HIV-Associated Oral Candidiasis

Oral candidiasis (thrush) in HIV is a mucosal infection by Candida albicans (and non albicans species) that signals immune suppression, usually with CD4 count under 200 cells/mm3. It is the commonest opportunistic infection in people with HIV and may involve the oesophagus.

• Risk factors: low CD4, uncontrolled viraemia, steroid use (including inhaled), antibiotics, diabetes, dentures, xerostomia, smoking.
• A persistent or recurrent episode should prompt HIV testing in those with unknown status.

Pseudomembranous: creamy white plaques on the palate, tongue and buccal mucosa that scrape off, leaving erythematous bleeding base.

• Erythematous: red atrophic patches on the palate or dorsal tongue; angular cheilitis; hyperplastic: adherent white plaques.
• Oesophageal involvement: dysphagia, odynophagia and retrosternal pain.
• Differential diagnosis: oral hairy leukoplakia (does not scrape off), lichen planus, leukoplakia, geographic tongue, aphthous ulcer, herpes simplex, CMV ulcer, histoplasmosis, Kaposi sarcoma, squamous cell carcinoma.
• Complications: oesophageal candidiasis, pain and poor intake leading to weight loss, azole resistance with prolonged therapy, dissemination (rare), recurrence.

Clinical.

• Scrape for KOH or Gram stain; culture and sensitivity for refractory disease.
• Endoscopy for persistent dysphagia not responding to 7 to 14 days of fluconazole.
• HIV test if status unknown; CD4 count, viral load; glucose.

Topical therapy for mild oral disease and systemic therapy for moderate to severe or oesophageal disease; start antiretroviral therapy.

• Supportive: oral hygiene with chlorhexidine 0.2 percent mouthwash (note it may inactivate nystatin, so give at a different time), soft diet, hydration, remove and clean dentures overnight, rinse mouth after inhaled steroids, spacer devices, treat dry mouth.
• Pharmacological: fluconazole 200 mg on the first day then 100 mg daily for 7 to 14 days; or nystatin oral suspension 100,000 units/mL, 4 to 6 mL four times daily for 7 to 14 days (hold in the mouth then swallow); clotrimazole 10 mg troche five times daily; miconazole buccal tablet 50 mg daily. Oesophageal candidiasis: fluconazole 400 mg on day 1 then 200 to 400 mg daily for 14 to 21 days. Fluconazole refractory: itraconazole solution 200 mg daily for 14 days, or amphotericin B 0.3 to 0.5 mg/kg IV daily. Start or optimise tenofovir, lamivudine and dolutegravir. Avoid long term fluconazole prophylaxis unless there are frequent severe recurrences.
• Procedures: endoscopy when needed.
• Special groups: pregnancy, topical nystatin or clotrimazole in the first trimester and fluconazole avoided in high doses; children, fluconazole 6 mg/kg on day 1 then 3 mg/kg daily for 7 to 14 days (oesophageal 6 mg/kg daily for 14 to 21 days), nystatin 1 to 2 mL four times daily in infants; liver disease, avoid azoles or monitor liver enzymes; drug interactions, fluconazole increases several drugs (warfarin, phenytoin).
• Red flags: dysphagia, odynophagia, weight loss, failure of treatment after 2 weeks, fever, CD4 under 100, suspected cryptococcal or other opportunistic infection.
• Follow-up: review at 1 to 2 weeks; CD4 recovery and viral load monitoring; recurrence requires adherence review.