3. Infections_integrated

DISCUSSION CASE

Case description: 51-year-old Male presenting with asymptomatic lesions shown. His medical history is non-contributory. He is a non-smoker and consumes minimal alcohol.

Activity:

1. Identify the pathosis and describe the clinical features
2. What is the differential diagnosis?
3. What are the relevant clinical investigations?
4. What is the diagnosis?
5. How would you manage this patient?

1. Identify the pathosis and describe clinical features

• The primary pathosis involves white plaques that are soft upon palpation.
• A key diagnostic feature is that the lesions wipe off, leaving an underlying surface, which is characteristic of pseudomembranous candidiasis.
• Patients often present with pain, an inability to eat, or difficulty brushing their teeth.

Case Study: 51-Year-Old Male

• Profile: Fit and healthy, non-smoker, no significant medical history.
• Symptoms: Presents with acute oral candidosis.
• Key Observation: No history of antibiotic use or steroid inhalers. This suggests an underlying systemic issue, as "Candidosis is a disease of the diseased."

2. What is the differential diagnosis?

• ==Candidiasis (Candidosis): Specifically the acute pseudomembranous type==
• ==Leukoplakia: Standard differential for white patches, though these typically do not wipe off==
• ==Lichen Planus: Can present with white striations or plaques==

3. What are the relevant clinical investigations?

• Remember patients presenting with candidosis and ulcerations ==hematinics
  • the standard protocol
    • FBC
    • Iron studies
    • B12
    • Folate
    • Fasting Glucose

Hematinic tests

Clinical Rationale

For classic presentations of candidiasis, a swab or smear may not be necessary as they incur costs for the patient. However, if the patient is otherwise healthy and presenting with a fungal infection, systemic investigations are mandatory to rule out nutritional deficiencies that predispose the patient to infection.

FBC

FBC Interpretation

• ==High Neutrophil Count: Suggests a bacterial infection==
• ==High Lymphocyte Count: Suggests a viral infection==
• ==White Cell Count: Used to identify infection types==
• ==Platelet Count: General health indicator==

The patient has an FBC that shows the following:

• they have low haemoglobin which shows they have anemai
• they have a low MCV : indicates microcytic anemia

Causes of anemia :

• microcytic: iron deficiency
• macrocytic: b12 or folate

Iron studies

• ==Ferritin: This is the primary marker checked within iron studies to confirm deficiency==

B12

• Deficiency can lead to macrocytic anemia and oral mucosal changes

Folate

• Deficiency is a known risk factor for oral ulceration and candidiasis

Fasting glucose

• this is at the very least but you can diagnose diabetes from the HbA1c

What ifs?

What if patient is on a corticosteroid inhaler

• If an inhaler explains the infection, an HIV test might be less urgent, but hematinics are still recommended because a patient can have multiple problems simultaneously.

• You would still give them the tests you can have multiple things going on

What if patient has microcytic anemia

1. what would we expect to see in the full iron studies?

   1. low hemoglobin

2. Why would he have low iron? 3. ==Urgent Referral: In a “fit and healthy” male, iron deficiency anemia is a major red flag for internal bleeding; the patient must be referred for a colonoscopy and endoscopy to rule out gastrointestinal malignancy.==

   1. We need to figure out hte cause, it could be colorectal cancer!

4. what is the diagnosis?

• acute candidosis
• ==Primary Diagnosis: Acute Pseudomembranous Candidiasis==
• ==Underlying Diagnosis: Potential Iron Deficiency Anemia or Diabetes Mellitus==

5. How would you manage this patient?

How to treat acute candidiasis

Would you do topical or systemic?:

• systemic has more significant side effects ex. fluconazole

Topical Options

• Nystatin droplets
  • Has a very high sugar content can cause caries
  • the nystatin drops tend to be swallowed quickly so it doesn’t stay around the mouth
• Amphotericin tablets
  • very pasty sugar free tablets, it is annoying for patients to take
  • If someone presents with a dry mouth they may not tolerate it
  • ==Advantage: doesn’t have any drug interactions
  • Stimulates saliva flow
  • Stays in the mouth longer than drops
• Miconazole (Gel formulation)
  • Causes drug interactions specifically with warfrin
    • can get patients INRs going up to 9
    • Avoid in patients with liver disease
    • Sugar-free and comfortable gel formulation

what is the dosing options?

• this is a debate but
  • 4x a day for a month
    • 7-14 days is not enough to control the candidiasis
  • Treatment should last at least three weeks to prevent recurrence
• there are no australian guidelines for treating f

Management Strategy

Management involves treating the local infection while simultaneously investigating and addressing the underlying systemic cause. ungal infections > - in different parts of the world there are different preparations

---