Review Question - QID 216503

This patient who presents with a burning sensation of the tongue and is found to have thick white exudate on his tongue most likely has oral candidiasis. Inhaled corticosteroid treatment for asthma can predispose to this disease if a spacer is not properly used.

Inhaled corticosteroids are used in combination with beta-adrenergic agonists in the treatment of asthma in children. These medications decrease inflammation of the bronchial tree resulting in fewer episodes of bronchospasm. Importantly, inhaled corticosteroids should be used in combination with a spacer so that the majority of the medication is delivered directly to the airway as opposed to settling on the oral mucosa. If a spacer is not used or used improperly, the inhaled corticosteroids may instead result in local immunosuppression on the tongue. This may result in oral candidiasis that is easily scraped off without propagation to either esophagitis or systemic infection.

Fukushima et al. studied potential factors that may be related to the development of oral thrush in patients who use inhaled corticosteroids. They find that total levels of oral IgA antibody are decreased in patients who develop thrush.

Figure A is a clinical photograph of oral findings on a physical exam. The tongue is covered with thick white lesions that are consistent with oral candidiasis.

Incorrect Answers:
Answer 2: Chewing tobacco can result in oral leukoplakia, which presents with a localized white patch or plaque that cannot be scraped off. This disease can be pre-malignant, so surgical intervention may be required if the lesion persists.

Answer 3: Cystic fibrosis is a predisposing factor for many infections of the respiratory tract such as Pseudomonas infections and pneumonia. The infections in this disease are due to inadequate clearance of microorganisms rather than systemic immunosuppression, so candidiasis is not classically associated with this disease.

Answer 4: HIV is a predisposing factor for candidal esophagitis as well as systemic infections with opportunistic fungi. This patient denies symptoms of odynophagia or other systemic symptoms, so this is likely localized oral esophagitis due to local immunosuppression.

Answer 5: Travel can result in infections with opportunistic mycoses such as Blastomyces, Histoplasmosis, and Coccidiodes. These species cause lower respiratory tract infections such as pneumonia rather than oral thrush.

Bullet Summary:
Inhaled corticosteroid treatment for asthma can cause the side effect of oral thrush development.