Candidiasis is a fungal infection caused by yeasts from the genus Candida. It is commonly called oral candidiasis or thrush when it affects the mouth. It is one of the common side effects associated with the long term use of steroid inhalers. Nebulizing therapy with corticosteroids is widely accepted treatment approach for patients with acute exacerbations of Chronic Obstructive Pulmonary Disease. The other side effects of steroid inhalers include hoarseness of voice and dysphonia, which are usually ignorable. We report this case of 74 year old male patient who was on metered dosage inhaler and nebulizer therapy with corticosteroid and presented with oral candidiasis. If oral thrush develops, treatment with oral fluconazole or nystatin mouth wash is beneficial. Proper patient education by the clinical pharmacist to the patient regarding safe and effective usage of inhalers and nebulizers especially corticosteroids can minimize these drug related problems.

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A CASE REPORT ON ORAL CANDIDIASIS INDUCED BY INHALER CORTICOSTEROIDS
Samson Deepak. A1*
, Gangula Amareswara Reddy1
, M. Venkata subbaiah2
, Dr. Venkata Ravi Kumar
chepuri3
1
Pharm D, Department of Pharmacy Practice, P. Rami Reddy Memorial college of Pharmacy, Kadapa, India.
2
Assistant Professor, P. Rami Reddy Memorial college of Pharmacy, Kadapa, India.
3
M.D, Assistant Professor, Department of Medicine, Rajiv Gandhi Institute of Medical Sciences, Kadapa, India.
Corresponding author
Samson Deepak. A
PharmD Intern,
Department of Pharmacy Practice,
P. Rami Reddy Memorial college of Pharmacy (PRRMCP),
Kadapa, Andhra Pradesh, India - 516001
samsondeepak121@gmail.com,
+91 9502896707.
Copy right © 2015 This is an Open Access article distributed under the terms of the Indo American journal of Pharmaceutical
Research, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ARTICLE INFO ABSTRACT
Article history
Received 21/02/2015
Available online
14/03/2015
Keywords
Oral Candidiasis,
Thrush,
Inhaled Corticosteroids,
Nebulizer Therapy,
Budesonide,
Immunosuppressant.
Candidiasis is a fungal infection caused by yeasts from the genus Candida. It is commonly
called oral candidiasis or thrush when it affects the mouth. It is one of the common side
effects associated with the long term use of steroid inhalers. Nebulizing therapy with
corticosteroids is widely accepted treatment approach for patients with acute exacerbations of
Chronic Obstructive Pulmonary Disease. The other side effects of steroid inhalers include
hoarseness of voice and dysphonia, which are usually ignorable. We report this case of 74
year old male patient who was on metered dosage inhaler and nebulizer therapy with
corticosteroid and presented with oral candidiasis. If oral thrush develops, treatment with oral
fluconazole or nystatin mouth wash is beneficial. Proper patient education by the clinical
pharmacist to the patient regarding safe and effective usage of inhalers and nebulizers
especially corticosteroids can minimize these drug related problems.
Please cite this article in press as Samson Deepak. A et al. A Case Report on Oral Candidiasis Induced By Inhaler
Corticosteroids. Indo American Journal of Pharm Research.2015:5(02).

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INTRODUCTION
It is identified by the presence of well-documented curdy white plaques. Curdy white lesions are displayed in the form of a
membrane and are reservoir for Candida albicans[1]. It is also termed by other words such as oral yeast infection, candidal stomatitis,
oral candidosis, oral mycosis and moniliasis[2]. Candidiasis is categorized into primary oral candidiasis in which the condition is only
confined to mouth where as in secondary oral candidiasis the condition is confined to other body parts in addition to mouth[3]. After
viral and bacterial infections, fungal infections stands third among total infections caused by microorganisms[4]. Candida albicans is
the important fungal species responsible for oral candidiasis. Other important species which have been found to cause candidiasis are
candida tropicalis, candida krusei and candida stellatoidea[5]. Predisposing factors for candidiasis include suppressed or
compromised immunity, long term administration of immunosuppressant's.The other conditions that play a prominent role in the
development of candidiasis are administration of chemotherapy, human immuno deficiency virus (HIV)infection, nutritional
deficiencies, stress and usage of steroids[6,7]. The fungal organism is buried underneath the superficial layers of epithelium. Hence
the mainstay for treatment is topical application of antifungal agents like fluconazole, nystatin, clotrimazole and ketoconazole[8].
Frequent usage of steroid inhalers will increase contact of drug with oral mucosa and it leads to immunosuppression in the
localized oral mucosa which further causes overgrowth of fungal species. Chronic asthmatics who are on inhaler steroids are more
prone to develop oral candidiasis[9,10]. The colonies appear as curdy white lesions on tongue, soft palate, gums and buccal mucosa.
Gradually, the curdy white precipitates peel off and it leaves behind an raw-looking oral severe erythematous area. The lesions usually
are asymptomatic. The patient usually complaints of burning sensation while taking foods. Along with candidiasis persistent usage of
steroid inhalers may additionally cause pharyngeal discomfort, hoarseness of voice, dysphonia[11,12]. Oropharyngeal candidiasis
must be suspected whenever an asthmatic who is on long term steroid inhalers and complaints of burning sensation or oral mucosal
lesions. Recently, nebulizer therapy with short acting corticosteroids such as fluticasone or budesonide are commonly given to
patients[5].
CASE REPORT
A 74 year old male patient reported to the department of General Medicine with complaints of shortness of breath and
generalized weakness even during resting state. The patient was diagnosed with acute exacerbation of COPD with respiratory failure.
The patient was known smoker and he gave up his habit two years back. The patient was on rescue therapy i.e., short acting β2 agonist
and inhaled corticosteroid from five years. In addition to that the patient frequently received Budesonide nebulizing therapy twice a
day. The patient was prescribed with following prescription: Nebulizer Corticosteroid (Budesonide) twice a day, oral bronchodilator
(Salbutamol) every 6th hourly and oral methylxanthine derivative (Deriphylline). On the fifth day of his admission the patient
complaints of itching sensation, roughness of soft palate and burning sensation while taking food. On intraoral examination, we
observed curdy white lesions all over tongue, buccal mucosa and soft palate (Figure-1). On gently rubbing this white patchy areas
erythematous underlying mucosa was visible with a tendency to bleed. For cytological evaluation, a smear was made from scrapings
of these lesions, and reports were supportive for candidiasis.
Figure-1: Curdy white lesions.
To establish the relationship between drug and suspected reaction we performed causality assessment using Naranjo's scale,
WHO probability scale and Karch and Lasagna's scale (Table-1). We further analyzed this reaction to find the severity with Modified
Hartwig and Siegel scale, predictability based on the pharmacological action and preventable with Schumock and Thornton
Preventability Scale (Table-2). The patient was advised to discontinue nebulizer corticosteroid therapy for a while. As the patient is
experiencing acute exacerbation of COPD, we did not recommend stopping rescue therapy (Metered dosage inhaler containing
levosalbutamol and beclomethaosne dipropionate). We advised the patient to use spacer while using MDI. Rinse or gargle his mouth
after every dose of inhaled corticosteroid, but do not swallow the gargled water.

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Table-1: Causality assessment of suspected ADR.
S. No. ADR Scale Result
1 WHO-UMC Probable
2 NARANJO'S Possible
3 KARCH AND LASAGNA Conditional
Table-2: Analysis of suspected ADR.
S. No. Assessment Result
1 Severity Moderate level:3
2 Preventability Probably preventable
3 Predictability Predictable
DISCUSSION
Cells of immune system such as macrophages, lymphocytes and neutrophils control fungal infections. Either systemic or oral
corticosteroid treatment, immunosuppressive therapy targeting these cells, and immunodeficiency diseases are important risk factors
for fungal diseases [5]. The genus Candida comprises of more than 150 species, only a few of which cause disease in humans. Human
pathogens are Candida albicans, Candida krusei, Candida guilliermondii, Candida galbrata, Candida kefyr and Candida lusitaniae.
Candida is small, thin-walled, ovoid yeast that measures 4-6 µm in diameter and it multiplies through the process of budding.
Organisms of this genus occur in three forms in tissues: blastospore, pseudohyphae and hyphae. These organisms are ubiquitous in
nature found on inanimate objects, foods, animals and are normal commensals of humans. They commonly reside in gastrointestinal
tract (including mouth and oropharynx), the female genital tract and skin[12].
For severe asthmatics, higher dosage of inhaled steroids or frequent usage of these medications can also lead to the development of
thrush.
If thrush develops person may need treatment with nystatin mouthwash or oral fluconazole. Some people require periodic
rinsing (once daily to few times per week) with nystatin in order to keep thrush from coming back.
CONCLUSION
In conclusion, we report a case of inhaler corticosteroid induced oropharyngeal candidiasis. These type of reactions are
common in patients receiving inhaler and nebulizer corticosteroids. So, we strongly recommend that assessment should be made
rapidly and prompt interventions must be implemented and followed to reduce this adverse effect among the patients receiving
nebulizer or inhaler corticosteroid therapy. If oral thrush develops, treatment with oral fluconazole or nystatin mouth wash may be
beneficial. We recommend further research.
Physicians may direct the patients to the clinical pharmacist for advise, patient counseling and close monitoring of
therapeutic outcomes which minimizes these drug related problems and improves patient compliance.
Conflict of interests
The authors have declared that they have no conflict of interest.

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