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Author: admin, 11.06.2015Oropharyngeal candidiasis occurs frequently among HIV-infected individuals, particularly those with more advanced immune suppression. Among HIV-infected persons, four different manifestations of oral candidiasis can occur: pseudomembranous candidiasis (thrush), atrophic (erythematous) candidiasis, angular cheilitis (perleche), and rarely, hyperplastic candidiasis.
In most clinical situations, the presumptive diagnosis of oral candidiasis is made based on the typical clinical appearance. Routine primary prophylaxis is not recommended, mainly because oropharyngeal candidiasis has a very low attributable mortality and regular use of antifungal agents can lead to the development of drug-resistant Candida species. Multiple studies have compared different regimens for the treatment of oropharyngeal candidiasis.
Extensive white plaques along the upper gums and lips in a patient with pseudomembranous candidiasis (thrush).
The diagnosis of oral candidiasis is a CDC category B diagnosis (in the 1993 CDC classification system). Pseudomembranous candidiasis typically manifests as creamy white plaque or patches on oral tissues that can usually be scraped off with a tongue blade (Figure 1. For patients who have angular cheilitis with no evidence of intra-oral candidiasis, topical antifungal creams are generally sufficient for therapy (Figure 9. In one small study of patients with oropharyngeal candidiasis, fluconazole (50 mg once daily) appeared superior to ketoconazole (200 mg once daily). Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America.
In addition, the presence of oropharyngeal candidiasis is an indication for initiating prophylaxis for Pneumocystis pneumonia and for initiating antiretroviral therapy.
Patients with pseudomembranous candidiasis can be destinguished from those with oral hairy leukoplakia by scraping the lesions with a tongue blade: the candidiasis plaques are usually removed whereas lesions caused by the oral hairy leukoplakia are not affected by scraping. In a study that involved 334 patients with oral candidiasis, fluconazole (100 mg once daily) and topical clotrimazole troches (10 mg 5 times per day) had similar initial clinical response rates, but clotrimazole was associated with a higher rate of return of symptoms during the second week of follow-up. The development of oral candidiasis generally reflects an imbalance in the normal ecological environment of the oral cavity.
Pseudomembranous Candidiasis (Thrush) on Lips and Gums">Figure 2); if the mouth is very dry or if the condition is more chronic, the plaques can be more adherent. When the clinical diagnosis of oral candidiasis is not clear, the diagnosis can be confirmed by obtaining a direct smear and performing either a potassium hydroxide (KOH) wet mount or a Gram's stain.
In the 2009 United States Guidelines for the Prevention and Treatment of Opportunistic Infections, fluconazole (Diflucan) is recommended as the drug of choice for patients with oropharyngeal candidiasis based on its good efficacy, convenience, and tolerance (Figure 10. Although HIV-related immune suppression is typically the most important risk factor for candidiasis, other factors can contribute, including use of antibiotics that change normal bacterial flora, use of corticosteroids, use of chemotherapeutic drugs, presence of diabetes, decreased salivary flow rates, and wearing dentures. Itraconazole solution, however, achieves higher serum levels and is more effective than itraconazole tablets.
Considering the strong association of HIV infection and oropharyngeal candidiasis, HIV assessment and testing is recommended for any person who presents with oropharyngeal candidiasis and does not have a known risk factor for oropharyngeal candidiasis. Erythematous candidiasis manifests as flat red patches anywhere on the oral mucosa, most commonly on the hard palate (Figure 3. Among HIV-infected patients with oral candidiasis, Candida albicans is the most common species involved, but non-albicans species, such as such as C.
Erythematous (Atrophic) Candidiasis in Upper Mouth">Figure 3), attached gingival or buccal mucosa, or the dorsal surface of the tongue (Figure 4.
For patients unlikely to adhere to a 7 to 14 day treatment, a study showed a single high dose of fluconazole (750 mg) was as effective as a standard 14-day course of fluconazole. Patients with pseudomembranous or erythematous candidiasis often complain of a burning sensation in their mouth and of altered taste. Hyperplastic candidiasis is seen with chronic mucosal colonization by Candida with very superficial invasion of the epithelium. Episodic treatment of clinical episodes is strongly preferred over chronic suppressive therapy, mainly because of lower cost with episodic therapy and the concern for development of antifungal drug resistance with chronic therapy. Initiating antiretroviral therapy would likely play a critical role in minimizing the need to treat recurrent episodes of oropharyngeal candidiasis. A detailed discussion of drug-resistant candidiasis will be reviewed in Case 4 in this same section (Oral Manifestations). Angular cheilitis usually occurs in conjunction with other intra-oral manifestations of candidiasis.
Because patients with advanced HIV disease and oral candidiasis may have concomitant esophageal candidiasis, they should be asked about dysphagia and odynophagia.
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