Chronic Tongue and Throat Soreness with Green Stuck-On Appearance
Primary Diagnosis and Management
This presentation is most consistent with chronic hyperplastic candidiasis (candidal leukoplakia), not typical acute thrush, which explains the minimal response to standard antifungal treatment. The green stuck-on appearance rather than white scrapable patches, combined with years of chronicity, strongly suggests this variant form of oral candidiasis that requires systemic therapy and evaluation for underlying immunodeficiency 1.
Why Standard Thrush Treatment Failed
- Chronic hyperplastic candidiasis differs fundamentally from acute pseudomembranous candidiasis (typical thrush) - it presents as adherent white or colored patches that cannot be scraped off, unlike the removable white plaques of acute thrush 1
- The green discoloration may represent chronic hyperplastic changes with altered keratin production or secondary bacterial colonization 1
- Topical antifungals (like nystatin) are ineffective for this variant because the fungal elements are embedded within hyperplastic epithelium 2
Required Systemic Treatment
Fluconazole 200-400 mg orally daily for 14-21 days is the definitive treatment for chronic hyperplastic candidiasis that has failed topical therapy 2, 3. This is significantly more aggressive than typical thrush treatment and addresses the deeper tissue involvement 3.
If Fluconazole Fails After 14-21 Days:
- Itraconazole solution 200 mg daily OR voriconazole 200 mg twice daily for 14-21 days 2, 3
- Posaconazole suspension 400 mg twice daily has 75% efficacy in refractory oropharyngeal candidiasis 3
- Intravenous echinocandins (micafungin 150 mg daily, caspofungin 70 mg loading then 50 mg daily, or anidulafungin 200 mg daily) for truly refractory cases 2, 3
Critical Underlying Evaluation Required
The chronicity over years mandates investigation for immunodeficiency, particularly chronic mucocutaneous candidiasis associated with autoimmune polyendocrinopathy syndrome 3. Specific evaluations needed:
- HIV testing - chronic oral candidiasis is an AIDS-defining condition 2, 4
- Diabetes screening - uncontrolled hyperglycemia predisposes to persistent candidiasis 2, 5
- Thyroid function and autoimmune panel - autoimmune polyendocrinopathy syndrome type 1 causes chronic mucocutaneous candidiasis and hypothyroidism 3
- Complete blood count and immunoglobulin levels - to assess for primary immunodeficiency 2, 5
- Nutritional assessment - vitamin deficiencies (particularly B12, folate, iron) contribute to chronic hyperplastic candidiasis 1
Long-Term Suppressive Therapy
If recurrences occur after completing initial treatment, fluconazole 100-200 mg three times weekly is indicated as chronic suppressive therapy 2, 3. This approach is more effective than intermittent treatment for preventing relapses 2, 3.
Alternative Diagnoses to Consider
While chronic hyperplastic candidiasis is most likely, the differential includes:
- Oral hairy leukoplakia (Epstein-Barr virus-related, typically on lateral tongue borders in HIV patients) 1
- Lichen planus (reticular white striae, often with erosions) 1
- Dysplastic leukoplakia - chronic hyperplastic candidiasis can harbor dysplasia and has malignant potential if untreated 1
- Geographic tongue (benign migratory glossitis) - but this typically has a map-like appearance with areas of depapillation 1
Critical Pitfall to Avoid
Biopsy is essential if the lesion does not completely resolve after appropriate systemic antifungal therapy - untreated chronic hyperplastic candidiasis can progress to dysplasia and squamous cell carcinoma 1. The stuck-on appearance and years of chronicity increase this concern.
Species Identification Required
Culture and species identification are mandatory in immunocompromised patients with refractory disease 2. Non-albicans species (particularly C. glabrata and C. krusei) may be intrinsically azole-resistant and require alternative therapy 2, 6.