Medication Summary
History of current medications and nutritional supplements should be reviewed and checked for possible pharmacological interactions.
Antifungal Agents
Class Summary
The mechanism of action usually involves inhibiting pathways (enzymes, substrates, transport) necessary for sterol and/or cell membrane synthesis or altering the permeability of the fungal cell membrane (polyenes).
Amphotericin B (Amphocin, Fungizone)
Amphotericin B is a polyene antibiotic produced by a strain of Streptomyces nodosus; it can be fungistatic or fungicidal. It binds to sterols, (eg, ergosterol) in the fungal cell membrane, causing intracellular components to leak, with subsequent fungal cell death.
Caspofungin (Cancidas)
Caspofungin is used to treat refractory invasive aspergillosis. It is the first of a new class of antifungal drugs (glucan synthesis inhibitors). It inhibits the synthesis of beta-(1,3)-D-glucan, an essential component of the fungal cell wall.
Flucytosine (Ancobon)
Flucytosine is converted to fluorouracil after penetrating fungal cells. It inhibits RNA and protein synthesis. Flucytosine is active against Candida and Cryptococcus species and is generally used in combination with amphotericin B. It treats aspergillosis.
Fluconazole (Diflucan)
Fluconazole has fungistatic activity. It is a synthetic oral antifungal (broad-spectrum bistriazole) that selectively inhibits fungal cytochrome P-450 and sterol C-14 alpha-demethylation, which prevents the conversion of lanosterol to ergosterol, thereby disrupting cellular membranes.
Ketoconazole (Nizoral)
Ketoconazole has fungistatic activity. It is an imidazole broad-spectrum antifungal that inhibits synthesis of ergosterol, causing cellular components to leak and resulting in fungal cell death.
Miconazole oral (Oravig)
Miconazole damages the fungal cell wall membrane by inhibiting the biosynthesis of ergosterol. Membrane permeability is increased, causing nutrients to leak and resulting in fungal cell death. It interferes with mitochondrial enzymes.
Itraconazole (Sporanox)
Itraconazole has fungistatic activity. It is a synthetic triazole antifungal agent that slows fungal cell growth by inhibiting cytochrome P-450 – dependent synthesis of ergosterol, a vital component of fungal cell membranes.
Posaconazole (Noxafil)
Posaconazole is a triazole antifungal agent. It blocks ergosterol synthesis by inhibiting the enzyme lanosterol 14-alpha-demethylase and sterol precursor accumulation. This action results in cell membrane disruption. Posaconazole is available as an oral suspension (200 mg/5 mL). It is indicated for prophylaxis of invasive Aspergillus and Candida infections in patients at high risk because of severe immunosuppression.
Voriconazole (Vfend)
Voriconazole is used for primary treatment of invasive aspergillosis and salvage treatment of Fusarium species or Scedosporium apiospermum infections. It is a triazole antifungal agent that inhibits fungal CYP450-mediated 14 alpha-lanosterol demethylation, which is essential in fungal ergosterol biosynthesis.
-
Cryptococcosis. Left image shows solitary, destructive lesion resulting in necrosis of alveolar bone and palatal mucosa; note the superficial pseudomembranous candidiasis of the palate. Right image shows nonspecific chronic ulceration of the buccal mucosa due to cryptococcosis; this is associated with submucosal induration and regional adenopathy. Courtesy of David Sirois, DMD, PhD.
-
Aspergillosis. Note deep mucosal ulceration and nodular expansion of the hard palate. Courtesy of David Sirois, DMD, PhD.
-
Blastomycosis. Top image shows nonspecific papillary nodular lesion on the hard palate. Bottom image shows extensive ulceration involving the skin of the face and neck. Courtesy of David Sirois, DMD, PhD.
-
Histoplasmosis. Top image shows periodontal recession and deep ulceration with exposed necrotic alveolar bone (arrow). Bottom image shows solitary, deep ulceration of the gingivae also associated with necrotic bone (arrow). Courtesy of David Sirois, DMD, PhD.
-
Mucormycosis. Top left image shows multiple, deep ulcerations (arrows) of the hard palate. Top right image shows destruction of the palate and the floor of the orbit (failed skin graft of the right eye after orbital enucleation); this infection originated in the maxillary sinus. Bottom image shows similar deep, destructive ulceration of the left posterior maxillary alveolar bone and mucosa due to mucormycosis of the maxillary sinus. Courtesy of David Sirois, DMD, PhD.
-
Rectangular conidia is observed (cotton blue 400x). Courtesy of Dr. Alexandro Bonifaz.
-
Pseudomembranous form affecting the tongue. Courtesy of Dr. Alexandro Bonifaz.
-
Culture of Geotrichum candidum on dextrose agar. Courtesy of Dr. Alexandro Bonifaz.
