DIAGNOSIS OF ORAL

INFECTION
 ORAL INFECTIONS

Viral infections
Bacterial infection •Human herpes
•Impetigo viruse
Fungal and ProtozoaL
•Erysipelas •Herpes simplex
infections
•Scarlet fever •Candidiasis viruses
•Streptococcal phayngitis •Histoplasmosis •Varicella
• Syphilis •Blastomycosis •Herpes zoster
•Diphtheria •Coccidiomycosis •Infectious
•Gonorrhea •Cryptococosis mononucleosis
•Leprosy •Zygomycosis •Enteroviruses
•Tuberculosis •Paracoccidiomycosis •Rubeola
•Actinomycosis •Aspergillosis •Rubella
•Cat scratch disease •Toxoplasmosis •Mumps
•Human
immunodeficiency
virus
DIAGNOSIS OF IMPETIGO
 Impetigo is usually diagnosed on the basis of clinical findings.
A strong presumptive diagnosis can normally be made from
clinical presentation
 The Nonbullous impetigo appears as red macules or papules
with subsequent development of the vesicles.amber colour rust
form on the vesicles which is adherent and can be described as
“cornflakes glued to the surface
 Bullous impetigo lesions are categorized by superficial
vesicles that enlarge to form flaccid bullae which are filled
with clear serous fluid.later on the fluid becomes turbid and
purulent.
Laboratory findings in impetigo
 Bacterial culture and sensitivity are recommended (1) in cases to identify methicillin-
resistant Staphylococcus aureus (MRSA), (2) if an outbreak of impetigo has occurred, or
(3) if poststreptococcal glomerulonephritis is present. Exudate from underneath the crust
is sent for culture.
 Leukocytosis
 Antideoxyribonuclease (anti-DNAase) B antibody levels are often elevated in persons
with streptococcal impetigo.
 A bacterial culture of the nares may be obtained to determine whether a patient is an S
aureus carrier.
 If the nares culture is negative and the patient has persistent recurrent episodes of
impetigo, bacterial cultures should be obtained from the axillae, pharynx, and perineum.
 Obtain serum IgM levels in cases of recurrent impetigo in patients with negative S
aureus carrier status and no predisposing factors such as a preexisting dermatosis.
 A biopsy may be necessary in doubtful or refractory cases of impetigo
DIAGNOSIS OF ERYSIPELAS
 Clinical findings: commonly occurs in traumatic regions.most commonly affected
area is the leg. In facial erysipelas increase prevalence is noted in the spring and
winter months. The lesion appears as butterfly rash involving cheeks,eyelids and
bridge of the nose.skin demonstrate a surface texture that resemble an orange peel
(peau d’orange). High fever and lymph- adenopathy are often present. Culture are
usually not beneficial therefore diagnostic confirmation is difficult.
 Laboratory Studies
 In general, diagnosis of erysipelas is made clinically.
 Complete blood count (CBC): Increased WBC with a may be observed but is not
specific for the diagnosis.
 Blood cultures
 Positive in only 5% of cases
 Antistreptolysin (ASO), streptozyme, and anti-DNAase titers may be helpful.
 Differential diagnosis of
impetigo
Contact dermatitis by poison ivy
Tinea infection
Herpes simplex infecton

Differential diagnosis of
erysipelas
Contact dermatitis
Angioneurotic edema
Lupous erythematous
Herpes zoster
DIAGNOSIS OF SCARLET FEVER
 Clinically disease occuras erythmatous and edematous tonsils ,soft palate and phaynx.
Tonsillar crypts may be filleda yellowish exudates.
 during first 2 days tongue demonstrate a white coating though which only the fungiform
papilae can be seen.this has been called as white strawberry tongue.
 By the fourth or fifth day white coating desquamates to teveal an erythematous dorsal
surface and called as red strawberry tongue.
 The pastia ‘s lines seen in the folds of the rash. Patient present with high fever.
 A culture of throat secretion may be used to confirm the diagnosis, but this has been
replaced by the several methods of detection of the antigens that are specific for group a
beta hemolytic streptococci.
Laboratory Studies
 Throat culture remains the criterion standard for confirmation of group A streptococcal
upper respiratory infection.
 Throat cultures are approximately 90% sensitive for the presence of group A beta-

hemolytic streptococci in the pharynx.

 Vigorously swab the posterior pharynx, tonsils, and any exudate with a cotton or

Dacron swab under strong illumination, avoiding the lips, tongue, and buccal
mucosa.
.
 Direct antigen detection kits (ie, rapid antigen tests [RATs], strep screens) have been proposed to
allow immediate diagnosis and prompt administration of antibiotics.
 Kits are latex agglutination or a costlier enzyme-linked immunosorbent assay (ELISA).
 Several studies of RAT kits report results of 95% specificity but only 70-90% sensitivity.
 Streptococcal antibody tests are used to confirm previous group A streptococcal infection
 The most commonly available streptococcal antibody test is the antistreptolysin O test.
 Complete blood count
 White blood cell (WBC) count in scarlet fever may increase to 12,000-16,000 per mm3, with a
differential of up to 95% polymorphonuclear lymphocytes.
 During the second week, eosinophilia, as high as 20%, can develop

Differential diagnosis
Mononucleosis
Kawasaki Disease
Roseola
Staphylococcal Scalded Skin Syndro
me
DIAGNOSIS OF DIPTHERIA
Clinical features
 Initial systemic symptoms include
 low grade fever headache malaise,sore throat etc.

 pseudomembrane formation of one or both the tonsils as a patchy yellow white

thin film that thickens to form an adherent gray covering

 attempts at removal results in bleeding.aithough the clinical presentation can be

distinctive in severe cases but lab confirmation is sought in all instances.

 Laboratory Studies

 The specimen for culture should be obtained from underneath the surface of the

membrane. Others areas for the culture are the nasal mucosa and swabs from the
wounded surface.
 Diagnostic tests used to confirm infection combine isolation of C diphtheriae on

cultures with toxigenicity testing

 Bacteriologic culturing is essential to confirm the diagnosis of diphtheria.
 Obtain specimens from the nose and throat (ie, nasopharyngeal and pharyngeal

swab) for culture.

 Obtain specimens from the membrane as well as from the nose and throat. If

possible, swabs also should be taken from beneath the membrane

 isolation of C diphtheriae requires special culture media containing tellurite. C
diphtheriae may be grown on various selective media, including tellurite agar or
specially enriched Loeffler, Hoyle, Mueller, or Tinsdale medium.

Toxigenicity testing is also performed.

 Perform toxigenicity testing using the Elek test to determine if the C diphtheriae

isolate produces toxin.

 Toxigenicity tests are not readily available in many clinical microbiology

laboratories; send isolates to a reference laboratory with personnel proficient in

performing the tests
 Measurement of the patient's serum antibodies to diphtheria toxin before
administration of antitoxin may help assess the probability of the diagnosis of
diphtheria.
 If antibody levels are low, diphtheria cannot be excluded, but if levels are high, C
diphtheriae is less likely to produce serious illness. 

Differential diagnosis
Vincent angina
Exudative pharyngitis due to
Streptococcus pyogenes and
Epstein-Barr virus
Mucositis
Herpes Simplex Virus Infection
Impetigo
Candidiasis
DIAGNOSIS OF GONORRHEA
CLINICAL PRESENTATION:
 Most common site of orophayngeal involvement is phaynx along with tonsils and uvula.
 Mild to moderate sore throat
 Involved tonsils demonstrate edema and erythema with scattered small punctate
pustules.
 Rarely involve anterior part of oral cavityand infectiuos areas appear as
erythematous,pustular edematous and ulcerative simulating NUG.
 Cervical or submandibular lymphadenopathy may be seen.
Laboratory Studies
 Males with a urethal discharge, a gram stain of the purulent material can be used to
demonstrate gram negative diplococcic within the neutrophils.
 Although gram stains may be beneficial, confirmation of the diagnosis is recommended
by culture of endocervical swabs if conditions are adequate to maintain the viability of
the organisms. Nucleic acid amplification tests (NAATs) amplify and detect
N.gonnorhea-speciic DNA or RNA sequences are recommended for the diagnosis when
onditions are not adequate to maintain the viability of the organisms.
 in spite of the availaibility of NAATs, culture remains the preferred diagnostic method for diagnosis
of oropharyngeal infections.
 Culture is the most common diagnostic test for gonorrhea, followed by the DNA probe, and then
polymerase chain reaction (PCR) and ligand chain reaction (LCR).
 The DNA probe is an antigen detection test that uses a probe to detect gonorrhea DNA in

specimens.
 PCR and LCR are gene amplification techniques that markedly increase the sensitivity
of specimen testing. Both techniques amplify the genetic fingerprint of specimens with
very few organisms present in order to more easily detect and identify the organisms
 Perform a culture or nonculture detection test for N gonorrhoeae on endocervical,
urethral, pharyngeal, or rectal discharge. Because organisms are intracellular, attempt
to obtain specimen in a manner that will contain mucosal cells and not merely
discharge
 Culture is performed on Thayer-Martin plates that must be stored
refrigerated but warmed to room temperature before obtaining sample. The
plate is then incubated in a carbon dioxide atmosphere. Poor technique
drastically reduces test sensitivity.
 Histologic Findings
 A Gram stain of urethral or cervical discharge may show gram-
negative intracellular diplococci (diagnostic in the male) and
polymorphonuclear cells.
 This is very useful if the physician has easy access to a microscope
because the diagnosis may be made without waiting for culture results.
TUBERCULOSIS

 The presumptive diagnosis is made by the medical history of

the patient. The definitive diagnosis of tuberculosis is made
by demonstration of positive delayed hypersensitivity skin
reaction purified protein derivative and demonstration of
acid fast bacilli in clinical specimen.
Clinical findings:
 Primary tuberculosis is usually asymptomatic.
 Secondary tuberculosis have a low grade fever, malaise
anorexia, weight loss and night sweats.
 Oral lesion of TB are uncommon, with most cases appearing
as a chronic painless ulcers.
 Less frequent presentations include nodular, granular or firm
leukoplakic areas.
 Primary oral TB usually involves the gingiva, mucobuccal
fold and ares of inflammation adjacent to teeth . Tese lesion
are usually associated with enlarged regional lymph nodes.
 Secondary oral lesion present on tongue palate and
lips.
 Scrofula is a mycobacterial infection characterized
by by enlargement of oropharyngael lymph nodes
and cervical lymph nodes.
 Caseous necrosis occurs in lymph nodes and form
numerous sinus tract through overlying skin.
Hitopathologic features
 CMI is responsible is responsible for classic
histopatholgic presentation of TB. Areas of
infection demonstrate granulomas formation which
are circumscribed collections of epithileoid
histiocytes, lymphocytes and multinucleated giant
cells often with central caseous necrosis.
 Special stains such as Ziehl-neelson or other acid
fast stains are required to demonstrate the
mycobacteria.
Lab tests
 Tuberculin tests or purified protein derivative skin tests.
o A positive tuberculin tests result in dictates exposure and to the organism and

does not distinguish infection from active disease.

 Detection of mycobacteria by special stains
 Culture
 PCR

Differential diagnosis
Sarcoidosis
Blastomycosis
Catscratch disease
Actinomycosis
Aspergillosis
Nocardiosis
Paracoccidiomycosis
Histoplasmosis
Bronchiectasis
LEPROSY
The definitive diagnosis is based o the clinical presentation and supported by the
demonstrated of the acid fast bacilli on a smear or in the tissue. The organism cannot be
cultivated on artificial media , but M.leprae without developing the disease ; this creates
difficulties in establishing the diagnosis and determining the prevalence of infection
Clinical presentation :
 clinically disease occurs in two forms paucibacillry and multibacillary with distinction
influencing the recommende formof therapy.
 oral lesion in the paucibacilary form is rare.
 The multubacillary lesion occurs mostly on face and skin enlargements can lead to
distorted facial appearances( leonine facies).nasal involvement results in nose
bleed,stuffiness, and loss of sense of smell. The hard tissue of floor,septum and bridge of
nose may be affected. Collapse of the bridge of nose is considered pathognomonic.
 The oral location affected in order of frequency are hard palate ,soft palate, labial
maxillary gingival, and buccal mucosa.
 affected soft tissue initially appear as yellowish to red ,sessile ,firm, enlarging papules
that develop ulceration and necrosis followed by attempted healing by secondary
intention.
 The infection creates a unique pattern of facial destruction that has been termed facies
leprosa and demonstrate a triad of lesions consisting of atrophy of anterior nasal spine,
atrophy of anterior maxillary ridge and endonasal inflammatory changes.
 Granulomatous involvement of the nasal cavity can erode through the palatal tissues
and result in perforation.

Laboratory Studies
Laboratory studies include the following:
 Skin biopsy, nasal smears, or both are used to assess for acid-fast bacilli using Fite stain.
Biopsies should be full dermal thickness taken from an edge of the lesion that appears
most active.
 Serologic assays can be used to detect phenolic glycolipid-1 (specific for M leprae) and
lipoarabinomannan (commonly seen in mycobacteria)
 Laboratory tests related to drug treatment follow-up include the following:
 CBC count
 Creatinine level
 Liver function tests
 Other Tests
Immunologic tests include the following
 Lepromin skin test.

 Phenolic glycolipid-1: This is a specific serologic test based on the detection of

antibodies to phenolic glycolipid-1. This test yields a sensitivity of 95% for the
detection of lepromatous leprosy but only 30% for tuberculoid leprosy.
 Polymerase chain reaction (PCR): PCR and recombinant DNA technology have

allowed for the development of gene probes with M leprae –specific sequences. This
technology can be used to identify the mycobacterium in biopsy samples, skin and
nasal smears, and blood and tissue sections.
 Lymphocyte migration inhibition test (LMIT): As determined by a lymphocyte

transformation and LMIT, cell-mediated immunity to M leprae is absent in patients

with lepromatous leprosy but present in those with tuberculoid leprosy.
 Histologic Findings
 Findings vary but can include giant cells, infiltration of nerve bundles with mononuclear
cells, and granulomas. Lepromatous lesions generally contain numerous acid-fast bacilli
and fat-laden macrophages with a paucity of lymphocytes. Histopathology of leprosy is
seen in the image below. 

Histopathology of leprosy: Large numbers of acid-fast bacilli

(in clusters) in histiocytes and within nerves. Fite-Faraco stain
500x
DIAGNOSIS OF SYPHILIS
 The presumptive diagnosis can be made by the clinical
features of syphilitic lesions. The definitive diagnosis of the
disease can be confirmed by demonstration of the spiral
organism and by various lab findings.
Clinical features
Primary syphlis:
 Characterize by chancre that develop at site of inoculation
 May be solitary or multiple in numbers.
 External genitalia and anus are the most common site.
 Oral cavity is most common extragenital site.
 Oral leions : commonly seen on lips,
painless and clear based ulceration
bilateral regional lymphadenopathy
Secondary syphilis:
 discovered after 4 to 10 weeks after initial infection.
 A consistent sign is diffuse, painless maculopapular rash and
heals without scarring.
 Systemic symptoms are also there.
 Elevated mucous patches may be centered over
the crease of oral commisure and termed as split
papules.
 Papillary lesion resemble viral pappilomas
known as condylomata lata may be occasionally
present
Tertiary syphilis:
 Gumma : indurated, nodular or ulcerated lesion
that may produce extensive tissue destruction.
 Tongue appear large , lobulated and irregularly
shaped. This lobulated pattern is known as
interstitial glossitis.
 Leutic glossitis : diffuse atrophy and loss of
dorsal tongue pappilae.
Congenital syphilis: three pathognomic diagnmostic
features known as Hutchinson’s triad:
 1. Hutchinson teeth,
 2. Ocular intertstial keratitis and
 3. Eight nerve deafness
Histopathologic findings :
PRIMARY SYPHLIS:
Histopathologic picture of the oral lesions in syphilitic patient
is not specific. The surface epithelium is ulcerated in primary
lesion and the underlying lamina propria is highly vascular
and chronic inflammatory reaction is present
SECONDARY SYPHILIS:
in secondary syphilis ulceration may not be present and
surface epithelium show hyperplasia with significant
spongiosis and exocytosis .
use of special stains such as Warthin-Starry or Steiner stains
often show scattered corkscrew like spirochetal organisms
that frequently found in surafce epithelium.
TERTIARY LESION:
oral tertiary lesion show surface ulceration with
psuedoepitheliomatous hyperplasia. The underlying
inflammatory infiltrate usually demonstrate foci of
granulomatous formation with circumscribed collections of
histiocytes and multinucleated giant cells.
 Lab diagnosis of syphilis
 Darkfield microscopy of chancre showing
– corkscrew-shaped organisms with tightly wound spirals
– forward and backward motion with rotation
– Soft side-to-side bending and twisting
– Specific but not sensitive
• Direct fluorescent antibody test of specimen (DFA-TP)
 Serologic tests
– Non-treponemal
• Venereal Disease Research Laboratory (VDRL)
• Rapid Plasma Reagin (RPR) test
– Tests for auto-antibodies to cardiolipin, a tissue lipid
– Easy and cheap, used for screening
– Used to follow treatment
– Sensitive except in late syphilis, specific
 Gold Standard:
– Culture of T. pallidum by in vivo intratesticular inoculation of rabbits
– Not done routinely
 Serologic tests
Treponemal
• Fluorescent treponemal antibody absorption (FTA-ABS)
test
• Microhemagglutination test for antibodies to Treponema pallidum (MHA-TP)
• Treponema pallidum particle agglutination assay(TPPA) – More sensitive and more
specific, even in late syphilis

Differentail diagnosis
•Candidiasis (oral or genital)
• Leprosy
•Chancroid
• Rubella
• Fungal infections
• Rubeola
• Herpes simplex
• Sarcoidosis
• Herpes zoster
• Tuberculosis
• Infectious mononucleosis
DIAGNOSIS OF ACTINOMYCOSIS
 The diagnosis of actinomycosis is made by culture and the isolation of the causative
organism. A presumptive diagnosis can be made by clinical features.
 Clinical features
 Classic lesions of cervicofacial actinomycosis are chronic low grade persistent
infection .
 Submandibular region is the most affected site.
 Associated changes may be seen such as nonhealing socket, exuberant granulomatous
tissue,or periosteal thickening of alveolus.
 Board like induration of the skin.
 Multiple draining sinus.
 Skin discharging sinuses is purplish and there may be areas of hypertropic granulation
tissue.
 Sulphur granules are often present in the pus .
Laboratory Studies
 CBC count: Anemia and mild leukocytosis are common.
 Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels are often
elevated.
 Chemistry results usually are normal, with the exception of a frequently elevated
alkaline phosphatase level in hepatic actinomycosis.
 Organism cultures
 Because actinomycosis is difficult to diagnose based on the typical clinical

features, direct identification and/or isolation of the infecting organism from a

clinical specimen or from sulfur granules is necessary for definitive diagnosis in
most cases.
 Acceptable specimen material is obtained from draining sinuses, deep needle

aspirate, or biopsy specimens;

 A Gram-stained smear of the specimen may demonstrate the presence of

beaded, branched, gram-positive filamentous rods, suggesting the diagnosis of

actinomycosis.
 Nucleic acid probes and polymerase chain reaction (PCR) methods are being

developed for more rapid and more accurate identification

Histologic Findings
 Actinomycosis is characterized by mixed suppurative and granulomatous
inflammatory reactions, connective-tissue proliferation, and the presence of sulfur
granules. The sulfur granules are nearly pathognomonic for actinomycosis, although
similar findings have been reported with infections caused by Nocardia brasiliensis,
Streptomyces madurae, and Staphylococcus aureus presenting as botryomycosis.
The granules are approximately 0.1-1 mm in diameter and may be seen with the
naked eye as yellowish particles.

 Microscopically, the granules manifest a cauliflowerlike shape at low magnification;

at higher magnification (X100), when the particle has been pressed between slide
and cover slip, a clump of filamentous actinomycete microcolonies surrounded by
polymorphonuclear neutrophils (PMNs) can be observed.
 Gram stain renders these microcolonies visible as gram-positive, intertwined
branching filaments, with radially arranged, peripheral hyphae. Coexisting with
them are the companion bacteria, which are gram-positive and gram-negative cocci
and rods.
ACTINOMYCOSIS IN THE ENDOMETRIAL ACTINOMYCOSIS IN THE ENDOMETRIAL
TISSUE, LOW-POWER VIEW TISSUE, HIGH-POWER VIEW

Differential diagnosis
Tuberculosis Cat scratch disease
Syphilis Lymphogranuoma venerum
Histoplasmosis Neoplasm
Osteomyelitis
Diagnosis of Cat scratch disease:

 The diagnosis of cat scratch disease is established via serologic tests that
demonstrate a high degree of sensitivity and specificity. The most widely
used is an indirect florescent antibody assay for detecting antibodies to
B.henselae.
 Another method is an enzyme linked immunosorbent assay for IgM

antibodies to the organism. Polymerase chain reaction techniques also are

available but are not widely used.
 Clinical features: the infection can appear as an intraoral mass in the buccal
mucosa when lymphoid aggregates became involved from an adjacent
cutaneous primary site. Primary lesion adjacent to eye can result in a
conjuctival granuloma that is associated with preauricular lymphaenopathy
(oculo-glandular syndrome of parinaud) this pattern is thought to occur when
an individual touches fur moistened with cat’s saliva during grooming
 Laboratory Studies
 Routine laboratory tests in patients with suspected catscratch disease (CSD) are
usually unremarkable and are very unlikely to aid in diagnosis. Findings such as
mild leukocytosis and elevated erythrocyte sedimentation rate are common but
are also nonspecific and of little value.
 Until recently, diagnosis was based on the fulfillment of specific clinical criteria.
The recent development of serologic testing has effectively provided laboratory
confirmation of the diagnosis. The addition of PCR from lymph node biopsy
provides an even more sensitive detection of disease. When such testing is
performed, it is usually performed on an outpatient basis.
 Indirect fluorescent antibody (IFA) testing for Bartonella is quite variable as many
different tests are available. Test sensitivity (as low as 53%) is typically quite poor, but this
can be improved by concurrent use of both IgG and IgM testing. Specificity of IgM and
IgG testing ranges from 88-98% and 50-62%, respectively. Most populations have low (2-
6%) background seropositivity rates, limiting false-positive test results. The IFA shows
cross-reactivity between Bartonella species, Epstein-Barr virus, cytomegalovirus,
Toxoplasma gondii, and Streptococcus pyogenes.5
 Infection is best demonstrated by rising immunoglobulin G (IgG) titers; however,
patients may already have high levels at presentation.
 Histopathological features of lymph nodes are consistent but not pathognomonic for CSD. Features include
granuloma formation, stellate abscesses, and lymphocytic infiltrates.
 Brown-Hopp tissue Gram stain and Warthin-Starry silver staining show small, curved, gram-negative bacilli .


Warthin-Starry stained sections of lymph node showing chains and clusters of organisms .

Differential diagnosis
Syphilis
Lymphogranuloma Venereum
Toxoplasmosis
Mononucleosis
Tuberculosis
Sarcoidosis
DIAGNOSIS OF CANDIDIASIS
CLIICAL FINDINGS:
 Psuedomembranous candidiasis characterized by adherent white plaques that

resmble cottage chese or curdled milk on the oral mucosa.scrapng the lesion
with tongue blade or rubbing them with dry gauge can remove these plaques.
 Eryhematous candidiasis:it may present as acute atrophic candidiasis or sore

mouth in which burning sensation in the mouth accompanied by loss of filiform

papillae of the dorsal resulting n a reddened bald appearance of the tongue.
 Cental papillary atrophy of tongue or median rhomboid glossoitis.clinically it

appers as well demarcated erythematous zone that effect the midline ,posterior
dorsal tongue and often is asymptomatic.erythema is due to loss of filliform
papilaein this area. It may also present as kissing lesion when dorsal
erythmatous lesion of the tongue and the palatal lesion come in close proximity.
 Angular chielitis is characterized by erythema fissuring and scaling
it often occurs elder person as aresult of reduced vertical dimension.
 Denture stomatitis it also classified as form of erythematous
candidiasis .this lesion is characterized by petechial hemorage
located o he denture bearing area it may present as pin point lesion or
as large erytmaous area under the denture.
 Chronic hyperplastic candidiasis whit plaques that are not removed
on scraping. Such lesion are locted on the anterior buccla mucosa and
often leukoplakic lesion is associated candidial infection has a fine
intermingling of red and white areas resulting in spekled leukoplakia.
 Mucocutaneous candidiasis white plaques some of which may be
removed.this lesion may be seen as relatively rare group of
immunologic disorders known as mucocutaneous candidiasis.
 Lab diagnosis demonstration of candida in the culture and smear confirm the diagnosis.
 A speimen for culture is obtained by rubbing a sterile cotton swab over the lesion and
then streaking the swab on the surface of sabouraud’s agar slant.
 The cytologic preparation demonstrates tubular appearing fungal hyphae and ovoid
yeasts of candida albicans.
 If the lesion is clinically suggestive of chronic hyperplastic candidiasis albicans but non
responsive to anifungal therapy then a biopsy should be performed to rule out the
possiblity of candida albicans superimposed on the epithelial dysplasia , squamous cell
carcinoma or lichen planus .
Histopathological finding:
 On staining with PAS ,the candidial hyphae and
yeast can be readily identified( as bright magenta
color)
 These hyphae may are approximately 2 um in dia.
 Elongation of epithelial ridges and increase
thickness of parakeratin.chronic inflammatory cell
infiltrate.neutrophil( micoabscess) are often
identified in the parakertin layer.

 Culture
 A specimen for culture is obtained by rubbing a
sterile cotton swab over the lesion and then
streaking on surface of sabouraud’s agar slant.
 Grow as creamy smooth surface colonie after 2 to 3
days of incubation at room temperature.
DIAGNOSIS OF HISTOPLASMOSIS
 Histoplasmosis diagnosis can be made by histopathologic identification of the
organism in tissue sections or by culture.
 Microscopic examation of the lesional tissue shows a diifuse infiltrate of
macrophages or more commonly collection of macrophages organized ito
granulomas the causative organism can be identified with some diificulty in the
routine hematoxylin and eosin .the special stains such as PAS and grocott-gomori
methemine silver methods readily demonstate the characterstics 1-2 um yeasts of H.
capsulatum.

Differential dianosis
Blastomycosis
Pneumonia
San Joaquin Valley fever
(coccidioidomycosis)
Aspergillosis
 Rapid diagnosis of blastomycosis can be peformed by microscoic examination of either
histopathologic sections or an alcohol fixed cytologic prepation. Most rapid diagnosis
is the KOH prepartion which may be used for examining scrapings from suspected
lesions.
 The most accurate method of identifying B. dermatidis is by obtaining culture
specimen from the sputum or fresh biopsy material and growing the organism on
sabourard’s agar. This is slow technique taking as long as 3 to 4 weeks for the
characteristics mycelium to yeast conversion to take place.
 A specific DNA probe has been developed allowing immediate identification mycelial
phase. Skin testing and sereologic studies are usually not helpful becuase of lack of
reactivity and specificity.

Differentila diagnosis
Bacterial pneumonia
Tuberculosis
Other endemic mycoses
Sarcoidosis
Cancer
HISTOPATHOLOGIC FINDINGS
 Histopathological examination shows a mixture of acute
inflammation and granulomatous inflammation surrounding
variable number of yeasts(8 to 20 um in dia).
 Yeast characyerized by doubly refractile wall and broad
attachment between budding daughter and parent cells.
 Induce pseudoepitheliomatous hyperplasia
 DIAGNOSIS OF PARACOCCIDIOMYCOSIS
 microscopic evaluation of tissue obtained from an oral lesion may reveal pseudoepitheliomtous
hyperplasia in addition to ulceration of the overlying surface epithelium.
 P .brasiliensis elicits a granulomatous inflammatory host response that is characterized by collection
of epithileiod macrophages and multinucleated giant cells.
 Scatterred ,large (upto 30 um in dia )yeasts are really identified after staining of the section with
Grocott-gomorri methenamine silver or PAS method. Organism show multiple daughter buds on the
parent cells resulting in an mickey mouse ears or the spokes of a ship steering wheel( mariner
wheel)
 Clinical findings : oral lesions appear as mulberry like ulceration that most commonly affect the
alveolar mucosa, gingival and palate. The lips ,tongue, orophaynnx ,and buccal mucosa are rarely
involved .
 Specimens for culture can be obtained but P. brasileinsis grow quite slowly

Differential diagnosis
Coccidioidomycosis (Infectious Diseases)
Histoplasmosis
Leishmaniasis
Syphilis
Leprosy
Tuberculosis
 Diagnosis of cocciodiomycosis
 The diagnosis of coccidiomycosis can be confirmed by culture or identification of
characteristics organism in biopsy material. If the organism do not have a classic
microscopic appeaance, then in situ hybridization studies using specific complementary
DNA probes for C.immitis cab be performed to definitively identify the fungus .
cytologic prepartions from bronchial swabbing or sputum samples may reveal the
organisms.
 Serologic studies are helpful in supporting the diagnosis and they may be performed at
the same time as skin testing

Differential diagnosis
Cryptococcosis
Pneumonia
Histoplasmosis
Lung Abscess
Tuberculosis
Wegener Granulomatosis
DIAGNOSIS OF CRYPTOCOCCOSIS

 microscopic sections of a cryptococcal lesion generally show a granulomatous inflammatory

response to the organism. The yeast appear as a round to ovoid structure ,4 to 6 um in diameter
surrounded by clear halo that represebnts the capsule staining with the PAS or Grocott- gomorri
methanaminesilver method readily identifies the fungus moreover a mucicaramine stain uniquely
demonstrate its mucopolysacchride capsule.
 The diagnosis of cryptococcosis can be made by several methods including biopsy and culture.
Detection of cryptococcal polysacchride antigen in the serum or cerebrospinal fluid is also useful as
a diagnostic procedure.

Differential daignosis
Basal Cell Carcinoma
Syphilis
Histoplasmosis
Toxoplasmosis
Lipomas
Tuberculosis
Molluscum Contagiosum
DIAGNOSIS OF ASPERGILOSIS
 the diagnosis of fungal infection can be established by identification of hyphae within tissue
section, this finding is only suggestive of aspergilosis because other fungal organisms may appear
similar microscopically.
 Ideally diagnosis is supported by culture of the organism from the lesion. Culture specimen of
sputum and blood are of limited value because they are often negative despite disseminated disease.

 Histopathologic features :
Tissue section show varying numbers of septate hyphae 3 to 4 um in dia . these hyphae show a
tendency to branch at an acute angle and to invade small blood vessels . the aspergilloma is
characterized by a tangled mass of hyphae with no evidence of tissue invasion .

Differential diagnosis
Mucormycosis
and other zygomycoses
(e.g., phycomycosis,
Fusariosis
Malignancy
Mycobacterial infection
Nocardiosis
TOXOPLASMOSIS

 Diagnosis is usually established by Identification of rising serum antibody titres to T .gondii

within10 to 14 days after infection
 Diagnosis may rest on the clinical findings and response of patient to therapy .
 Biopsy of an involved lymph node may suggest the diagnosis and the causative organisms
sometimes be detected immunohistochemically using antibodies directed against T.gondii specific
antigens. The diagnosis should also be confirmed by serologic studies, if possible
 Laboratory Studies
 Results from basic laboratory studies such as complete blood cell count (CBC), chemistries, and
liver function tests (LFTs) are typically normal, although lymphocytosis may be present.
 Indirect detection
 Indirect detection is performed in pregnant women and immunocompromised patients.
 Detection of immunoglobulin G (IgG) is possible within 2 weeks of infection using enzyme-
linked immunoassay (ELISA), IgG avidity test, and agglutination and differential agglutination
test. The presence of IgG indicates a likely past infection, while the presence of IgM usually
indicates acute infection (particularly in the absence of IgG).
  Sabin-Feldman dye test: Live organisms are used to demonstrate the presence of anti-T gondii
antibodies. This test is primarily used as a confirmatory test at reference laboratories.
 IgG avidity test: IgG produced early in infection is less avid and binds to T gondii antigens
more weakly than antibodies produced later in the course of infection. High antibody avidity
indicates an older, earlier infection. This test may be helpful in the setting of pregnancy, as the
timing of infection has prognostic value.
 Direct detection
 Polymerase chain reaction (PCR) amplification of T gondii genes is possible (samples may be
taken of the CSF, blood, lymph node, or tissue biopsies or aqueous humor).
 Culture: T gondii may be isolated from the blood via either inoculation of human cell lines or
mouse inoculation. Mouse inoculation may require a longer time to yield results and also is
likely to be more expensive.
DIAGNOSIS OF ZYGOMYCOSIS
Zygomycosis:
 diagnosis of zygomycosis is usally based on the histopathologic findings.
 a neutrophic infiltrate usually predominates in the viable tissue , but the host
inflammatory cell response to the infection may be minimal , particularly if the patient
is immunocompromised
 Histopathologic examination of lesional tissue shows extensive necrosis with numerous
large,branching, nonseptate hyphae at the periphery . the hypahe tend to branch at 90
degree angles .

Differential diagnosis
Actinomycosis
Peptic Ulcer Disease
Aspergillosis
Toxoplasmosis
Cryptococcosis
Nocardiosis
DIAGNOSIS OF VIRAL INFETION
MEASLES

 The diagnosis of measles is made based on clinical findings, including the classic triad
of cough, coryza, and conjunctivitis; the pathognomonic Koplik spots; and the
characteristic cephalocaudal progression of the morbilliform exanthem. However,
laboratory identification and confirmation of the diagnosis is necessary for purposes of
public health and outbreak control.

The US Centers for Disease Control and Prevention (CDC) clinical case definition for
reporting purposes requires only the following:
Generalized rash lasting greater than or equal to 3 days
Temperature greater than or equal to 101.0°F (38.3°C)
Cough, coryza, or conjunctivitis
 Available laboratory tests are as follows:
1. Immunoglobulin M (IgM): Measles-specific IgM antibody titers become positive around
3 days after the exanthem manifests and persist for at least 28 days.
2. Immunoglobulin G (IgG): A significant (>4-fold) rise in measles-specific IgG titers
between acute and convalescent sera confirms the diagnosis of measles, although relying
solely on rising IgG titers for the diagnosis delays treatment considerably.
 IgG testing in atypical measles: In atypical measles, laboratory evaluation of
serum/blood reveals very low titers of measles antibody early in the course of the
disease, followed by extremely high measles IgG antibody titers (eg, 1:1,000,000).
 Viral culture:
1. Throat swabs and nasal swabs
2. Urine specimens
 Polymerase chain reaction (PCR): Reverse transcription PCR is highly sensitive at
visualizing measles virus RNA in blood, throat, nasopharyngeal, or urine specimens and,
where available, can be used to rapidly confirm the diagnosis of measles.
 A complete blood cell count may reveal leukopenia with a relative lymphocytosis and
thrombocytopenia.
 Liver function test results may reveal elevated transaminase levels in patients with
measles hepatitis.
Histopathologic Findings
 Koplik spots represents the area of focal
hyperparakeratosis in which uncerlying epithelium
shows spongiosis and vesiculation in the epidermis
with scattered dyskeratotic keratinocytes.
Occasional multinucleated epithelial giant cells can
be seen.
 As the spots ages the epithelium exhibit exocytosis
by neutrophils leading to microabscess formation,
epithelial necrosis and ulceration.
 within the hyperplastic lymphoid tissue, numerous
multinucleated giant cells can be seen. These cells
are known as warthin-finkeldey giant cells
Differential diagnosis of Rubeola
•Drug reactions
• Kawasaki's disease
• Rocky Mountain spotted fever
• Rubella (German measles)
• Scarlet fever
• Secondary syphilis
RUBELLA
 The diagnosis of rubella solely based on clinical signs and symptoms is unreliable
because there are many other causes of rash that may mimic rubella infection and up to
50% of rubella infections may be subclinical.
Clinical presentation;
 Exanthematous rash: first sign , occurs on face and neck
spread to entire body within 1 to 3 days rash
resolved completely within 3 days
 Rash form discrete pink papules and finally fades with flaky desquamation .
Oral lesions
 Known as Forchheimer’s sign
 These consist of small dark red papules that develop on soft palate and may extend to
hard palate
 Available laboratory tests are as follows:
 Detection of rubella IgM

 IgG seroconversion or a fourfold or greater rise in titre to rubella virus (where the

second serum sample is collected at least 10 days after the first, acute sample)
 Detection or rubella virus genome in an appropriate specimen (not routinely

preformed for diagnosis as it is more difficult to perform than serologic techniques)

 A positive culture for rubella virus (not routinely performed)
 Rubella virus can be isolated from nasal, blood, throat, urine and cerebrospinal fluid
specimens from rubella. Virus may be isolated from the pharynx 1 week before and up
to 2 weeks after rash onset. Although isolation of the virus is diagnostic of rubella
infection, viral culture is demanding and labour intensive. Nasal, throat, blood, urine
and cerebrospinal fluid specimens can be used, together with tissues from biopsy or
autopsy for laboratory confirmation of CRS cases.

DIFFERENTIAL DIAGNOSIS OF RUBELLA

Allergic drug reaction
Roseola
Rubeola (measles)
Scarlet fever
HERPES SIMPLEX
 Clinical signs and symptons
 Microscopic diagnosis
 PCR
 Tissue culture
 Elevated Ig M titres followed by Ig G titres

1. Clinical presentation
 Most Herpes labialis cases are diagnosed clinically. Most episodes are preceded by a
prodromal phase that is characterized by pain, burning, itching, and erythema, lasting
about six hours. These symptoms are usually followed by lesions on or near the lips.
Over the next 72-96 hours these papules progress to vesicles (blisters) and then ulcers.
As the lesions heal they form hard crusts. The lesions are generally completely healed
by 8 to 10 days. Pain can be severe at the start of the infection and resolves over the
next 4 - 5 days.
 Most lesions occur on the lips. However, lesions can also occur on the nose, cheeks, or chin.
Lesions occurring in the oral cavity or face are less common. Intraoral lesions are hard to
locate and are difficult to distinguish from apthous ulcers or canker sores.
 About 25% of all episodes do not progress beyond the papule stage. These are called
"aborted" episodes. About one-half of these do not progress beyond the prodromal stage. HSV
isolation by cell culture is the “gold standard” for hsv 1 since it grows readily in tissue culture
.

Lab tests
 Viral isolation :most definitive diagnostic procedure Differential diagnosis
 Detect HSV antigens by fluorescent assay Herpangina
 Viral DNA by PCR Hand Foot and Mouth Disea
Most commonly diagnostic procedure se
 Cytologic smear Eryhthema multiforme
 Tissue biopsy Oral aphthous ulcers
Chancroid
Apthous ulcers
Syphilis
Cytomegalovirus
HISTOPATHOLOGIC FEATURES
 Infected epithelial cells exhibit acantholysis,nuclear clearing and nuclear enlargement or
ballooning degeneration.
 The acantholytic cells are termed tzank cells.

Intercellular edema appears and lead to formation of intarepithelial vesicles .
VARICELLA ZOSTER( CHICKEN POX)
 The diagnosis of varicella can be made from the history of exposure to VZV within last 3 weeks
and presence of typical exanthem.
 Confirmation can be obtained through a demonstration of viral cytopathologic effects present
withinepithelial cells harvested from vesicular fluid.
 Viral isolation in cell culture or rapid diagnosis from fluorescein-conjugated VZV monoclonal
antibodies can be performed.
 Serum samples can be obtained during the acute stage and 14 to 28 days later. Later sample
demonstrate fourfold increase in antibody titers to VZV.

Histopthological findings
 The cytolgic alterationare virtually identical to those described to HSV.

Differential diagnosis
Contact Dermatitis
Enteroviral Infections
Herpes Simplex Virus Infection
Impetigo
Urticaria
ENTEROVIRUS

Diagnosis of enterovirus infections is often clinical.

Clinical presentation:
Herpangina:
 acute onset of sore throat, dysphagia, fever,vomiting, myalgia
and headache.
 Oral lesions: few in numbers(two to six), usually on the
posterior area.(soft palate and tonsillar pillars) ,appear as red
macules which form fragile vesicle that rapidly ulcerate.(2 to 4
mm in dia). Ulcerations take 7 to 10 days to heal

Hand –foot and mouth disease:

 Skin rash and oral lesions are associted with flu like symptoms.
 the cutaneous lesion range from few to dozens and primarily
affect the borders of palms and soles and ventral surface and
sides of fingers.
 The oral lesion resemble those of herpangina but more numerous and not confined to posterior areas
of mouth.
 The labia mucosa, buccal mucosa and tongue are the most common sites
 acute lymphonodular pharyngitis: characterized by sore throat, fever and mild headache. Low
numbers of yellow to dark pink nodules develop on soft palate or tonsillar pillars. Nodules resolved
within 10 days without vesiculations or ulceration

Histopthological findings
 In pateints with herpangina and hand –foot and mouth disease, the areas of affected epithelium
exhibit intracellular and intercellular edema, which leads to extensive spongiosis and formation of
an intraepithelial vesicle. The vesicle enlarge and rupture through epithelial basal layer ,with
resulatnt formation of a subepithelial vesicle. Epithelial necrosis and ulceration soon
follows.inclusion bodies and multinucleated giant cells are absent
 Laboratory diagnosis can be achieved with serological tests, viral isolation by cell culture, and
polymerase chain reaction (PCR).
 Serology: The microneutralization test is the most widely used method for detecting antibodies
to enteroviruses.
 Viral isolation: The virus can be isolated from CSF, blood, or feces, depending on the site
affected, and the yield is increased if multiple sites are sampled. Enterovirus proPCR: This
rapid test is highly sensitive and specific for detecting enteroviral RNA in CSF specimens, with
a sensitivity of 100% and specificity of 97%.
 Cardiac enzyme levels may be elevated in persons with myopericarditis, indicating myocardial
damage.
 CSF analysis: The CSF profile in patients with aseptic meningitis usually reveals a mildly
elevated white blood cell count, and the differential invariably shifts to a predominance of
lymphocytes during the initial 1-2 days of illness. Glucose levels are normal or mildly
decreased, while the protein level is normal or slightly increased.
INFECTIOUS MONONUCLEOSIS

 The diagnosis of infectious mononucleosis is suggested by the clinical presentation and

should be confirmed through lab procedures.
Clinical presentation:
 In classic infectious mononucleosis in a young adult the prodromal fatigue,maliase, and
anorexia occur up to 2 weeks before development of pyrexia.
 80% of affeted young adults have oropharyngeal tonsillar enlargement.
 Lingual tonsils become hyperplastic and compromise the airway.
 Oral lesion include petechiae on the hard and soft palate. the petechiae are transient and
usually disappear within 2 to 48 hours.
Lab diagnosis:
 Serological findings:
Presence of paul bunnel heterophil antibodies
Positive in 90% of individual
In case of negative paul bunnel test, indirect immuofluorecsence testing to detect EBV
antibodies should be done
 ELISA and recombinant DNA derived antigens also may be used

Blood profile
 Increased WBC COUNT
 Lymphocytosis as high as 70%during second week
 Atypical lymphocytes in peripheral blood.
CYTOMEAGALO VIRUS
 The diagnosis of CMV is made by considering a combination
of clinical features and by conducting other examinations.
Clinical features:
 Often begin with prolonged fever, malaise, anorexia, fatigue,

night sweats, myalgia and arthralgia. Liver function

abnormalities, leucopaenia, thrombocytopaenia and atypical
lymphocytosis may be observed during these episodes
Oral finding:
 chronic oral ulcers in immunocompromised patient.

 Coinfection usually occurs( CMV combined with HSV)

 LABORATORY_DIAGNOSIS
1. Virus Isolation ;- Urine, saliva, blood and biopsy samples can be used for virus
isolation.. Tissue biopsies should be placed in sterile plastic containers. The
specimens can be treated in the following ways ;-
 Cell culture -
 DEAFF ( Detection of early antigen fluorescent foci ) ;- This is a method used
for the early diagnosis of CMV infection. In immunocompromised patients, a
sensitivity of 78% and a specificity of 100% has been claimed.
 Tissue immunofluorescence - Infected lung and liver cells may be stained by
specific anti-CMV antibodies. Broncheolavage specimens can also be
examined in this manner. Results of high sensitivity and specificity are
possible.
 Electron microscopy - Virions in the urine of congenitally infected infants may
be visualized by EM in up to 80% of cases.
 ELISAs for CMV antigen in the urine - these tests carry low sensitivity as
CMV is complexed to ß2-microglobulin in the urine
 
 Detection of CMV DNA by PCR - the use of PCR in the diagnosis of CMV infection had been widely studied.
PCR offers the advantages of being rapid and sensitive. However, its inherent sensitivity poses a problem since
latent CMV genomes, which are present in practically all seropositive individuals, may be detected. Therefore, it
is critical to adjust the sensitivity of the PCR so that latent genomes are not detected.
 CMV antigenaemia test - this test is based upon the detection of pp65, a structural protein expressed on the
surface of infected polymorphonyclear lymphocytes. The number of infected leucocytes present had been
reported to correlate with the severity of infection. The main advantage of this test is that it is very rapid so that a
result can be available within the same day. As a result, this test is now widely used especially in the monitoring
of transplant recipients.

Histopthological features
 Biopsy specimen of intraoral lesin dempnstrate changes within vascular endothelial cells. Scattered infected cells
are extrmely swolen showing both intracytoplasmic and intranuclear inclusions and prominent nuclei. This
enlarged cell has been termed as “owl eye” cell. Gomori methenamine silver and PAS demonstrate cytoplasmic
inclusion.
Serelogical tests:
 CMV IgM antibodies are detected in primary infection and lasts 3 - 4 months. It is not detectable in
recurrent infection except in immunocompromised patients where it is detectable in about a third of
the cases.
 CMV IgM may be undetectable in primary infection in immunocompromised individuals.
 Solid phase sandwich or antibody capture ELISAs or RIAs are now in routine use.
 CMV IgG is produced early in primary infection and persists lifelong. The detection of CMV IgG is
useful as an "immune status screen" (Seropositive individuals are not protected from reactivation of
reinfection). Rising titres of IgG can be used as markers of acute infection.
 This is particularly useful in diagnosing recurrent infections in normal individuals, and in
immunocompromised patients who may not develop a IgM response to primary infection. Various
methods are used for detecting CMV IgG including CFT, IFT, latex agglutination, ELISAs and
RIAs. The test used at the RVL is a LA.
 Where possible, serological investigation should be backed by virus culture, especially in the case
of immunocompromised patients who may fail to mount an immune response. CMV IgG may also
be transferred by blood products which may produce false positive results. The following are
recommended methods for use in the diagnosis of CMV infection.
MUMPS
 The diagnosis of mumps can be made from the clinical presentation
 Clinical; presentation:
 30% of the infection are subclinical.in symptomatic cases prodromal symptoms arise first
 Discomfort and swelling ( reaches peak wihtin 2 to 3 days)
 Chewing tend to increase the pain
 Second finding is epididymorchitis
 Rapid swelling with significant pain and tenderness
 Most common oral manifestation is redness and enlargement of wharton’s duct and
stenson’s salivary duct.

Lab findings :
 Demonstration of mumps-specific IgM or a fourfold rise of mumps specific IgG titers

during acute phase .

 Viral isolation

 Reverse transcriptase PCR testing.

LAB DIAGNOSIS OF HIV

 Antibody detection
 Antigen detection
 Detection of viral nucleic acid
 Viral isolation
 Indirect predictors of HIV infection
THREE TYPES OF TESTS

(i) Screening tests - ELISA and simple/rapid tests.

(ii) Confirmatory or supplemental tests-
Western Blot assay.
(iii) Nucleic acid and antigen screening tests. Polymerase
chain reaction (PCR), Ligase chain reaction (LCR),
Nucleic acid based Sequence assays (NASBA) and some
ELISA tests.
SPECIMENS TO BE COLLECTED FOR ANTIBODY
DETECTION
 Blood / Serum / Plasma
 Saliva / Urine

LAB DIAGNOSIS DURING WINDOW PERIOD

 P24 antigen assay (<40%)
 Viral Culture
 PCR
BLOOD DETECTION TESTS

 Enzyme-Linked Immunosorbent Assay/Enzyme

Immunoassay (ELISA/EIA)
 Radio Immunoprecipitation Assay/Indirect
Fluorescent Antibody Assay (RIP/IFA)
 Polymerase Chain Reaction (PCR)
 Western Blot Confirmatory test
THANK YOU