Oral mucositis

Coexisting infection by Candida may occur and is common in patients receiving head and neck irradiation and/or chemotherapy, especially those with significant salivary compromise.[39]Lalla RV, Latortue MC, Hong CH, et al. A systematic review of oral fungal infections in patients receiving cancer therapy. Support Care Cancer. 2010 Aug;18(8):985-92. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2914797 http://www.ncbi.nlm.nih.gov/pubmed/20449755?tool=bestpractice.com [40]Soysa NS, Samaranayake LP, Ellopola AN. Cytotoxic drugs, radiotherapy and oral candidiasis. Oral Oncol. 2004 Nov;40(10):971-8. http://www.ncbi.nlm.nih.gov/pubmed/15509487?tool=bestpractice.com ​​ Lesions may be seen at locations unusual for mucositis, such as the keratinized mucosa (hard palate, gingiva, dorsal tongue), and may show delayed healing.

Diagnosis may be made on clinical appearance with smear microscopy and/or fungal culture.

Treatment with antifungal agents is required.

Oral candidiasis

Coexisting reactivation of herpes simplex virus (HSV) infection may occur, presenting as vesicular ulceration at locations unusual for mucositis, such as the keratinized mucosa (hard palate, gingiva, dorsal tongue), and may show delayed healing.[Figure caption and citation for the preceding image starts]: Oral herpes virus infection presenting as painful ulcers covered by pseudomembranes on the right side of the dorsum of the tongue. Diagnosed during the third week of radiation therapy for the management of the maxillary sinus carcinoma. Responded to acyclovirFrom the collection of Professor Ourania Nicolatou-Galitis [Citation ends].

HSV infection is more likely in highly immunocompromised patients, such as in those undergoing hematopoietic stem cell transplant.[42]Tomblyn M, Chiller T, Einsele H, et al. Guidelines for preventing infectious complications among hematopoietic cell transplantation recipients: a global perspective. Biol Blood Marrow Transplant. 2009 Oct;15(10):1143-238. https://www.astctjournal.org/article/S1083-8791(09)00300-0/fulltext ​​

Viral culture or polymerase chain reaction (PCR) of lesional fluid may confirm HSV infection; PCR has a higher sensitivity than viral culture.[43]Wald A, Huang ML, Carrell D, et al. Polymerase chain reaction for detection of herpes simplex virus (HSV) DNA on mucosal surfaces: comparison with HSV isolation in cell culture. J Infect Dis. 2003 Nov 1;188(9):1345-51. http://www.ncbi.nlm.nih.gov/pubmed/14593592?tool=bestpractice.com

Treatment with systemic antivirals is required.

Herpes simplex infection

Ability to maintain normal oral intake is influenced by the severity of mucositis.[35]Berger K, Schopohl D, Bollig A, et al. Burden of oral mucositis: a systematic review and implications for future research. Oncol Res Treat. 2018;41(6):399-405. https://karger.com/ort/article-abstract/41/6/399/263525/Burden-of-Oral-Mucositis-A-Systematic-Review-and?redirectedFrom=fulltext http://www.ncbi.nlm.nih.gov/pubmed/29734184?tool=bestpractice.com [36]Lee SC, Wang TJ, Chu PY. Predictors of weight loss during and after radiotherapy in patients with head and neck cancer: a longitudinal study. Eur J Oncol Nurs. 2019 Apr;39:98-104. http://www.ncbi.nlm.nih.gov/pubmed/30850144?tool=bestpractice.com ​ 

In severe cases of reduced oral intake, parenteral feeding or feeding through a gastrostomy tube may be necessary.[10]Iovoli AJ, Turecki L, Qiu ML, et al. Severe oral mucositis after intensity-modulated radiation therapy for head and neck cancer. JAMA Netw Open. 2023 Oct 2;6(10):e2337265. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2810484 http://www.ncbi.nlm.nih.gov/pubmed/37819659?tool=bestpractice.com

Ulcerative lesions of OM can serve as a portal of entry for host flora to cause local or systemic infection. This is more of a concern for highly immunosuppressed patients (e.g., hematopoietic stem cell transplant patients), especially if neutropenic.

Blood cultures for bacterial or fungal organisms are necessary, to confirm etiology and drug sensitivities, although these may be negative. Treatment is with empiric or tailored antimicrobial therapy and supportive care. Consultation with an infectious disease physician may be required.

Sepsis in adults