Photo Rounds

White coating on infant’s tongue

A 2-month-old infant was brought to the family physician (FP) for a well-baby visit and to receive her vaccines. During the screening exam, the FP noted that the infant’s tongue was coated white. At first, the white coating seemed to be milk from a recent breastfeeding. But on further examination, an alternative explanation seemed more likely. The remainder of the exam was normal.

What’s your diagnosis?


The FP diagnosed thrush or candidiasis of the oral mucosa . To make sure it was not just milk, the FP gently drew a tongue blade over the tongue and the white exudate was mostly adherent (milk wipes away rather easily). The tongue blade was then rubbed onto a glass slide and 2 drops of potassium hydroxide (KOH) solution were applied. Microscopic evaluation revealed pseudohyphae and budding yeasts consistent with Candida albicans . (See video on how to perform a KOH preparation.)

Thrush is a common condition in infants with normal immune systems and does not require work-up for immunosuppression if this is the only finding at this age. Of course, thrush is seen in people who are immunosuppressed from various diseases (such as human immunodeficiency virus) and medications (like chemotherapy).

The FP chose to treat the child with oral nystatin suspension 2 mL 4 times a day. The directions were to give 1 mL in each side of the infant’s mouth and to continue this until 48 hours after signs and symptoms resolved. The mother was not having any symptoms or erythema of the nipples, but if she was, a topical antifungal agent (to be washed off before breastfeeding) could be used.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R. Candidiasis. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine . 2nd ed. New York, NY: McGraw-Hill;2013:777-781.

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