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	Providers' Home > Clinical Manual > Diseases > Article	Enlarge Text Size:

Disease-Specific Treatment

Candidiasis, Oral and Esophageal

July 2006

Contents

Background

SOAP (Subjective, Objective, Assessment, Plan)

Patient Education

References

Background

Oropharyngeal candidiasis ("thrush"), a fungal disease of the oral mucosa and tongue, is the most common intraoral lesion in persons infected with HIV. In the absence of other known causes of immunosuppression, oral thrush in an adult is highly suggestive of HIV infection. Three clinical presentations of thrush are common in people with HIV: pseudomembranous, erythematous, and angular cheilitis. Thrush usually occurs with CD4 counts of <300 cells/µL and is not an AIDS-defining illness.

Candida may also infect the esophagus in the form of esophageal candidiasis which causes dysphagia (difficulty with swallowing) or odynophagia (pain with swallowing). Esophageal candidiasis is an AIDS-defining condition, generally occurring in individuals with CD4 counts of <100 cells/µL. It is the most common cause of esophageal infection in persons with AIDS.

Oropharyngeal and esophageal candidiasis are most commonly caused by Candida albicans, although occasionally non-albicans species cause disease and may be resistant to first-line therapies.

SOAP (Subjective, Objective, Assessment, Plan)

Subjective

Oropharyngeal Candidiasis

The patient may complain of white patches on the tongue and oral mucosa, smooth red areas on the dorsal tongue, burning or painful areas in the mouth, a bad or unusual taste, sensitivity to spicy foods, or decreased appetite.

Esophageal Candidiasis

The patient complains of difficulty or pain with swallowing, or the sensation that food is "sticking" in the retrosternal chest. Weight loss is common, and nausea and vomiting may occur. Fever is not common with candidal esophagitis and suggests another cause.

Objective

Patients presenting with oral candidiasis may be totally asymptomatic, so it is important to inspect the oral cavity thoroughly. Lesions can occur anywhere on the hard and soft palates, under the tongue, on the buccal mucosa or gums, or in the posterior pharynx.

Pseudomembranous oral candidiasis appears as creamy white, curdlike plaques on the buccal mucosa, tongue, and other mucosal surfaces. Typically, the plaques can be wiped away, leaving a red or bleeding underlying surface. Lesions may be as small as 1-2 mm, or may form extensive plaques that cover the entire hard palate.

Erythematous oral candidiasis presents as 1 or more flat, red, subtle lesions on the dorsal surface of the tongue or the hard or soft palate. The dorsum of the tongue may show loss of filiform papillae.

Angular cheilitis causes fissuring and redness at 1 or both corners of the mouth and may appear alone or in conjunction with another form of oral Candida infection.

Patients with esophageal candidiasis usually have oral thrush and often have weight loss.

Assessment

A partial differential diagnosis for the 2 conditions is as follows:

Oropharyngeal Candidiasis

	Oral hairy leukoplakia

	Burn

	Bacterial gingivitis

	Periodontitis

Esophageal Candidiasis

	Cytomegalovirus (CMV)

	Herpes simplex virus (HSV)

	Aphthous ulceration

Plan

Diagnostic Evaluation

Oropharyngeal candidiasis

Clinical examination alone usually is diagnostic. If the diagnosis is unclear, organisms may be detected on smear or culture if necessary.

	Potassium hydroxide (KOH) preparation of a smear collected by gentle scraping of the affected area with a wooden tongue depressor. Visible hyphae or blastospheres on KOH mount indicate Candida infection.

	Culture is diagnostic and may detect non-albicans species in cases resistant to first-line therapies. Sensitivities may also be needed in such cases to diagnose azole-resistant infections.

Esophageal candidiasis

A presumptive diagnosis can usually be made with a recent onset of dysphagia, especially in the presence of thrush, and empiric antifungal therapy may be started. If the patient fails to improve clinically after 3-7 days of therapy, endoscopy should be performed for a definitive diagnosis.

Treatment

Treatment of oropharyngeal candidiasis

Oral therapy is convenient and very effective as first-line treatment. Note that azole antifungal drugs are not recommended for use during pregnancy.

	Fluconazole 100 mg once daily for 7-14 days

Alternative topical therapy is less expensive, safe for use during pregnancy, and effective for mild to moderate disease. Such therapies include:

	Clotrimazole troches dissolved in the mouth 5 times per day for 2 weeks

	Nystatin oral suspension 5 mL "swish and swallow" 4 times daily for 2 weeks

Other alternatives include the following:

	Itraconazole oral solution 200 mg once daily for 7-14 days

	Itraconazole capsules and ketoconazole 200 mg once daily for 7-14 days (less effective)

These agents present a greater risk of drug interactions and hepatotoxicity than do fluconazole or topical treatments.

Treatment of esophageal candidiasis

	Fluconazole 200 mg as an initial dose, then 100 mg by mouth once daily for 14 days. Intravenous therapy can be given if the patient is unable to swallow pills.

	Itraconazole oral suspension 200 mg once daily for 14 days

	Alternative (less effective) treatments include itraconazole capsules 200 mg once daily or ketoconazole 200 mg once daily for 14 days

Treatment of refractory candidiasis

Oral or esophageal candidiasis that does not improve after at least 7-14 days of azole antifungal therapy can be considered refractory to treatment. The primary risk factors for development of refractory candidiasis are CD4 counts <50 cells/µL and prolonged, chronic antifungal therapy (especially with azoles). In such cases, it is important to confirm the diagnosis of candidiasis. As noted previously, other infections such as HSV, CMV, and aphthous ulcerations can cause similar symptoms. Once refractory candidiasis is confirmed, several treatment options are available, including the following:

	Patients with candidiasis refractory to low-dose fluconazole (100-200 mg once daily) may respond to higher dosages (400-800 mg once daily)

	Itraconazole oral suspension 200 mg once daily

	Voriconazole 200 mg intravenously or by mouth twice daily (Voriconazole therapy is contraindicated for patients taking protease inhibitors because of significant drug interactions.)

	Amphotericin B 100 mg/mL oral suspension, 1 mL 4 times daily

	Amphotericin B 0.5 mg/kg/d intravenously, or amphotericin liposomal complex 3-5 mg/kg/d intravenously

	Caspofungin 50 mg intravenously once daily

The choice of treatment depends upon the patient's preferences and tolerance, convenience, availability of medications, and the provider's experience. Consult with an HIV or infectious disease expert for advice about treatment regimens.

Maintenance therapy

Use caution when considering chronic maintenance therapy, because it has been associated with refractory and azole-resistant candidiasis, as noted above. Fluconazole 100-200 mg daily or weekly, or itraconazole solution, can be effective for patients who have had multiple recurrences of oral or esophageal disease (azole sensitive). Patients who achieve immunologic and virologic responses to antiretroviral therapy may be able to discontinue maintenance therapy.

Patient Education

Key teaching points

	Patients should maintain good oral hygiene by brushing teeth after each meal.

	A soft toothbrush should be used to avoid mouth trauma.

	Advise patients to rinse the mouth of all food before using lozenges or liquid medications.

	Tell patients to avoid foods or liquids that are very hot in temperature or very spicy.

	Patients who have candidiasis under a denture or partial denture should remove the prosthesis before using topical agents such as clotrimazole or nystatin. At bedtime, the prosthesis should be placed in a chlorhexidine solution until reinserting it into the mouth.

	Pregnant women or women who may become pregnant should avoid azole drugs (eg, fluconazole, itraconazole, voriconazole) during pregnancy because they can cause skeletal and craniofacial abnormalities in infants.

References

	The appearance of external hyperlinks does not constitute endorsement by the Department of Veterans Affairs of the linked Web sites, or the information, products or services contained therein.

	U.S. Public Health Service, Infectious Diseases Society of America. Guidelines for preventing opportunistic infections among HIV-infected persons--2002. MMWR Recomm Rep. 2002 Jun 14;51(RR08);1-46. Available online at aidsinfo.nih.gov/Guidelines/. Accessed May 19, 2006.

	Centers for Disease Control and Prevention, National Institutes of Health, HIV Medicine Association/Infectious Diseases Society of America. Treating Opportunistic Infections Among HIV-Infected Adults and Adolescents. MMWR Recomm Rep. 2004 Dec 17; 53(RR15);1-112. Available online at aidsinfo.nih.gov/Guidelines/GuidelineDetail.aspx?GuidelineID=14. Accessed May 19, 2006.

	Fichtenbaum CJ. Candidiasis. In: Dolin R, Masur H, Saag MS, eds. AIDS Therapy, 2nd ed. Philadelphia: Churchill Livingstone; 2003:531-542.

	Mönkemüller KE, Wilcox CM. Diseases of the Esophagus, Stomach, and Bowel. In: Dolin R, Masur H, Saag MS, eds. AIDS Therapy, 2nd ed. Philadelphia: Churchill Livingstone; 2003:885-901.

	Pappas PG, Rex JH, Sobel JD, et al. Guidelines for treatment of candidiasis. Clin Infect Dis. 2004 Jan 15;38(2):161-89.