oral thrush includes topical
antifungal applications containing the polyene drugs like
Nystatin and Amphotericin or azole group drugs like
Clotrimazole, Fluconazole, and Ketoconazole.
CASE REPORT
A 55-year-old male patient visited the Department of Oral
Medicine and Radiology with the complaint of itching
and burning sensation in his mouth since one and a half
month. Burning sensation increased on taking spicy food.
A medical history revealed that he was hypertensive and
was asthmatic since 6 years. He was treated for asthma
with bronchodilator (Salbutamol with Ipratropium
bromide) as a reliever. Because of increased frequencies
of asthmatic exacerbations his physician prescribed him
(ICS beclomethasone 400 μg) which the patient was using
for about 3  months. On intraoral examination, diffuse
curdy white patches were seen on his right and left buccal
vestibules and mucosa, as well as on his hard palate and
soft palatal region (Figures 1 and 2).
Lesions were scrapable and left diffuse erythematous areas
on scraping. Smear made from scrapings of lesions were sent
for cytological examination which confirmed the presence
of candidal hyphae (Figure 3).

Corresponding Author:
Dr. H R Susmitha, Department of Oral Medicine and Radiology, No. 21/1, 9th Main, 5th Block, Jayalakshmipuram, Mysuru - 570 012, Karnataka, India.
E-mail: hrsusmitha@yahoo.com

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 Patil, et al.: Drug-induced Oral Candidiasis
To rule out any underlying systemic cause’s complete
hemogram and rapid test for HIV was done which revealed
all values within the normal range and nonreactive status for
HIV. Based on history, clinical presentation and cytological
report, final diagnosis of drug-induced pseudomembranous
Figure 1: Pre-treatment image of right and left buccal mucosa
Figure 2: Pre-treatment image of hard palate and soft palatal region
Figure 3: Photomicrograph demonstrates tubular-appearing fungal hyphae and
ovoid yeasts of Candida albicans (Periodic acid–schiff stain)
2 IJSS Case Reports & Reviews | May 2016 | Vol 2 | Issue 12
candidiasis was made. The patient was advised to follow
strict oral hygiene measures and he was also asked to use
spacer along with metered dose inhaler (MDI) while using
steroid inhaler with topical application of clotrimazole
1% mouth paint around 4-5 times per day for about 2 weeks.
The patient was reviewed after 15 days where he presented
with complete remission of the lesions (Figures 4 and 5).
DISCUSSION
Fungal infections in humans caused by various Candida
species range from certain inconsequential condition like
oral or genital candidiasis to super-infections in patients
with systemically immunocompromised conditions. 4
Carriage rates of Candidal species in the general population
have been reported to range from 20% to 75% without any
symptoms. The incidence rates of C. albicans in the oral cavity
of neonates, healthy children and healthy adults have been
reported to be between 45-65% and 30-45%, respectively.
50-65% of people who wear removable dentures, 65-88% in
those residing in acute and long-term care facilities, 90% of
patients with acute leukemia undergoing chemotherapy and
95% of patients with HIV. Candidal species are considered
Figure 4: Post-treatment image of right and left buccal mucosa
Figure 5: Post-treatment image of hard palate and soft palatal region
 Patil, et al.: Drug-induced Oral Candidiasis
among the normal commensal of the mouth.1 Certain factors
that predispose the host to oral candidiasis are physiologic
like old age, infancy and pregnancy with altered immunity,
local trauma, poor denture hygiene, malnutrition, usage of
broad-spectrum antibiotics, corticosteroids, immune defects
like in HIV infection, thymic aplasia, endocrine disorders,
malignancies like leukemia, agranulocytosis, hyposalivation
due to autoimmune diseases or head and neck radiation,
certain cytotoxic medications.2 Candidal overgrowth due to
predisposing factors, can lead to local discomfort, an altered
taste sensation, dysphagia from oesophageal overgrowth.
These can lead to malnutrition, delayed recovery, and long-
term hospital stay. Systemic candidiasis is associated with
a mortality rate of 71% to 79%.1
Traditionally, the most commonly used classification
of oral candidosis divides the infection into four types
including (1) acute pseudomembranous candidosis
(thrush), (2) acute atrophic (erythematous) candidosis,
(3) chronic hyperplastic candidosis, and (4) chronic atrophic
(erythematous) candidosis. Chronic hyperplastic type is
further divided into subtypes based on localisation pattern,
they are (a) Chronic oral candidosis (candidal leukoplakia),
(b) endocrine candidosis syndrome, (c) Chronic localised
mucocutaneous candidosis, and (d) Chronic diffuse
candidosis.3 Different presentations of oral candidiasis
(either primary or secondary) are (1) pseudomembranous
variant, (2) erythematous variant, and (3) hyperplastic
variant.2 Pseudomembranous candidosis (oral thrush) presents
as creamy white lesions on the oral mucosa and a diagnostic
feature of this infection is that these plaques can be
removed by gentle scraping leaving behind an underlying
erythematous mucosal surface. Histological examination
of recovered pseudomembranes reveals desquamated
epithelial cells together with yeast and filamentous forms
of Candida. The infection has, traditionally, been regarded
as an acute condition often affecting newborn babies where
there is an immature immune system. In older individuals,
acute pseudomembranous candidosis often occurs when
there is a nutritional limitation, local immune suppression
(e.g. steroid inhaler administration for the treatment of
asthma), or an underlying disease most notably HIV
infection and AIDS.5
Bronchial asthma is a chronic inflammatory disease of the
respiratory system which is characterized by dyspnea,
shortness of breath, coughing, and wheezing due to the
narrowing of the bronchial airways by muscle spasm,
mucosal swelling or nasal and bronchial secretions. An
immune complex allergic reaction is suggested to be the
etiological factor.6
Bronchial asthma itself will not cause any oral lesions but
indirect effects of asthma drug therapy can induce clinical
IJSS Case Reports & Reviews | May 2016 | Vol 2 | Issue 12 3
lesions. Patients most prone to develop oral manifestations
are chronic asthmatics who use corticosteroid inhalants
since these are the main stay therapeutic agents in the
management of bronchial asthma. 7 Repeated contact
of steroid inhalant on the oral mucosa can result in the
development of acute pseudomembranous candidiasis
(oral thrush) because of fungal overgrowth in an area of
localized immunosuppression.7 According to Salzman et al.
increased concentration of glucose in saliva resulting from
the effect of deposited corticosteroids may be responsible
for oral candidiasis.8 A study done in 2013 showed that
a relative risk is the highest in the first 3  months of ICS
usage, but remain increased up to at least 1 year after
ICS initiation.9 This steroid-induced infection consists of
C. albicans colonies that appear as curdy white lesions
located commonly on the soft palate and oropharynx.
Eventually, the white precipitates peel off leaving behind
an intensely erythematous and raw-looking area.
In this reported case, along with a proper history and
clinical evaluation, patient was also analysed for underlying
systemic causes. Once the final diagnosis was arrived,
appropriate treatment was considered by the use of spacer
along with metered dose steroid inhaler and topical
application of antifungal agent clotrimazole 1% mouth paint
for 2 weeks. It was effective enough in healing the lesions.
Measures like rinsing the mouth with water after MDI use
can also prevent the occurrence of oral candidiasis.10 When
the patient was re-evaluated during follow-up visit, he
presented with complete remission of the lesions.
CONCLUSION
Diagnosing oral fungal lesions along with appropriate
management measures are the prime responsibilities of
any dental professional. Carefully recording the medical
history is important in identifying this clinical problem.
Predisposing factors should be treated or eliminated where
feasible. Since topical anti-candidal therapy is efficacious
in the management of oropharyngeal candidiasis, it alone
is not sufficient in asthmatic patients who continue to use
steroid inhalers. The effective measure is either to change
the medication to a non-steroid inhaler after consulting the
patient’s physician or to use a spacer along with MDI so that
less medication gets deposited in the mouth or throat and
then concomitantly instituting anti-candidal therapy. The
prognosis is good for oral candidiasis with appropriate and
effective treatment.
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How to cite this article: Patil A, Susmitha HR, Basappa S, Mahesh MS.
Drug-induced Oral Candidiasis: A Case Report. IJSS Case Reports & Reviews
2016;2(12):1-4.
Source of Support: Nil, Conflict of Interest: None declared.

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