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A fungal infection
Causative Organisms
Candida albicans is the predominant causative agent
of all forms of mucocutaneous candidiasis. Less frequently,
C. glabrata, C. parapsilosis, C. tropicalis, C. kruseii
and several other species may cause disease.
Symptoms of active infection
Mouth or oesophagus
White patches on gums, tongue or lining; pain (odynophagia)
and difficulty in swallowing (dysphagia).
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Vagina
Creamy white abnormal vaginal discharge; pruritus, burning
pain.
Diagnostic Procedures
Mouth and vagina
Visual examination, smear
Oesophagus
Usually diagnosed presumptively if dysphagia and odynophagia
are present with thrush.
Alternatively, upper GI tract endoscopy can confirm
the diagnosis.
Treatment
Fluconazole is widely used in patients with fungal infection,
because of its oral administration, high bioavailability
and low toxicity. Unlike ketoconazole and itraconazole,
it does not require an acidic medium for absorption
and does not affect testosterone levels or adrenal function.
Oral candidiasis
Treatment is effective in most cases, but recurrence
is common (>60%). Initial episodes respond to topical
clotrimazole, or nystatin, 500,000 units for 7-14 days.
Systemic therapy with fluconazole 200 mg on the first
day, followed by 100 mg once daily for 7 to 14 days
or ketoconazole 200 mg/day orally for 7 to 14 days or
itraconazole 100 mg/day for 7-14 days is also effective,
and often required for patients with multiple recurrences.
Candida vaginitis
Topical therapy with clotrimazole vaginal cream 1% (5
gm bi.d. for 3 days or 5 gm/day for 7 days) or suppositories
(500 mg single dose) or nystatin vaginal suppositories
100,000 units at bedtime for 14 days. Alternatively,
fluconazole 150 mg single dose.
Candida oesophagitis
This is more serious and should be treated with fluconazole
200 mg on the first day, followed by 100 mg/day orally
for a minimum of 3 weeks and for at least 2 weeks following
resolution of symptoms. Alternatively, ketoconazole
400 mg/day for 14-21 days, or itraconazole 200 mg/day
for 14-21 days.
Invasive Candidiasis
Despite the frequency of mucosal candidiasis, invasive
disease is uncommon in persons with HIV infection. Persons
with HIV infection may occasionally develop candidemia.
Intravenous fluconazole is indicated in these cases.
Suppressive therapy
Frequent relapses may be an indication to continue treatment
to prevent recurrence.
Fluconazole-refractory disease
This is more likely to be seen in patients with advanced
HIV disease (CD4+ counts <50 cells/ l) who have received
extensive prior courses of fluconazole.
Response may occur at higher doses of fluconazole (400
to 800 mg/day orally) or parenteral amplotericin B 0.5-1
mg/kg/day i.v. o.d.
Drug interactions
Fluconazole
Avoid astemizole, terfenadine, warfarin, rifampin, oral
contraceptives, cimetidine, phenytoin, hydrochlorothiazide
and sulfonylureas.
Itraconazole and ketoconazole
Terfenadine, astemizole. Take antacids and didanosine
2 hours apart.
Fluconazole and itraconazole may interact with clarithromycin
and rifabutin.
Clotrimazole
Clotrimazole troches raise liver function tests.
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