Orofacial fungal infections. Nine pathogens that may invade during chemotherapy.

Immunosuppression due to antineoplastic drugs or malignant tumor leaves patients extremely vulnerable to infection. Opportunistic fungi that rarely infect healthy persons can have very severe consequences in these patients. Candida albicans is the pathogen found most often, but several other Candida species may cause infection as well. Aspergillosis is the second most frequently seen fungal infection of the face and mouth in patients receiving chemotherapy. Less commonly seen but equally dangerous are infections with Torulopsis glabrata, Mucor, Absidia, Rhizopus oryzae, Histoplasma capsulatum, Cryptococcus neoformans, Coccidioides immitis, Fusarium species, and Trichosporon cutaneum. Restoration of impaired host defenses and use of nystatin (Mycostatin, Nilstat, O-V Statin), clotrimazole (Mycelex), amphotericin B (Fungizone Intravenous), and flucytosine (Ancobon) when appropriate are methods of control.

Effect of antileukemia chemotherapy on marrow, blood, and oral granulocyte counts.

This study was designed to elicit the effects of antileukemia chemotherapy on marrow production, blood carriage, and oral extravasation of granulocytes, and on the phagocytic activity of those harvested from the mouth. Fifteen adult patients with various morphologic forms of acute leukemia were followed through one to four courses of chemotherapy. Oral saline rinse samples were obtained thrice weekly and prepared for enumeration in a hemocytometer. The oral granulocyte counts were compared with concurrent counts in the bone marrow and peripheral blood. Phagocytic activity of the oral granulocytes was measured by the method of Smith and Rommel. The 15 patients were followed through 30 courses of chemotherapy and recovery. During each, there was a drug-induced decrease in marrow, blood, and oral granulocytes that was reversed when therapy was discontinued and bone marrow activity was restored. Phagocytic activity of the oral granulocytes was not perceptibly affected by the antileukemic drugs. Oral granulocyte counts provide a noninvasive method for monitoring the onset and recovery of chemotherapy-induced myelosuppression and granulocytopenia in patients with leukemia.

The many faces of adult leukemia.

This article describes the facial complications of adult leukemia, as derived from a study of more than 3,000 patients treated at the University of Texas M.D. Anderson Hospital during the past 25 years. Facial leukemia cutis, leukemia-associated facial hemorrhages, leukemia-induced cranial nerve facial palsies, and leukemia-provoked pure and mixed facial infections are discussed.

The butterfly rash and the malar flush. What diseases do these signs reflect?

The butterfly rash and malar flush are common facial manifestations of several disorders. Systemic lupus erythematosus may produce a transient rash before any other signs. In pellagra, symmetric keratotic areas on the face are always accompanied by lesions elsewhere on the body. Erysipelas produces brawny, fiery red facial lesions, and scarlet fever causes facial eruptions as part of a generalized eruption. Lupus vulgaris and lupus pernio produce nodules that may spread in a butterfly pattern, and seborrheic dermatitis has a predilection for the malar prominences and other areas of the face. Carcinoid syndrome often causes flushing attacks that vary in duration, and facial flushing that lasts throughout treatment may accompany chemotherapy if the patient has a hypersensitivity reaction. Deep-red rashes and/or lichenoid lesions may be caused by graft-versus-host disease in a patient undergoing bone marrow transplantation.

Acral erythemas induced by chemotherapy and graft-versus-host disease in adults with hematogenous malignancies.

Acral erythema is being seen with increasing frequency in patients with hematologic malignancies, because of the administration of more aggressive high-dosage chemotherapy and the increasing use of allogeneic bone marrow transplantation, which may be followed by the development of cutaneous graft-versus-host disease. The varieties induced by both drugs and graft-versus-host disease are grossly similar but can be differentiated on the basis of symptoms, medical history, and response to therapy. Each also has to be differentiated from the painless palmar erythema commonly associated with pregnancy and with chronic liver disease. When making such a diagnosis, attention to the clinical history and an awareness of the points of distinction will help the physician to determine the precipitating cause and initiate appropriate treatment promptly.

Analysis of positive cultures from endodontically treated teeth: a retrospective study.

A study of 12,150 endodontically treated teeth from 11,797 patients in a private patient setup revealed an incidence of 10.2% positive cultures obtained just before obturation of the root canal. Streptococcal predominance was reflected by a presence of nearly 60% in the pure culture and nearly 98% in the mixed cultures. No significant changes in microbial predominance or bacterial sensitivities were detected over the 7-year period of study. Ampicillin, cephalothin, erythromycin, and penicillin were the most effective antibiotics against the viridans streptococci, the most prevalent organism in the infected teeth.

Nutritional deficiencies in patients receiving cancer chemotherapy.

Cancer often causes malnutrition and specific vitamin and protein deficiencies. Chemotherapy also causes deficiencies by promoting anorexia, stomatitis, and alimentary tract disturbances. Antimetabolite drugs in particular inhibit synthesis of essential vitamins, purines, and pyrimidines. Because vitamin levels in the blood are often nondiagnostic, nutritional deficiency is identified almost exclusively on the basis of clinical signs and symptoms and the patient's response to therapy. Signs and symptoms of cachexia and hypoalbuminemia are common in patients with advanced cancer. Deficiencies of vitamins B1, B2, and K and of niacin, folic acid, and thymine also may result from chemotherapy. Nutritional deficiencies are chemically correctable; however, the tumor must be eradicated to relieve cachexia.

Oral complications of cancer therapies. Description and incidence of oral complications.

No part of the body reflects the complications of cancer chemotherapy as visibly and as vividly as the mouth. The infectious, hemorrhagic, cytotoxic, nutritional, and neurologic signs of drug toxicity are reflected in the mouth by changes in the color, character, comfort, and continuity of the mucosa. The stomatologic complications of radiotherapy for oral cancer are physical and physiological in nature, transient or lasting in duration, and reversible or irreversible in type. Some linger as permanent mementos long after the cancer has been destroyed. They stem from radiation injury to the salivary glands, oral mucosa, oral musculature, alveolar bone, and developing teeth. They are expressed clinically by xerostomia, trismus, radiation dermatitis, nutritional stomatitis, and dentofacial malformation. In both cancer chemotherapy and cancer radiotherapy, the oral complications vary in pattern, duration, intensity, and number, with not every patient developing every complication.

Dietary and nutritional counseling in the prevention and control of oral disease.

Diet, nutrition, and oral health are intimately interlinked. Oral tissues, like all tissues in the body, are diet- and nutrition-dependent. The diet provides the food chemicals that are converted into health and life-sustaining nutrients by metabolic processes. Much has been learned of the food sources, biochemical properties, metabolic functions, and the physiological, physical, and psychological consequences of insufficient or excessive availability of these nutrients. Enough has been learned of the interdependence of diet, nutrition, and dental disease to warrant including diet and nutrition counseling as an integral part of a total dental care program. This article will discuss various oral diseases caused by nutritional deficiencies and review some of the types of counseling necessary to control and prevent oral disease.

Chemotherapy-induced acral erythema: desquamating lesions involving the hands and feet.

Patients receiving very high doses of chemotherapeutic drugs, particularly cytarabine (cytosine arabinoside, ara-C, Cytosar), may develop chemotherapy-induced acral erythema, a painful toxic rash of the palmar surfaces of the hands that progresses to edema, blister formation, and desquamation. In more severe cases, the feet are involved, and they show similar changes. Plastic surgeons may be consulted because of the hand involvement and the clinical resemblance, after desquamation, to a very superficial second-degree burn. In patients who have had bone marrow transplantation, this diagnosis must be distinguished from graft-versus-host reaction--a desquamating skin lesion that can affect a similar anatomical area but that is progressive and productive of serious consequences. Acral erythema appears to be self-limited and requires only supportive treatment.

Intertriginous infections in adults receiving antileukemia chemotherapy.

Because intertriginous infections in patients receiving antileukemia chemotherapy may be life-threatening, all sites where skin contacts skin should be thoroughly examined daily. Early detection and immediate medical intervention designed to confine and cure the infection before it progresses to blood-borne dissemination of the infecting organisms are essential in these immunosuppressed patients.

The mouth as an indicator of internal nutritional problems.

The mouth is a uniquely sensitive repository of nutritional information reflecting past and present nutritional insults with a speed and to a degree unmatched by almost any other body site. Changes in the structural integrity of the teeth provide a history of exposure to deficiencies of vitamin A, vitamin C, vitamin D and iodine and to an excess of fluorides during the years of tooth formation. Changes in the structural integrity of the oral mucosa may signal ongoing deficiencies of riboflavin, niacin, folic acid, vitamin B6, vitamin B12, biotin, vitamin C, vitamin K, iron and protein calories. The evidence is readily accessible and painlessly procured. The clinician alert to and familiar with the stomatological reactions to prolonged deprivation of many of the essential nutrients is in a privileged position for the early diagnosis and effective management of the nutritional deficiency states.

Mucocutaneous herpetic infections during cancer chemotherapy.

Adults who are given immunosuppressive and myelosuppressive cancer chemotherapy have a heightened risk for development of herpetic infections during treatment. The impact is much greater in patients who are given antineoplastic drugs for leukemia and lymphoma than in those who are given such drugs for carcinoma and sarcoma. In the series reported here, the incidence of herpes simplex infections exceeded that of herpes zoster infections in patients treated for leukemia by a ratio of more than 12:1, compared to slightly more than 2:1 in patients treated for solid tumor. The frequency of herpes simplex and herpes zoster infections during treatment for leukemia was 25%. Corresponding frequencies for patients with lymphoma, carcinoma, and sarcoma were 28%, 8%, and 3%, respectively.

External expressions of internal malignancy.

Paraneoplastic conditions are cancer-connected but are not produced as a direct effect of the tumor or metastasis. Some antedate the appearance of the internal malignancy; some run a course parallel to the tumor; some follow a pattern independent of the neoplasm. They occur in a small minority of patients with cancer and are, for the most part, of unknown cause. When an external disorder is present, it may act as a marker of hidden malignancy and thus contribute to its detection, or it may serve as an indicator of successful treatment. Many of the conditions described occur commonly without any underlying malignancy, but an unusual frequency of association with cancer makes their presence significant.

Necrotizing dermatitis in patients receiving cancer chemotherapy.

Necrotizing dermatitis in patients being treated with cancer chemotherapeutic agents can be of several types. Microbial causes can include a variety of bacteria and fungi, the most common being Pseudomonas aeruginosa. Gangrene from occlusive causes is not uncommon among cancer patients with coexisting atheromatous, thromboembolic, or obliterative vascular disease. Toxic gangrene is most commonly caused by extravasation of intravenously administered cytotoxic antineoplastic drugs but has also been associated with the use of coumarin congeners and the bite of the brown recluse spider. Pyoderma gangrenosum is an idiopathic condition that has been reported in association with myeloproliferative disorders. Finally, necrosis can be caused by the neoplasm itself, when its growth is so great that blood vessels are compressed and ischemia of the surrounding tissue results.

Mucocutaneous granulocytic sarcomas of the head and neck.

Granulocytic sarcomas are malignant solid tumors composed of poorly differentiated myeloid cells that occur in association with myelocytic leukemia. The clinicopathologic characteristics of granulocytic sarcomas that presented in the oral mucosa and in the facial, scalp and neck skin of 8 patients in the acute phase of myelocytic leukemia are described and discussed. Although most of the tumors were demonstrably sensitive to cytosine arabinoside, alone or in combination with other antineoplastic drugs, the prognostic portent of these lesions was extremely poor.

Quantitative analysis of the oral complications of antileukemia chemotherapy.

Almost half of 1500 patients (46.9%) treated for acute leukemia developed chemotherapy-related oral infections, oral mucositis, and/or oral hemorrhages at some time during their hospitalization. The frequencies of 34.2% for infections, 16.3% for mucositis, and 13.6% for hemorrhages were each within 1.3% to 3.1% of those previously reported from this institution for smaller groups of patients. The stomatologic disruptions reflected the cytotoxic, myelosuppressive, and immunosuppressive properties of the antileukemia drugs. Because there are as yet no alternatives to the use of potent stomatotoxic drugs for the treatment of acute leukemia, it is essential that their side effects be kept to a minimum by early recognition and appropriate treatment.