Oral Presentation of Chronic Hyperplastic Candidiasis in Patient


Oral Presentation of Chronic Hyperplastic Candidiasis in Patient
Case Report
DOI: 10.17354/cr/2016/217
Oral Presentation of Chronic Hyperplastic
Candidiasis in Patient under Imatinib Mesylate:
A Rare Case
Vishwanath Pattar1, Zameera Nalaband2, Anjana Bagewadi3
Post Graduate Student, Department of Oral Medicine and Radiology, KLE Vishwanath Katti Institute of Dental Sciences, Belagavi, Karnataka, India,
Professor, Department of Oral Medicine and Radiology, KLE Vishwanath Katti Institute of Dental Sciences, Belagavi, Karnataka, India, 3Head and
Professor, Department of Oral Medicine and Radiology, KLE Vishwanath Katti Institute of Dental Sciences, Belagavi, Karnataka, India
Candida albicans is the major human pathogen among Candida species. It is a commensal yeast of the oral, gastrointestinal, and vaginal
mucosa in healthy individuals. The genus Candida has about 154 species, and different species show a different level of resistance to antifungal
drugs and have a high degree of phenotypic similarity. Oropharyngeal candidiasis is the most common infection in oral cavity both pre- and
post-treatment of cancer. Immunocompromised state in a cancer patient induces candidal species which get activated as a pathogen. It is
found that in certain high-risk groups antifungal prophylaxis reduces the incidence and severity of infections. This case report discusses the
occurrence of hyperplastic candidiasis in the patient under treatment by a chemotherapeutic agent imatinib mesylate for gastric tumor. We
have discussed the probable cause for oral candidiasis in patients under imatinib mesylate and treatment advised for the oral hyperplastic
Keywords: Candida, Candidiasis, Chemotherapy, Imatinib mesylate
Imatinib mesylate is a chemotherapeutic drug, which
acts as a tyrosine kinase inhibitor and is used in the
treatment of acute lymphoblastic leukemia, chronic
eosinophilic leukemia, gastrointestinal stromal tumor,
myelodysplastic/myeloproliferative neoplasm, systemic
mastocytosis, etc.1,2 Short-term toxicity of the imatinib
mesylate in 1-10% includes pancytopenia, febrile
neutropenia, and flushing. Imatinib mesylate inhibition of
c-kit and platelet-derived growth factor receptors (PDGF-R),
which plays role in normal immune responses, causing
altered immune function.2 It has been reported that there
is a significant hypogammaglobulinemia in patients treated
with imatinib mesylate.3 Fungal infections in patients
under certain other chemotherapeutic drugs occurs due
to suppressed oral/mucosal immunity, salivary gland
dysfunction causing xerostomia and alteration in oral flora.4
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Some cases have been reported about the lesion in the oral
cavity such as painful erosions with lichenoid reactions in
patients under imatinib mesylate.5 Till date, there are no
case reports about occurrence of oral candidiasis in patients
who are under treatment of imatinib mesylate. The most
common form of oral candidiasis in cancer patients are
pseudomembranous and erythematous type of candidiasis
while the hyperplastic type of candidiasis is rarely reported.6
Herein, we report a rare case of oral hyperplastic candidiasis
in a patient under the treatment of malignant gastric tumor
with imatinib mesylate.
A 48-year-old female patient reported to our Department of
Oral Medicine and Radiology with a chief complaint of pain
in the gums in both right and left side of lower jaw. The pain
was moderate, burning type, intermittent, and aggravates
while chewing food or drinking water relieves on taking
rest. The patient gave medical history of malignant tumor
in the hypogastric region on left side for which she had
undergone surgery 4 months back. The patient was on the
medication, glivac 400 mg tablets (imatinib mesylate 400 mg,
Novartis Pharma AG, Switzerland) daily since 4 months. On
general examination subconjunctival pallorness, pallorness
of the nail bed were seen. On extra oral examination,
Corresponding Author:
Dr. Vishwanath Pattar, Department of Oral Medicine and Radiology, KLE Vishwanath Katti Institute of Dental Sciences, Nehru Nagar,
Belagavi - 590 010, Karnataka, India. E-mail: [email protected]
IJSS Case Reports & Reviews | April 2016 | Vol 2 | Issue 11
Pattar, et al.: A Rare Case of Oral Presentation of Chronic Hyperplastic Candidiasis in Patient under Imatinib Mesylate
submandibular lymph nodes were palpable on both right
and left side 3 in number on the right side and 1 in number
on the left side. Lymph nodes were of dimension 1 cm each
in left side and 1.5 cm on right side. Lymph nodes were firm
in consistency, tender on palpation, mobile. On intraoral
examination white hyperkeratotic patch was seen on gingiva
extending from distal of 43 to mesial of 47 and anteriorly in
relation to 32, 31, 41, 42 and on left side in relation to 34, 35
and lingual to 47, 48 of the mandibular jaw (Figures 1 and 2).
Superiorly hyperkeratotic patch extending from attached
gingival to the buccal vestibular region inferoirly. Surface
over the hyperkeratotic area was rough and borders were
irregular. Gingiva surrounding the hyperkeratotic area was
erythematous and tender on palpation. Hyperkeratotic area
was non-scrapable on application of pressure with gauze
piece at its entire extent. There was the presence of white
coating on the tongue.
advised wherein Candida albicans were isolated. On the
basis of history, clinical and pathological findings, a final
diagnosis of chronic hyperplastic candidiasis was given.
Antifungal treatment with clotrimazole 1% mouth paint
and chlorhexidine mouthwash of 0.12% were started and
followed up after 2 weeks, and there was 30% decrease in
the size of the lesion (Figures 3 and 4). Further follow-up of
patient was not possible in the event of death of the patient.
Superficial layer was forcibly scraped off with blunt end
of the BP blade, and the pathological evaluation was
Mutations of c-kit proto-oncogene are reported in 85%,
and mutations of PDGF-Rα chain are reported in 35% of
gastointestinal tumors.7 BCR-ABL tyrosine kinase is the
product of Philadelphia chromosome, which is a causative
factor for chronic myelogenous leukemia.8 Imatinib is
an inhibitor of the receptor tyrosine kinases for PDGF
and stem cell factor (SCF), c-kit, and inhibits PDGF and
SCF-mediated cellular events and thereby acts as anti-tumor
drug.2 Therefore, imatinib mesylate is used either as the
Figure 1: Pre-treatment image showing hyperkeratotic area on the buccal
aspect of 43-47
Figure 3: Post-treatment image with reduced hyperkeratotic area on buccal
aspect of 43-47
Figure 2: Pre-treatment image showing hyperkeratotic area on the labial aspect
of 43 on right side to 35 on left side
Figure 4: Post-treatment image with reduced hyperkeratotic area on labial
aspect 43-35 region
IJSS Case Reports & Reviews | April 2016 | Vol 2 | Issue 11
Pattar, et al.: A Rare Case of Oral Presentation of Chronic Hyperplastic Candidiasis in Patient under Imatinib Mesylate
first line of treatment or as an adjuvant in the treatment of
gastrointestinal tumors.9
The most common side effect of other chemotherapeutic
drugs like methotrexate, cyclophosphamide related to
oral cavity is oral mucositis. Mucositis provides favorable
conditions for the development of oral candidiasis.
Candida, commensal yeast of the digestive tract, is capable
of colonizing mucositis lesions and infecting the oral
mucosa. Overall, 60-90% of mucositis lesions are infected
by Candida. 10 For candidiasis to occur particularly in
chemotherapeutic patients, there has to be altered local
resistance to the infection (e.g., Xerostomia), compromised
immune function (e.g., altered functions of inflammatory
cells), and generalized debilitation of the patient (e.g.,
malnutrition and malabsorption).11
Oral lesions associated with imatinib mesylate reported
are painful erosions associated with lichenoid reactions.5
The cause for oral candidiasis in patients under treatment
with imatinib mesylate is unknown. However, it
can be hypothesized that as there will be altered
immune function, hypogammaglobulinemia leading to
immunocompromised state in patients with imatinib
mesylate drug therapy along with the associated poor oral
hygiene can aggravate the normal commensal Candida to
colonize leading to oral candidiasis, as was reported in
the present case (Figure 5). Cases have been reported in
which there was reactivation of hepatitis B virus after the
therapy with imatinib mesylate.12
In our case, candidiasis was treated with clotrimazole
1% mouth paint, local application 5 times daily. Other
treatment options for oral candidiasis include nystatin
(available as a suspension of 100,000 U/mL (4-6 mL q.i.d.) or
as flavored 200,000 U pastilles (one or two 4-5 times daily)
for 7-14 days).12 Chlorhexidine mouthwash 0.12% used in
1:1 dilution with water, for 3 times a day.
However, most important intervention is to maintain proper
oral hygiene, as in most of the cases poor oral hygiene is
the main inducing factor for the occurrence of candidiasis.
Oral candidiasis is an avoidable complication in
chemotherapeutic patients. Educating the patients about
the oral hygiene maintenance by referring them to dentist
is a piece of advice needed to be provided by the oncologist.
As the chances of occurrence of oral candidiasis are high,
regular oral hygiene maintenance, regular referral to the
dentist is important as to improve the quality of life of the
1. Available from: http://www.cancer.gov. National Cancer Institute.
Available from: http://www.cancer.gov/about-cancer/treatment/
drugs/imatinibmesylate. [Last accessed on 2014 Sep 17; Cited on
2015 Jul 15].
2. Mughal TI, Schrieber A. Principal long-term adverse effects of
imatinib in patients with chronic myeloid leukemia in chronic
phase. Biologics 2010;4:315-23.
3. Santachiara R, Maffei R, Martinelli S, Arcari A, Piacentini F,
Trabacchi E, et al. Development of hypogammaglobulinemia in
patients treated with imatinib for chronic myeloid leukemia or
gastrointestinal stromal tumor. Haematologica 2008;93:1252-5.
4. Akpan A, Morgan R. Oral candidiasis. Postgrad Med J 2002;78:455-9.
5. Kantarjian H, Sawyers C, Hochhaus A, Guilhot F, Schiffer C,
Gambacorti-Passerini C, et al. Hematologic and cytogenetic
responses to imatinib mesylate in chronic myelogenous leukemia.
N Engl J Med 2002;346:645-52.
6. Lalla RV, Latortue MC, Hong CH, Ariyawardana A,
D’Amato-Palumbo S, Fischer DJ, et al. A systematic review of
oral fungal infections in patients receiving cancer therapy. Support
Care Cancer 2010;18:985-92.
7. Dematteo RP, Ballman KV, Antonescu CR, Maki RG, Pisters PW,
Demetri GD, et al. Adjuvant imatinib mesylate after resection of
localised, primary gastrointestinal stromal tumour: A randomised,
double-blind, placebo-controlled trial. Lancet 2009;373:1097-104.
8. Remesh A. Toxicities of anticancer drugs and its management. Int
J Basic Clin Pharmacol 2012;1:2-12.
9. Byung WK, Lee SJ. Chronic myeloid leukemia patient manifesting
fatal hepatitis B virus reactivation during treatment with imatinib
rescued by liver transplantation: Case report and literature review.
Int J Hematol 2009;90:383-7.
10. Borg C, Terme M, Taïeb J, Ménard C, Flament C, Robert C, et al.
Novel mode of action of c-kit tyrosine kinase inhibitors leading to
NK cell-dependent antitumor effects. J Clin Invest 2004;114:379-88.
11. Burket LW. Textbook of Oral Medicine. 11th ed. Hamilton: BC
Decker Inc.; 2008.
12. Williams D, Lewis M. Pathogenesis and treatment of oral
candidosis. J Oral Microbiol 2011;3.
How to cite this article: Pattar V, Nalaband Z, Bagewadi A. Oral Presentation
of Chronic Hyperplastic Candidiasis in Patient under Imatinib Mesylate: A Rare
Case. IJSS Case Reports & Reviews 2016;2(11):17-19.
Figure 5: Pathogenesis of oral candidiasis
IJSS Case Reports & Reviews | April 2016 | Vol 2 | Issue 11
Source of Support: Nil, Conflict of Interest: None declared.

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