VCOM Research Day Program Book 2023

Medical Resident Research Case Reports

05 Thrush in Sjogren Syndrome

Nida Zaheer, MD; Michael Caplan, MD Corresponding author: Nida.zaheer@lpnt.net

SOVAH Health Internal Medicine Residency Program

swallowing and associated loss of appetite. Dry grainy eyes requiring OTC artificial tears. Pertinent Physical Exam: BP 145/95. HR 85. RR 20. T 97.5, O2 saturation 100% on RA. Significant mucosal breakdown and ulcerations of the oral cavity. Multiple whitish patches leaving petechiae upon scraping with a tongue depressor. Pertinent Labs: Low hemoglobin, chronic (Baseline 9-10), ANA +, Anti Ro, and La positive. Imaging: Chest X-ray portable- Chronic interstitial changes with no acute findings. Diagnosis: Severe oropharyngeal thrush and Sjogren syndrome. Treatment: To keep mucosal membranes wet, the patient was initiated on conservative measures with topical lubrication, ice chips, and swish-and-swallow mouthwash. The patient was also recommended to maintain adequate hydration and avoid oral desiccants (e.g., coffee, alcohol, tobacco, and cannabis smoke). After conservative therapy failed, Sialagogues were initiated with pilocarpine 5 mg by mouth, up to four times daily, and cevimeline 30 mg by mouth, up to three times daily, to be taken a half-hour before meals

to allow time for the medication to enhance salivary flow. This medication regimen improved the patient's condition. Comments: Oral Thrush is a common complication seen in patients with Asthma/COPD requiring regular inhaler therapy. Patients with recurrent oral thrush and a history of autoimmune conditions warrant evaluation for Sjogren syndrome. Treatment recommendations should also include avoidance of medications that may worsen oral dryness, especially those with anticholinergic side effects. Over-the-counter cold and sleep remedies may be overlooked as potential contributors. Multiple medications can lead to worsening mouth dryness and contribute to thrush development. Medications for urinary incontinence and depression are strongly associated with this side effect. In our situation, we suspect that the use of inhalers and antidepressants were the likely reasons her Sjogren syndrome was not diagnosed earlier.

Context: Sjögren's syndrome (SS) is a chronic autoimmune inflammatory disorder characterized by diminished lacrimal and salivary gland function with resultant dryness of the eyes and mouth. Sjogren syndrome is also associated with rheumatic diseases such as rheumatoid arthritis or systemic lupus erythematosus and affects 0.5 to 1% of the population. It also may affect other organs of the body, including the kidneys, blood vessels, lungs, liver, pancreas, and brain. Case Report: A 61-year-old female presented to the office with complaints of pain and bleeding in her mouth. Medical History: Rheumatoid arthritis, hypothyroidism, recurrent episodes of oral ulcers and candidiasis (previously attributed to inhaler use for Asthma), hypertension, hyperlipidemia. Family History: Maternal grandmother and sister with a history of “Joint and skin issues.” Social History: Worked part-time as a janitor, independent for all basic ADLs. Pertinent Review of Systems: Bleeding and pain from the mouth with severe difficulty

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