1Associate Professor, E.G.S. Pillay College of Pharmacy, Nagapattinam – 611002
²Pharm.D Interns, E.G.S. Pillay College of Pharmacy – 611002 (Affiliated with Government Medical College and Hospital, Orathur-Nagapattinam – 611108)
Oral candidiasis is a common opportunistic fungal infection, typically observed in immunocompromised individuals. Its occurrence in immunocompetent individuals is uncommon and can mimic premalignant lesions such as leukoplakia, leading to diagnostic uncertainty. We present a rare case of oral candidiasis in a healthy adult male, diagnosed and managed at a tertiary care hospital. Comprehensive clinical examination and laboratory investigations, including fungal culture, confirmed the diagnosis. The patient responded favourably to topical antifungal therapy. This case underscores the importance of considering candidiasis in the differential diagnosis of non-scrapable white oral lesions.
Oral candidiasis, primarily caused by Candida albicans, is commonly associated with immunosuppressive conditions. ¹ Its occurrence in immunocompetent individuals is rare. When it presents as a white patch, it may resemble leukoplakia, a premalignant disorder with malignant potential. ² ³ This case report describes a rare presentation of oral candidiasis in an immunocompetent individual, evaluated and managed at a tertiary care government hospital. In clinical practice, white lesions in the oral cavity—especially non-scrapable types—are often initially suspected to be premalignant conditions such as leukoplakia. However, chronic hyperplastic candidiasis (CHC), though uncommon, can mimic these lesions and pose a diagnostic challenge. CHC is distinct among Candida infections due to its non-scrapable nature and potential for malignant transformation, reported in approximately 15% of cases. ?
CASE PRESENTATION
A 45-year-old male presented with complaints of a persistent white lesion on the tongue, associated with a burning sensation for the past two weeks. The lesion had gradually increased in size, and the patient reported discomfort while eating spicy food and during tooth brushing. Baseline laboratory investigations—including complete blood count (Hb: 13.9 g/dL; TLC: 7,200/mm³; N/L ratio: normal), ESR (12 mm/hr), and CRP (<5 mg/L)—were within normal limits. Random blood sugar was 112 mg/dL, and HIV testing was non-reactive. These findings supported the absence of systemic immunosuppression. The patient denied any history of tobacco or alcohol use, diabetes, HIV, malignancy, or other immunocompromising conditions. He was not on prolonged corticosteroid or antibiotic therapy and had no recent history of COVID-19 infection or hospitalization. On oral examination, a well-defined, non-scrapable white patch with erythematous margins was noted on the dorsal surface of the tongue. There were no associated ulcers or lymphadenopathy. The clinical differential diagnosis included oral leukoplakia, lichen planus, and chronic hyperplastic candidiasis. A potassium hydroxide (KOH) mount of the lesion scraping revealed pseudohyphae, and fungal culture on Sabouraud Dextrose Agar confirmed the presence of Candida albicans, establishing the diagnosis of chronic hyperplastic candidiasis.
Figure 1: Clinical photograph showing a thick, white, plaque-like lesion with erythematous borders on the dorsum of the tongue.
The patient was initiated on clotrimazole 1% oral paint, applied four times daily after meals. He was advised to maintain good oral hygiene, including the use of a soft-bristled toothbrush and antiseptic mouthwash. Within 10 days, significant improvement in lesion size and symptoms was observed, with complete resolution by the two-week follow-up.
DISCUSSION
CHC is a distinct clinical subtype that differs from other forms of oral candidiasis. While pseudomembranous candidiasis presents as soft, scrapable white plaques, CHC is characterized by firm, adherent white lesions, often requiring differentiation from leukoplakia, lichen planus, and oral hairy leukoplakia. ? Unlike other variants, CHC carries a reported 15% risk of malignant transformation. ? Most studies associate CHC with risk factors such as tobacco use (present in up to 80% of cases), use of dentures, and systemic immunosuppression. ? In contrast, our patient was immunocompetent, non-smoking, HIV-negative, and without systemic illness—highlighting an atypical presentation. This aligns with documented cases where CHC appeared in individuals without predisposing factors, suggesting that even subtle mucosal disruption or microbial imbalance may contribute to candidal overgrowth. ? Microbiological confirmation through KOH mount and fungal culture is essential, as clinical features alone may be misleading. ? In our case, Candida albicans was identified, consistent with most CHC cases. While biopsy and histopathology remain the gold standard for dysplasia assessment, our patient responded promptly to topical antifungal therapy, making invasive procedures unnecessary. Differentiating CHC from leukoplakia is important. Although leukoplakia may appear similar, it lacks fungal elements on microscopy unless secondarily infected. ? Lichen planus, another differential, typically presents bilaterally with reticulated patterns and exhibits basal cell degeneration histologically, but not fungal hyphae. ¹? Topical antifungal agents such as clotrimazole and miconazole are considered first-line for uncomplicated CHC. ¹¹ Systemic antifungals like fluconazole are reserved for refractory cases. ¹² Our patient responded well to clotrimazole 1% oral paint, highlighting the efficacy of early localized intervention.
CONCLUSION
CHC is a rare but clinically significant variant of oral candidiasis that should be considered in the differential diagnosis of persistent white oral lesions, even in immunocompetent individuals. This case emphasizes the value of microbiological confirmation and demonstrates that timely initiation of topical antifungal therapy can lead to complete resolution. Early diagnosis helps avoid misdiagnosis and ensures prompt, appropriate treatment.
ACKNOWLEDGMENT
The authors gratefully acknowledge the Department of Dermatology, Government Medical College and Hospital, Orathur-Nagapattinam, for their clinical assistance and support. We also thank the Department of Microbiology for their timely diagnostic guidance.
CONFLICT OF INTEREST
The authors declare no conflict of interest related to the publication of this case report.
INFORMED CONSENT
Written informed consent was obtained from the patient for publication of this case and accompanying clinical images. A copy of the signed consent form is available with the corresponding author and will be provided upon request.
REFERENCES
Dr. S. Mahalakshmi, Jayasri K.*, V. Nafeela Safreen, R. Sivaraj, G. R. Haripriya, B. Deepasree, Oral Candidiasis Mimicking Leukoplakia in An Immunocompetent Male: A Rare Case Report, Int. J. of Pharm. Sci., 2025, Vol 3, Issue 6, 5343-5346. https://doi.org/10.5281/zenodo.15756944
10.5281/zenodo.15756944
