Thrush

THRUSH (Soor, from Old German sor- dry), a specific fungal local lesion of the oral mucosa. In folk medicine, this disease is also known as "mold" or "child's thrush." In medicine, thrush has been known for a long time. Hippocrates described a similar disease under the general name "aphthae." A more precise acquaintance with it dates to 1840, when Langenbeck and Berg discovered the fungal origin of this condition. Despite the long history of study, much related to thrush remains unresolved to the present day. The exact place of the fungus in the botanical classification has not been established. It has been classified in ten classes, including molds and yeasts. The fungus is widely distributed in the environment. It has been found in the air, on household items, rubber nipples, bottles, bath water, cow's milk, on the fingers of nursing personnel, and in the oral cavity of healthy people. Epstein (V. Epstein) often found it in mothers and infants. The fungus stains by Gram's method, and due to its glycogen content, often also by Best's method; it grows well on nutrient media, especially those containing starch and cane sugar, and gives numerous morphological variations. There are indications that the main development proceeds in the direction of conidia formation on one hand and hyphae on the other. Epstein distinguishes three main variations. The first grows only in the form of conidia (oval formations 4-6 μ in size) and does not produce hyphae, even on favorable media. The second, along with conidia, especially on media containing sugar or in the absence of oxygen, forms hyphae on the seventh to ninth day of growth. The third produces predominantly two-celled hyphae, divided into segments of varying sizes and bearing sporangia at their ends. When the fungus culture is applied to the mucous membrane of healthy experimental animals, it is non-pathogenic; however, in weakened animals, improperly fed, thrush develops (Grawitz). Injection into a vein of a culture killed by heating to 60° leads to cachexia in the animal. On autopsy, degenerative changes are found without any specific changes - evidence of the toxic effect of the fungus. Injection of live culture into the blood of a rabbit already after one day causes refusal of food, severe weakness, difficult frequent breathing, and death, which occurs at different rates - from one day to a month - depending on the virulence of the fungus. On dissection, a general mycosis is found. Parenchymal organs (kidneys, liver, spleen, heart, brain) are hyperemic, studded with small, sharply demarcated foci consisting of necrotic cell masses, and a large number of hyphae and conidia of the fungus. In addition to foci, the organs contain fungi that surround and penetrate individual cells and vessels without noticeable surrounding reaction. The routes of penetration of the fungus into the human body have not been precisely established. The supposed transmission through the air (Kehrer) is not confirmed by the research of Steiner and Fischl, who did not find fungal spores even in the air of hospital wards. Ascribes the decisive role to the mother. He established that sporulation (latent microbism) occurs in 57% of pregnant women, in 53% in the first year after childbirth, then decreases to 42%; in childless women - 32%. This corresponds to findings in children: in the first week of life in 58%, by the end of the year - in 46.5%, and after a year - in 35.8%. According to B. Epstein, the transfer of spores to the child from the mother occurs through constant contact, especially through kisses. He substantiates this opinion with the mentioned parallelism between the findings of spores in the mother and child, the identity of the forms of the fungus found in them, and the absence of spores and disease in those children whose mothers are free of the fungus. This well-founded opinion does not, however, exclude the transfer of the fungus through contact of the child with care items and the environment. The latter especially applies to children on artificial feeding, as well as those whose mothers are free of spores. The latter children, under certain conditions, especially in hospitals, are not guaranteed against infection. One can also assume secondary acquisition of spores and disease from a fungus more pathogenic than the one previously obtained from the mother. Clinically, thrush manifests itself predominantly in infancy. According to Epstein, only newborns up to five days are spared; the highest figures occur in the second week of the child's life - 45%. Subsequently, they decrease (in the third week - 17%, fourth - 12%, after a year - 2.1%). However, older children as well as adults also get thrush. According to some, the frequency of diseases is influenced by hot weather, according to others - rainy weather. Other researchers do not confirm this. The dependence of thrush on social conditions is indisputable. A difficult life situation, overcrowding, improper care and nutrition contribute to the spread of latent microbism, lower the body's resistance, and make it a victim of severe general diseases, with which thrush is associated. It is known that among those with thrush, only a small percentage are apparently healthy (according to B. Epstein - 19%). The overwhelming majority are patients with severe intestinal, pulmonary, and other exhausting diseases. This circumstance gives grounds for the assertion that a favorable general condition for the appearance of thrush is a decrease in immunity and general resistance to secondary infections (for example, in diabetes, in tuberculosis). Fischl also points to the importance of increased general acidity - acidosis. Along with this, the change in the mucous membrane itself is also important. Epstein and Soltmann established that an undamaged mucous membrane in children remains healthy, and that catarrhal condition of the oral cavity or traumatic damage to the mucous membrane are prerequisites for thrush. The delicate mucous membrane of infants and the weakened mucous membrane of patients are especially unstable, easily damaged, become infected, and give the highest percentage of morbidity; decreased saliva, dryness of the oral cavity only contribute to this. Kehrer disagrees with this opinion, denying the need for prior disease of the mucous membrane, and considers saliva a nutrient medium for the fungus. According to Kehrer, a predisposition to thrush is created exclusively by weakness of swallowing and chewing movements, due to which a good nutrient medium is formed in the oral cavity from secretions, remnants of cell protein, milk sugar, etc. However, frequent cases of thrush in particularly restless and crying children speak against this. The previous opinion that thrush develops due to an acidic reaction in the mouth as a result of the decomposition of milk residues contradicts the facts. According to Epstein, thrush occurs in children who have never received milk. Ritter proved that 95% of children normally have an acidic reaction of the oral cavity. Clinic. An early clinical symptom of thrush is often overlooked redness of the oral mucosa. Then, on the hyperemic base, white spots resembling curdled milk residues are found. Subsequently, the spots increase and reach various sizes - from small plaques to a continuous felt that can extend far beyond the oral cavity. Thrush never forms true plaques. The deposits are relatively closely connected to the underlying mucous membrane, and after their removal, erosions and bleeding are found on the mucous membrane. On microscopic examination of the affected parts of the mucous membrane and the deposits, it turns out that the latter consist of a network of hyphae, among which are conidia, cells of the mucous epithelium, leukocytes, and various bacteria from the oral flora. The hyphae are immersed in the thickness of the mucous membrane, surround cells, and penetrate into vessels. The paths of penetration are accompanied by cell necrosis, the formation of a clot in the lumen of the vessel, which in many cases prevents both bleeding and the spread of the fungus throughout the body. The favorite place for the primary eruption of thrush is the inner surface of the lips, the edges and tip of the tongue. Steiner distinguishes two clinical forms of thrush: the first, torpid - develops in relatively healthy children; it first appears on the mucous membrane of the cheeks and on the lower surface of the tongue; the connection with the underlying mucous membrane is loose; it spreads per continuitatem and does not give metastases. Under favorable conditions, it passes within 3-4 days without special treatment. The second, disseminating - occurs in premature infants, weakened children, exhausted by severe diseases. It appears first on the tongue, accompanied by severe redness and swelling of the mucous membrane. In the first period, the spots are visible only with a magnifying glass, are solitary, and have a star-shaped outline. Subsequently, they quickly merge and form a continuous felt, tightly fused with the mucous membrane. This form gives metastases and is difficult to treat. Local changes are accompanied by a number of general phenomena: the child becomes capricious, restless, due to pain and difficulty in sucking, refuses the breast, sometimes vomiting and increased temperature occur. In general, however, "the general symptoms of thrush are covered by the main disease, which may worsen with complications of thrush."

Cases are observed of fungal deposits spreading to the esophagus, stomach, and intestines, leading to severe digestive and nutritional disorders; sometimes the spread occurs to the respiratory tract, which can lead to lobular pneumonia, asphyxiation, and paralysis of the vocal cords. A more severe complication is the entry of the fungus into the blood and its carriage to organs. Cases are known of the fungus being found in the liver, kidneys, peritoneum, pleura, and brain. Cases of general fungal infection with purulent lesions of many organs (So-orpyaemia) have been described, in particular abscesses in the brain. Rare forms are isolated lesions of the middle ear, renal pelvis, and tonsils ?2 <Stoos et al.). Cases of lesion of the vagina (especially in pregnant or elderly women) are observed. The most practical significance is that of thrush of the skin. According to Ibrahim, it manifests in the form of vesicles and pustules in which the fungus is found. According to Epstein, intertriginous or erythematous skin changes are more common, as well as the formation of sharply demarcated, easily scaling, elevated nests. The favorite location for this form is the area around the anus, buttocks, perineum, lower abdomen, and less commonly the neck and trunk. Cases of thrush of the nipple in nursing women, as well as fungal lesions of the skin in the depth of the fold under the breast gland, are known. Cases of fungal lesions of acute and chronic gastric ulcers are also noted. The diagnosis of thrush is generally not difficult. Difficulties may arise in cases of isolated thrush of the pharynx, which can be confused with diphtheria, and thrush of the skin, which is difficult to distinguish from many other skin lesions and even syphilis. Decisive in all cases is the examination for fungus. It differs from aphthous stomatitis, characterized by the formation of round, shiny, asbestos-like plaques, in that it does not form membranes.-The prognosis in thrush depends entirely on the course of the underlying disease. In healthy children it is favorable; it is especially poor in those with severe intestinal disorders and in cases of disseminated form.-Treatment of thrush consists in combating the underlying disease and in proper care of the oral cavity, careful removal of fungal deposits, and subsequent lubrication of the mucous membrane with a silver solution. Various gargles and irrigations are also used: solutions of soda (5%), borax (10-15%), and others. Fischl recommends ferric chloride (2-3%).-Prevention is of great importance. When breastfeeding, the nursing mother must observe thorough cleanliness of the hands and before feeding wipe the breast with a swab moistened with boiled water; it is important to keep the body clean. With mixed and artificial feeding, careful attention must be paid to the cleanliness and sterility of utensils and bottles. A poorly maintained nipple can often be a source of infection and should be discarded from the child's use. All these measures are especially important in relation to the sick child. For patients, it is particularly necessary to ensure an adequate supply of water and care for the visible mucous membrane of the mouth (lubrication with oil, vaseline). Wiping and lubrication of the mucous membrane for prevention are not recommended, as they injure the mucous membrane. Social prevention coincides with the prevention of those diseases that create a favorable environment for thrush, primarily intestinal diseases in early childhood. In view of the important role of transmission of the fungus from the mother, it is necessary to wage a vigorous struggle for the improvement of her oral cavity, especially during pregnancy and lactation.