ENT Case No7. Oral Thrush

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𝙊𝙧𝙖𝙡 𝙏𝙝𝙧𝙪𝙨𝙝______

Oral Thrush যার আরেক নাম 𝐨𝐫𝐚𝐥 𝐂𝐚𝐧𝐝𝐢𝐝𝐢𝐚𝐬𝐢𝐬….যেটি মুলত ফাংগাল ইনফেকশন_Candida albicans দিয়ে হয়ে থাকে। Candida নরমাল organism আমাদের ওরাল cavity এর but Sometimes overgrowth এর জন্য Candida এর symptoms দেখা যায়…….

সবার ই হতে পারে,তবে বেশী দেখা যায় বাচ্চাদের এবং বয়স্কদের Due to lack of of Immunity & immune suppressd দের। Healthy Individuals এ Oral thrush minor প্রবলেম but weeken immune দের জন্য severe এবং difficult to Contrl*

অনেকসময় esophagus এ ও দেখা যায়,Esophagial Candidiasis বলা হয়…Esophagial candidiasis ওয়ান অফ দা most Common in HIV/AIDs পেশেন্ট।

Oral thursh এর D/D হতে পারে 𝐋𝐞𝐮𝐤𝐨𝐩𝐥𝐚𝐤𝐢𝐚যা দেখতে অনেক্টা Oral thrush এর মতোই !But Fact is that___𝐋𝐞𝐮𝐤𝐨𝐩𝐥𝐚𝐤𝐢𝐚 হলো pre malignant condition __ Must be Reffred করে দিবেন

Oral thrush এর উপর নরম কাপড় বা গজ দিয়ে হালকা ঘসে দিলেই উঠে যায় অনেক টা but In case of 𝐋𝐞𝐮𝐤𝐨𝐩𝐥𝐚𝐤𝐢𝐚 উঠবে না। এভাবে আলাদা করতে পারি সহজে।

𝐑𝐢𝐬𝐤 𝐅𝐚𝐜𝐭𝐨𝐫__________

Especially বাচ্চার বেশি Affected হয়।

এছাড়াও যাদের

• Dm

•দুর্বল immunity

• মেডিকেশন ( Corticosteroid)

•wearing Denture

•Cancer/ HIV/AIDS

𝐒𝐲𝐦𝐩𝐭𝐨𝐦𝐬_________________________

• Creamy white lession on

•Tongue_Cheeks কখনও Roof of mouth,গাম & টনসিল এও দেখা যায়

•লেশনটা Raised থাকে Cottage cheese এর মতো

•Redness or Soreness

•খাবার খাওয়ার সময় Pain হয়

• loss of Taste

• Cracking & Redness

Treatmentplan

•Nystatin ( Drop Nystat)____7-14 দিন,

Oral Suspension 1.Candex 100000Unites/ml (AS A Nystatin AS A Drugs for subcutaneous and mycoses, Drugs used in Vaginal and Vulval condition).

Indications of Oral Suspension:-Candex 100000Unites/ml (AS A Nystatin AS A Drugs for subcutaneous and mycoses, Drugs used in Vaginal and Vulval condition).

Candex is an antifungal antibiotic active against a wide range of yeasts and yeast like fungi including Candida albicans. It is used for the prevention and treatment of Candida infections of oral cavity, esophagus and intestinal tract. It provides effective prophylaxis against oral candidiasis in those born of mothers with vaginal candidiasis. It is used for the prophylaxis of Candida overgrowth during courses of broadspectrum antibiotics.

Pharmacology of Oral Suspension:-Candex 100000Unites/ml (AS A Nystatin AS A Drugs for subcutaneous and mycoses, Drugs used in Vaginal and Vulval condition).

Nystatin is an antifungal antibiotic. Which has fungistatic or fungicidal activity against variety of pathogenic and nonpathogenic yeast and fungi, including Candida albicans. Nystatin exerts its antifungal activity by binding to sterols in the fungal cell membrane. As a result of binding, the membrane is no longer able to function as a selective barrier, and potassium and other cellular constituents are lost. It is poorly absorbed from the gastrointestinal tract.

Dosage & Administration of Oral Suspension:-Candex 100000Unites/ml (AS A Nystatin AS A Drugs for subcutaneous and mycoses, Drugs used in Vaginal and Vulval condition).

Children:

In intestinal and oral candidiasis (thrush): 1,00,000 units (1 ml) should be dropped into the mouth four times daily.The longer the suspension is kept in contact with the affected area in the mouth, before swallowing, the greater will be its effect.
For prophylaxis in the newborn: The suggested dose is 1,00,000 units (1 ml) once daily or as prescribed by the physician.

Adult:

For the treatment of intestinal or esophageal candidiasis: 5,00,000 units (5 ml) by mouth 3 or 4 times daily. The dose may be doubled, if required.
For prophylaxis of intestinal candidiasis in adults: 10,00,000 units (10 ml) daily.
For prophylaxis to suppress the over growth of Candida albicans in patients receiving broad spectrum antibiotic therapy: 10,00,000 units (10 ml) daily.
For the treatment of dental sores and oral infection: 1,00,000 units (1 ml) suspension should be dropped into the mouth four times daily.

Elderly: Older people with intestinal candidiasis who are unable to swallow tablets should be given 5,00,000 units (5 ml) suspension four times daily.

Contraindications of Oral Suspension:-Candex 100000Unites/ml (AS A Nystatin AS A Drugs for subcutaneous and mycoses, Drugs used in Vaginal and Vulval condition).

There is no known contraindication to the use of Nystatin.

Side Effects of Oral Suspension:-Candex 100000Unites/ml (AS A Nystatin AS A Drugs for subcutaneous and mycoses, Drugs used in Vaginal and Vulval condition).

Nausea, vomiting and diarrhoea have occasionally been reported with high doses of Candex. No systemic effects or allergic reactions have been associated with its oral dose.

Pregnancy & Lactation of Oral Suspension:-Candex 100000Unites/ml (AS A Nystatin AS A Drugs for subcutaneous and mycoses, Drugs used in Vaginal and Vulval condition).

Absorption of Nystatin from the gastrointestinal tract is negligible, therefore no special precautions apply in pregnancy.

Precautions & Warnings

Absorption from the gastrointestinal tract is negligible, therefore no special precaution is required to apply in pregnancy and lactation.

Therapeutic Class of Oral Suspension:-Candex 100000Unites/ml (AS A Nystatin AS A Drugs for subcutaneous and mycoses, Drugs used in Vaginal and Vulval condition).

Drugs for subcutaneous and mycoses, Drugs used in Vaginal and Vulval condition

অথবা

•Miconazole(Micoral gel)___7-14 দিন

Oral Gel 2.Micoral Gel 2%w/w 30gm Tube (AS A Miconazole Nitrate AS A Aural Anti-fungal preparations).

Indications of Oral Gel:-Micoral Gel 2%w/w 30gm Tube (AS A Miconazole Nitrate AS A Aural Anti-fungal preparations).

Micoral oral gel is indicated-

For the treatment of oral and gastrointestinal candidiasis.
For eradication of fungal colonization in the mouth and gastrointestinal tract.
For the treatment of super infections due to gram-positive bacteria.

Micoral cream is indicated in dermatomycoses, e.g.:

Tinea pedis (Athlete’s foot)
Tinea corporis (Tinea circinata)
Tinea manuum
Tinea cruris due to: Trichophyton mentagrophytes, Trichophyton rubrum, Microsporum audouinii, Epidermophyton floccosum
Candidial infections
Tinea versicolor.
Infections of the skin (e.g. intertrigo)
Perianal infections
Stomatitis angularis (cheilitis)
Balanoposthitis
Otitis externa

In addition miconazole cream has a very rapid alleviating effect on the pruritis which frequently accompanies infection.

Pharmacology of Oral Gel:-Micoral Gel 2%w/w 30gm Tube (AS A Miconazole Nitrate AS A Aural Anti-fungal preparations).

Pharmacodynamics: Miconazole possesses an antifungal activity against the common dermatophytes and yeasts as well as an antibacterial activity against certain gram-positive bacilli and cocci. Its activity is based on the inhibition of a demethylation step in the ergosterol biosynthesis. Ergosterol, the end-product of the biosynthetic pathway and the main sterol in yeast and fungi. The disruption in production of ergosterol disrupts the fungal cell membrane, causing holes to appear in it. These holes allow the essential constituents of the fungal cells to leak out and ultimately the fungal cells die.

Pharmacokinetics: The oral bioavailability of Miconazole is low (25-30%) because there is little absorption of Miconazole from the intestinal tract. Miconazole is systemically absorbed after administration as the oral gel. Absorbed Miconazole is bound to plasma proteins (88.2%), primarily to serum albumin and red blood cells (10.6%). The absorbed portion of Miconazole oral gel is largely metabolized; less than 1% of the administered dose is excreted unchanged in the urine. The terminal plasma half-life is 20-25 hours in most patients. The elimination half-life of Miconazole is similar in any renal impaired patient.

Dosage of Oral Gel:-Micoral Gel 2%w/w 30gm Tube (AS A Miconazole Nitrate AS A Aural Anti-fungal preparations).

Miconazole Oral Gel–
Oropharyngeal candidosis-

Infants 4-24 months: 1.25 ml (1⁄4 measuring spoon) of gel, applied 4 times day after meals.
Adult and children 2 years of age and older: 2.5 ml (1⁄2 measuring spoon) of gel, applied 4 times a day after meals.

Gastrointestinal tract candidosis-

Infants (4 months of age or above): Children and adults who have difficulty swallowing tablets: 20 mg per kg body weight per day, in four divided doses. The daily dose should not exceed 250 mg (10 ml gel) four times daily.

Missed Dose: Apply the missed dose as soon as you remember. In case of next dosing time, omit the missed
dose and continue your usual course.

Miconazole Cream: Sufficient Miconazole Cream should be applied to cover affected areas twice daily (morning and evening) in patients with tinea pedis, tinea cruris, tinea corporis and cutaneous candidiasis and once daily in patients with tinea versicolor. If Miconazole Cream is used in intertriginous areas it should be applied sparingly and smoothed in well to avoid maceration effects.

Early relief of symptoms (2 to 3 days) is experienced by the majority of patients and clinical improvement may be seen fairly soon after treatment is begun.All lesions usually disappear after 2 to 5 weeks.Prolong treatment for 10 days to prevent relapse. However, Candida infections, tinea cruris and corporis should be treated for two weeks and tinea pedis for one month in order to reduce the possibility of recurrence.

Administration of Oral Gel:-Micoral Gel 2%w/w 30gm Tube (AS A Miconazole Nitrate AS A Aural Anti-fungal preparations).

In case of localized lesions of the mouth, a small amount of gel may be applied 2-4 times a day directly to the affected area with a clean finger. For best results, Miconazole oral gel should be kept in contact with the affected area as long as possible. The treatment should be continued for at least a week after symptoms have disappeared. For oral candidosis, dental prosthesis should be removed at night and brushed with the gel.

Interaction of Oral Gel:-Micoral Gel 2%w/w 30gm Tube (AS A Miconazole Nitrate AS A Aural Anti-fungal preparations).

Concomitant treatment with Terfenadine, Astemizole and Cisapride should be avoided because in vitro studies suggest that Micoral may inhibit their metabolism, so these products miqht precipitated.
Micoral may delay Phenytoin and Cyclosporine metabolism and this might precipitate Phenytoin and Cyclosporine toxicity, respectively.

Contraindications

Miconazole is contraindicated in patients with known hypersensitivity to the active ingredient.

Side Effects of Oral Gel:-Micoral Gel 2%w/w 30gm Tube (AS A Miconazole Nitrate AS A Aural Anti-fungal preparations).

Occasionally nausea and vomiting, diarrhea with long term use and rarely allergic reactions.

Pregnancy & Lactation of Oral Gel:-Micoral Gel 2%w/w 30gm Tube (AS A Miconazole Nitrate AS A Aural Anti-fungal preparations).

There is no information regarding the safety of Miconazole oral gel during pregnancy. So Miconazole oral gel should be avoided in pregnant women if possible or the potential hazards should be balanced against the possible benefits. As many drugs are excreted in human milk, caution should be exercised when Miconazole is administered to a nursing woman.

Precautions & Warnings of Oral Gel:-Micoral Gel 2%w/w 30gm Tube (AS A Miconazole Nitrate AS A Aural Anti-fungal preparations).

If the concomitant use of Micoral and anticoagulant is considered, the anti-coagulant effect should be monitored and titrated. Micoral and phenytoin plasma level should also be monitored when used concomitantly. In infants and young children, caution must be taken to ensure that the gel does not obstruct the throat.

Overdose Effects

Accidental overdosage may cause vomiting and diarrhea. Treatment is symptomatic and supportive. A specific antidote is not available.

Therapeutic Class of Oral Gel:-Micoral Gel 2%w/w 30gm Tube (AS A Miconazole Nitrate AS A Aural Anti-fungal preparations).

Aural Anti-fungal preparations

Severe case এর ক্ষেত্রে Systemic Fluconazol দেয়া হয়ে থাকে. কিছু 𝐅𝐮𝐧𝐠𝐚𝐥 𝐢𝐧𝐟𝐞𝐜𝐭𝐢𝐨𝐧 এ ফ্লুকোনাজল বেশ ভালো কাজ করে…এইটার Advantage হলো ,এটি 𝐎𝐫𝐚𝐥 & 𝐈𝐕 দুইভাবেই পাওয়া যায় & বাচ্চাদের সিরাপ ও…..Half life ও বেশি! & Drug Interaction ও কম!! খুব Rarely Liver toxicity করে। তবে High Dose এ দিলে 𝐀𝐥𝐨𝐩𝐞𝐜𝐢𝐞 ,𝐃𝐫𝐲 𝐦𝐨𝐮𝐭𝐡,𝐌𝐞𝐭𝐚𝐥𝐥𝐢𝐜 𝐭𝐚𝐬𝐭𝐞 হতে পারে…

𝐂𝐫𝐲𝐩𝐭𝐨𝐜𝐨𝐜𝐜𝐚𝐥 𝐌𝐞𝐧𝐢𝐧𝐠𝐢𝐭𝐢𝐬 এ ফ্লুকোনাজল কে prefer করা হয় & Drug Of choice !!

IV route এ দিল Amphotericin B এর সমান Effective ***

𝐂𝐚𝐧𝐝𝐢𝐝𝐞𝐦𝐢𝐚 তে ICU পেশেন্ট দের With নরমাল WBC কাউন্ট..(ImmuneSuppressed না হলে Candidemia তে ইউস করা হয়..)

Molds & Dimorphic fungi এর বিরুদ্ধে Fluconazole তেমন Effactive না

প্রেগ্ন্যাসির তে Low Dose এ ও দেওয়া যাবে না Miscarriage & Still birth হতে পারে।

Fluconazole যেহেতু Liver কে তেমন damage করে না ,তাই liver Disease এ High risk Pt এর ক্ষেত্রে Prophylaxis এ প্রেফার করা হয় Also Allogeneic bone marrow transplants .. এখন Posoconazole ও দেয়া হয়..

ফ্লুকোনাজল prophylaxis in leukemic পেশেন্ট ;AIDS পেশেন্ট with low CD4+ T-cell counts, and in patients on surgical intensive care units is controversial….

Capsule 3:-Flugal 150mg (AS A Fluconazole AS A Drugs for subcutaneous and mycoses).

Indications of Capsule :-Flugal 150mg (AS A Fluconazole AS A Drugs for subcutaneous and mycoses).

Flugal is indicated in-

Vaginal Candidiasis
Oropharyngeal Candidiasis
Esophageal Candidiasis
Tinea corporis/Tinea cruris/Tinea pedis/Other Tinea
Kerion
Pityriasis versicolor
Onychomycosis
Invasive candidal infections and cryptococcal infections (including meningitis)
Prevention of cryptococcal meningitis
Prevention of fungal infections in immunocompromised patients
Systemic Candidiasis and Cryptococcal infection
In Superficial Candidiasis
In Systemic Candidiasis & Cryptococcal infection

Other indications-

Fungal urinary tract infections
Disseminated candidiasis
Prophylaxis for fungal infection in neutropenic cancer patients.
Acute treatment of other systemic fungal infections such as coccidioidomycosis and histoplasmosis.

Pharmacology of Capsule :-Flugal 150mg (AS A Fluconazole AS A Drugs for subcutaneous and mycoses).

Fluconazole is a triazole antifungal agent. It is a potent inhibitor of fungal cytochrome P-450 dependent enzymes. Cytochrome P-450 enzyme system is essential component of fungal cell membrane which is responsible for the synthesis of ergosterol.

Dosage & Administration of Capsule :-Flugal 150mg (AS A Fluconazole AS A Drugs for subcutaneous and mycoses).

Adults:

Vaginal Candidiasis: 150 mg as a single dose.
Oropharyngeal Candidiasis: 200 mg in 1st day followed by 100 mg daily for 14 days.
Oesophageal Candidiasis: 200 mg in 1st day followed by 100 mg daily for 14-30 days.
Tinea corporis/Tinea cruris/Tinea pedis/Other Tinea: 150 mg weekly for 4-6 weeks.
Kerion: 50 mg daily for 20 days.
Pityriasis versicolor: 400 mg as a single dose.
Onychomycosis: 150 mg weekly for 12 months.
Invasive candidal infections and cryptococcal infections (including meningitis): Orally or by IV infusion, 400 mg on first day then 200-400 mg daily.
Prevention of cryptococcal meningitis: Orally or by IV infusion 200 mg daily.
Prevention of fungal infections in immunocompromised patients: Orally or by IV infusion, 50-400 mg daily.

Child over 1 year-

In Superficial Candidiasis: 1-2 mg/kg daily.
In Systemic Candidiasis & Cryptococcal infection:3-6 mg/kg daily.

In serious life threatening infections upto 12 mg/kg daily has been given to children aged 5-13 years (Maximum 400 mg daily)

1 year: 9 kg: 1/2 measuring spoonful
1-2 years: 12 kg: 1 measuring spoonful
2-3 years: 14 kg: 1½ measuring spoonful
3-4 years: 16 kg: 2 measuring spoonful
4-6 years: 20 kg: 2½ measuring spoonful

Use in Specific Population-

Elderly patient: The normal dose should be used if there is no evidence of renal impairment.

Renal Impairment: No adjustment in single dose therapy is required. In multiple dose therapy of patients with renal impairment, normal doses should be given on days 1 and 2 of treatment and there after the dosage intervals should be modified as follows:

Creatinine clearance (>41 ml/min): Dosage interval (hours) 24
Creatinine clearance (21-40 ml/min): Dosage interval (hours) 48
Creatinine clearance (10-20 ml/min): Dosage interval (hours) 72
Patients receiving regular dialysis: One dose after every dialysis session

Children: Renal clearance in children may be proportionately more rapid than in adults and doses up to 12 mg/kg is recommended.

Side Effects of Capsule :-Flugal 150mg (AS A Fluconazole AS A Drugs for subcutaneous and mycoses).

Flugal is generally well tolerated. The commonest side-efects associated Flugal are symptoms associated with the gastrointestinal tract; these include nausea, abdominal discomfort, diarrhoea and fatulence. Other adverse events such as rash are rarely encountered (Incidence less than 1%). In rare cases, as with other azoles, anaphylaxis has been reported.

Pregnancy & Lactation of Capsule :-Flugal 150mg (AS A Fluconazole AS A Drugs for subcutaneous and mycoses).

Fluconazole adverse fetal efects have been seen in animals only at dose levels associated with maternal toxicity. These levels are many times in excess of those recommended for therapeutic use. There has been little use during human pregnancy. Accordingly, fuconazole should not be used in pregnancy or in women of child bearing potential unless adequate contraception is employed.

Therapeutic Class of Capsule :-Flugal 150mg (AS A Fluconazole AS A Drugs for subcutaneous and mycoses).

উপদেশ

• Oral Hygiene মেইনটেইন করুন

• Denture use করলে পরিষ্কার রাখুন

•Plenty of water_

• রাতে Denture না পড়া

Raiyyan Tahsan Date:23-01-2025 Thursday Time:3-13-35 PM

Raiyyan Tahsan

Raiyyan Tahsan