Oropharyngeal Candidiasis in Patients With AIDS

8/2/2019 Oropharyngeal Candidiasis in Patients With AIDS

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Oropharyngeal Candidiasis inPatients with AIDS


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Case

29-year-old male with AIDS CD4 198 Complaining of painful cracks at the

corners of the mouth

What is your diagnosis?


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Oropharyngeal Candidiasis: Angular Cheilitis


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Learning Objectives

Upon completion of this activity,participants should be able to:

Describe symptoms of oropharyngeal

candidiasis Discuss methods for diagnosing

oropharyngeal candidiasis Review treatments for oropharyngeal

candidiasis


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Overview on Oropharyngeal Candidiasis

Candida albicans is the most commoncause of oropharyngeal candidiasis

Oral candidiasis is broadly known as

thrush Candida albicans is a mouth commensal


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Overview

Common risk factors include CD4


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Clinical Presentation

Discovered on routine examination Often asymptomatic but patients may

experience: Burning sensation in mouth Taste alteration Pain


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Clinical Presentations ofOropharyngeal Candidiasis


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Pseudomembranous Candidiasis

White/Grey Plaqueson the Hard Palate(Pseudomembranouscandidiasis)


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Erythematous Candidiasis

ErythematousCandidiaisis Affectingthe Hard Palate


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Corners of theMouth AngularCheilitis

Angular Cheilitis


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Diagnosis

Diagnosis usually clinical Easily removable white/grey plaques with

erythematous base Scraping away these plaques reveals raw

ulcerated area Can also present atypically as

erythematous patches and angularcheilitis


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Diagnosis

Fungal culture of mouth lesions not usefulfor diagnostic purposes since positiveresults may be due to high rates of mouth

colonization Fungal culture of mouth lesions used for

identification of Candida species and

resistance testing


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Diagnosis

If laboratoryconfirmation needed,exudates of epithelialscrapings may beexaminedmicroscopically foryeast and/orpseudohyphae by 10%KOH (potassiumhydroxide) wet mountpreparation


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Treatment

Use oral topical treatments as initialtherapy Systemic therapy seldom required and

only use if absolutely necessary Relapse common, therefore prescribe

intermittent treatment rather than

continuous


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Treatment

Preferred First Line Therapy Topical nystatin or clotrimazole


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Second Line Therapy for Refractory Cases

Fluconazole 100 mg po daily for 7 14 daysafter clinical improvement (preferred) Itraconazole 200 mg po daily for 7 14

days after clinical improvement


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Second Line Therapy for Refractory Cases

Topical amphotericin B OR Amphotericin B 0.3 mg/kg per day IV for

7 14 days after clinical improvement


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Treatment

If no Response to Alternative Therapy Check adherence Reconsider diagnosis Consider resistance to azole and/or

amphotericin


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Drug Interactions

Azoles are prone to drug interactions throughthe cytochrome P450 (CYP450) enzymes The CYP450 pathway is involved in the

metabolism of commonly prescribed drugs Check package insert for drug interactions

when prescribing azoles concurrently with otherdrugs

Azoles can be associated with hepatotoxicityand gastrointestinal intolerance


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Drug Interactions: Absorption

Itraconazole capsules require gastric acidfor absorption. Absorption affected byBuffered didanosine, proton pump

inhibitors, H2 blockers and antacids Itraconazole liquid is better absorbed and

should be taken on an empty stomach

Fluconazole absorption is not affected byfood or gastric pH


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Treatment Side Effects

Clotrimazole Generally well tolerated Occasionally can cause gastrointestinal

toxicity Nystatin

Bitter taste

Can be associated with gastrointestinaltoxicity


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Maintenance Therapy

Generally not recommended Occasionally needed if recurrence

frequent Topical therapy preferred


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Maintenance Therapy

If refractory to topical therapy considerazoles Fluconazole or itraconazole 100 mg po daily

Chronic use of azoles can lead toresistance Optimal prevention is immune

reconstitution with ART


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Additional Considerations

Reinforce importance of maintainingadequate nutrition Educate the patient on good mouth

hygiene Counsel the patient on which foods may

be difficult to chew as they can

exacerbate mouth discomfort


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Summary

Common in patients with AIDS Diagnosis usually clinical Treat with topical agents Preserve systemic treatment and only use

if absolutely necessary Relapse common


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Summary

Maintenance generally notrecommended Reinforce the importance of good oral

hygiene Optimal prevention is immune

reconstitution with ART


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References

Bartlett, J and Gallant, J. 2007. Medical Management of HIV Infection. Johns Hopkins University. Baltimore, MD.

Boon, NA et al. 2006. Davidsons Principles and Practice of Medicine. Elsevier Science Health Science div. 20th Edition. pg 373-375.

The Hopkins HIV Guide: http://www.hopkins-hivguide.org

Ramrez-Amador, V. et al. 2003. The Changing Clinical Spectrum of Human Immunodeficiency Virus (HIV)-Related Oral Lesions in 1,000 Consecutive Patients: A 12-Year Study in a Referral Center in Mexico. Medicine . 82: 39-50.

Vazquez, JA. 2000. Therapeutic options for the management of oropharyngeal and esophageal candidiasis in HIV/AIDS patients. HIV Clin Trials . Jul-Aug; (1): 47-59.

Oropharyngeal Candidiasis in Patients With AIDS

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