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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.