Diagnosis
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Diagnosis: Oral Candidiasis (Pseudomembranous Type / Oral Thrush)
The image shows white, curd-like plaques covering the dorsal surface of the tongue, consistent with pseudomembranous oral candidiasis - the most common form of oral thrush.
Key Findings in the Image
- Thick, white, irregularly distributed plaques covering most of the tongue dorsum
- Underlying mucosa appears erythematous/pink where visible
- The plaques have a patchy, cottage-cheese-like texture characteristic of Candida overgrowth
- A small area of central erythema/rawness is also visible (mid-tongue)
Clinical Classification
There are four recognized forms of oral candidiasis:
| Type | Features |
|---|---|
| Pseudomembranous (Thrush) | White curd-like plaques, can be scraped off, leaving erythematous or bleeding base - this case |
| Atrophic/Erythematous | Red mucosa, loss of tongue papillae |
| Angular cheilitis | Cracking/ulceration at oral commissures |
| Hyperplastic | Thick white plaques that cannot be scraped off, rare |
Causative Organism
Candida albicans is the most common causative species.
Predisposing Factors to Consider
- HIV/AIDS (oral candidiasis is the most common oral lesion in HIV; incidence decreases with ART)
- Systemic antibiotic use (suppresses competing bacterial flora)
- Uncontrolled diabetes mellitus
- Chronic salivary dysfunction / xerostomia
- Corticosteroid use (inhaled or systemic)
- Immunosuppression of any cause
- Anemia
Confirmation
Diagnosis can be confirmed with KOH preparation (showing pseudohyphae and budding yeast) or PAS stain on scrapings.
Management
- CD4 > 200 cells/mm³ (or non-HIV): Topical antifungals - nystatin oral suspension (swish-and-swallow) or clotrimazole troches
- CD4 < 200 cells/mm³ or severe/refractory: Systemic azoles - fluconazole 100-200 mg/day x 7-14 days (first-line)
- Fluconazole-resistant candidiasis may develop with repeated courses; in such cases, itraconazole solution or amphotericin B oral suspension can be used
Differential Diagnosis to Rule Out
- Hairy leukoplakia (EBV-related; lateral tongue, bilateral; cannot be wiped off; persists despite antifungals - seen in HIV/immunosuppression)
- Lichen planus (reticular white lesions, bilateral, symmetrical, does not wipe off)
- Geographic tongue (benign migratory glossitis; areas of papillae loss with hyperplastic borders)
- Secondary syphilis (condyloma latum/mucous patch)
Clinical note: The extent and density of this thrush is significant and warrants investigation for underlying immunosuppression. If not already known, HIV testing and fasting glucose should be considered in an otherwise healthy-appearing adult presenting with this degree of oral candidiasis.
Sources: K.J. Lee's Essential Otolaryngology; Goldman-Cecil Medicine, 26th ed.
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