Indian Journal of Transplantation 10 (2016) 7779

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Indian Journal of Transplantation

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Case Report

Hyperplastic candidiases on dorsum of tongue

B.G. Chenna Keshava a,*, S. Tharanath b, K. Rooparani c, A.L. Shyam Prasad d
a
Consultant Intensivist, Department of Critical Care, MSR Memorial Hospital, New BEL Road, Bangalore 560054, India
b
Post Graduate in Department of General Medicine, MSR Memorial Hospital, New BEL Road, Bangalore 560054, India
c
Assistant Professor, Department of Anaesthesiology, MSR Memorial Hospital, New BEL Road, Bangalore 560054, India
d
Senior Professor, Department of Dermatology, MSR Memorial Hospital, New BEL Road, Bangalore 560054, India

A R T I C L E I N F O A B S T R A C T

Article history: Introduction: Oral candidiasis in renal transplant patients is common. The most common types are acute
Received 9 November 2015 atrophic (erythematous) and acute pseudo-membranous (thrush), even in renal transplant patients.
Accepted 30 June 2016 Hyperplastic variant is uncommon even in transplant patients.
Available online 16 July 2016
Case: We report a 42-year-old female, post-cadaveric renal transplant recipient who developed
hyperplastic oral candidiases on the dorsum of the tongue. Patient was on immunosuppressants and
Keywords: developed post-operative acinetobacter pneumonia. With a combination of anti-fungals, antibiotics and
Candidiasis
supportive care patient was successfully treated and discharged home.
Hyperplastic candidiasis
Immunosuppressants
2016
Renal transplant
Transplant

A 42-year-old female with chronic kidney disease (CKD
secondary to chronic glomerulonephritis) on maintenance hemo-
dialysis (MHD) for 4 years, hypertension for 7 years and fully
treated pulmonary tuberculosis, was shifted to our ICU after
cadaveric renal transplantation (Day 0).
She had undergone an uneventful surgery. Her immunosup-
pressant regimen included intra operative I.V. Basiliximab 20 mg
and post-operative Tacrolimus 1 g BD and Mycophenolate Mofetil
1 g BD. Her ICU stay was uneventful, with good recovery in terms of
renal output and other parameters.
Patient continued to improve in the 1st week but with a drop in
cell lines. On post-operative day (POD) 9, there was drop in urine
output, which did not respond to medications and hemodialysis
was initiated. On POD 11, she had pulmonary inltrates, with a
PaO2/FiO2 ratio of 70 mmHg, suggestive of Acute Respiratory
Distress Syndrome. She was started on Meropenem and Colistin.
She was given intermittent non-invasive ventilation (NIV)
support, cycles of 4 h NIV and 2 h face mask. In view of the
severity of dyspnea, she continued to require prolonged periods of
NIV with minimal breaks for maintaining normal saturations and
some times for 23 cycles she was on NIV mask. Pulmonologists
* Corresponding author. Tel.: +91 9886051598.
E-mail addresses: ckeshava7@gmail.com (B.G. Chenna Keshava),
tharanath37@gmail.com (S. Tharanath), drrooparani@gmail.com
(K. Rooparani), prashyam2@yahoo.co.in (A.L. Shyam Prasad).
opinion was taken and she was started on Caspofungin, in view of
her immune-suppressed state. Sputum culture revealed Colistin
Only Sensitive (COS) Acinetobacter Baumanii. On POD 14 it was
noted that she had a white raised plaque on the tongue (Fig. 1). The
plaque was adherent to the tongue and could not be scraped off.
Dermatologists opinion was oral candidiasis, hyperplastic vari-
ant. Scrapings were taken from the lesion and sent for KOH mount
and fungal cultures. Anti-fungals (Flucanozole orally 400 mg OD
and Clotrimazole mouth paint Q6 hourly) were started. KOH
mount showed pseudohyphae and spores, suggestive of
Candida. Initial culture reports grew Candida species. On POD
19 the plaque started reducing in size (Fig. 2). On POD 20 it had
reduced considerably.
Patients general condition improved over the next 2 weeks and
she was discharged and sent home for follow up on OPD basis.
1. Discussion
Oral candidiasis/candidosis (OC) in renal transplant patients is
quite frequent. The prevalence is variable but it ranges between
9.4% and 46%.1 There are considered to be six variants of OC: acute
pseudo-membranous (thrush), acute atrophic (erythematous),
chronic atrophic, chronic hyperplastic candidosis (CHC), median
rhomboid glossitis and chronic mucocutaneous.2 Of these, only the
rst two are seen quite commonly. It has been suggested3 that
these disorders be grouped into two distinct entities-the rst
(Group I) involving the oral mucosa alone and the second (Group II)

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78 B.G. Chenna Keshava et al. / Indian Journal of Transplantation 10 (2016) 7779
Fig. 1. Initial lesion on Day 14.
Fig. 2. Resolving lesion on Day 19.
with lesions in other extra-oral sites as well. The latter are
generally seen in rare inherited immune disorders, starting in
childhood, while the former are adult-onset.
OC occurs very frequently in immunosuppressed patients due
to various reasons. Up to 50% of the population harbor it as a
commensal, and a change in local environment predisposes to
an increased tendency to clinical manifestations. OC typically
occurs when there is a modication of three general factors.
They are: (1) Decreased immune status of the patient. (2)
Change in oral mucosal environment.3 A different strain of
Candida albicans.4
Candidiasis appearing as a leukoplakic patch in the oral mucosa
has been recognized since the mid-60s.5,6 The most common and
classic clinical presentation of CHC is a white plaque that cannot be
rubbed off and presenting most frequently in the commissural
regions of the oral mucosa, infrequently other oral sites can be
affected. The initial terminology for this was Candidial leukoplakia
(CL), which continued despite the term chronic hyperplastic
candidiasis (CHC) also being used in a similar context. CL affects
the following oral sites in decreasing order of frequency: the buccal
commissures, cheeks, palate, and the tongue. CHC requires to be
recognized as a distinctive, though rare entity, because it is
frequently misdiagnosed as leukoplakia. According to a WHO
denition,7 leukoplakia is a white patch on mucosal surfaces which
cannot be rubbed off, or characterized clinically or pathologically
as any other disease. CHC can be recognized as a separate entity
from leukoplakia, as only about 10% of the latter fulll the clinical
and histological criteria laid down.8
Epidemiological factors which have been identied as impor-
tant in the pathogenesis of CHC include local factors such as
xerostomia and dentures, smoking and tobacco chewing, nutri-
tional factors such as deciencies of various vitamins, Blood group
O, Diabetes mellitus and immunological deciencies against
Candida.3 Clinically, CHC usually presents as a whitish plaque
with a homogeneous surface, although a speckled or nodular
variant, with interspersed erythematous specks or nodules has
been described, especially in CHC of the commissural area.9 The
histopathology may not be specic enough for a diagnosis, unless
there is the presence of neutrophilic collections in the sub-corneal
location, termed as Munros micro-abscesses along with candidial
hyphae in the upper layers of the epidermis. Culture of Candida
species on Sabourauds dextrose agar should be possible in the
majority of cases of CHC, through swabs, smears or washings. The
hyperplasic response of the epidermis is considered to be a
protective response to a possible deeper invasion by Candida.
The treatment options are either medical or surgical.10
Antifungal therapy or topical application of 0.18% iso-retinoids,
bleomycin, beta carotene or mixed tea. Surgical options include
cold-knife surgery, laser therapy and cryosurgery. There is no
clinical consensus as to the right treatment, starting non-
invasively would be the ideal management.
Our patient had a lesion suggestive of homogeneous CHC, which
responded well to treatment. She had multiple predisposing
factors such as immune-suppression, xerostomia (due to pro-
longed periods on NIV), Diabetes mellitus, CKD and blood group
O+ (non-secretor). A poor response to treatment would have
warranted a biopsy for the possibility of dysplastic change, which
can occur in this entity.
In conclusion, CHC although a rarity and possibly a dangerous
condition, if addressed early, is completely amenable to treatment.
Conicts of interest
The authors have none to declare.
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