Download Oropharyngeal Candidiasis

Oropharyngeal Candidiasis in
Patients with AIDS
Case
• 29-year-old male with AIDS
• CD4 198
• Complaining of painful cracks at the
corners of the mouth
What is your diagnosis?
Oropharyngeal Candidiasis: Angular Cheilitis
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
Overview on Oropharyngeal Candidiasis
• Candida albicans is the most common
cause of oropharyngeal candidiasis
• Oral candidiasis is broadly known as
thrush
• Candida albicans is a mouth commensal
Overview
• Common risk factors include CD4 <250,
chronic antibiotic and/or steroid use,
diabetes and cancer
• Differential diagnosis: oral HSV, hairy
leukoplakia, and aphthous ulcerations
• Usually a recurrent process
Clinical Presentation
• Discovered on routine examination
• Often asymptomatic but patients may
experience:
– Burning sensation in mouth
– Taste alteration
– Pain
Clinical Presentations of
Oropharyngeal Candidiasis
Pseudomembranous Candidiasis
White/Grey Plaques
on the Hard Palate
(Pseudomembranous
candidiasis)
Erythematous Candidiasis
Erythematous
Candidiaisis Affecting
the Hard Palate
Angular Cheilitis
Corners of the
Mouth Angular
Cheilitis
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 angular
cheilitis
Diagnosis
• Fungal culture of mouth lesions not useful
for diagnostic purposes since positive
results may be due to high rates of mouth
colonization
• Fungal culture of mouth lesions used for
identification of Candida species and
resistance testing
Diagnosis
If laboratory
confirmation needed,
exudates of epithelial
scrapings may be
examined
microscopically for
yeast and/or
pseudohyphae by 10%
KOH (potassium
hydroxide) wet mount
preparation
Treatment
• Use oral topical treatments as initial
therapy
• Systemic therapy seldom required and
only use if absolutely necessary
• Relapse common, therefore prescribe
intermittent treatment rather than
continuous
Treatment
Preferred First Line Therapy
• Topical nystatin or clotrimazole
Second Line Therapy for Refractory Cases
• Fluconazole 100 mg po daily for 7–14 days
after clinical improvement (preferred)
• Itraconazole 200 mg po daily for 7– 14
days after clinical improvement
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
Treatment
If no Response to Alternative Therapy
• Check adherence
• Reconsider diagnosis
• Consider resistance to azole and/or
amphotericin
Drug Interactions
• Azoles are prone to drug interactions through
the 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 other
drugs
• Azoles can be associated with hepatotoxicity
and gastrointestinal intolerance
Drug Interactions: Absorption
• Itraconazole capsules require gastric acid
for absorption. Absorption affected by
Buffered 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 by
food or gastric pH
Treatment Side Effects
• Clotrimazole
– Generally well tolerated
– Occasionally can cause gastrointestinal
toxicity
• Nystatin
– Bitter taste
– Can be associated with gastrointestinal
toxicity
Maintenance Therapy
• Generally not recommended
• Occasionally needed if recurrence
frequent
• Topical therapy preferred
Maintenance Therapy
• If refractory to topical therapy consider
azoles
– Fluconazole or itraconazole 100 mg po daily
• Chronic use of azoles can lead to
resistance
• Optimal prevention is immune
reconstitution with ART
Additional Considerations
• Reinforce importance of maintaining
adequate 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
Summary
• Common in patients with AIDS
• Diagnosis usually clinical
• Treat with topical agents
• Preserve systemic treatment and only use
if absolutely necessary
• Relapse common
Summary
• Maintenance generally not
recommended
• Reinforce the importance of good oral
hygiene
• Optimal prevention is immune
reconstitution with ART
References
• Bartlett, J and Gallant, J. 2007. Medical Management of
HIV Infection. Johns Hopkins University. Baltimore, MD.
• Boon, NA et al. 2006. Davidson’s Principles and Practice
of Medicine. Elsevier Science Health Science div. 20th
Edition. pg 373-375.
• The Hopkins HIV Guide: http://www.hopkinshivguide.org
• Ramírez-Amador, V. et al. 2003. The Changing Clinical
Spectrum of Human Immunodeficiency Virus (HIV)Related Oral Lesions in 1,000 Consecutive Patients: A 12Year 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.