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Candidiasis, Oral and Esophageal 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
6–6 | Clinical Manual for Management of the HIV-Infected Adult/2006 P: 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 firstline 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
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Table of Contents Clinical Manual f
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Clinical Manual for Management of t
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Preface—About this Manual | Clini
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Previous Editions Atlanta Contribut
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♦ ♦ ♦ ♦ ♦ | Clinical Manu
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1-2 | Clinical Manual for Managemen
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Initial Physical Examination Backgr
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Genitals/Rectum • Inspect the gen
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Initial and Interim Laboratory and
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Section 1—Testing and Assessment
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Patient Education ♦ ♦ ♦ ♦ D
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Section 2—Health Maintenance and
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References ♦ ♦ ♦ ♦ ♦ ♦
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Occupational Postexposure Prophylax
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P: Plan Laboratory Testing Provide
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For hepatitis C, no recommended pro
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as hepatitis C or another sexually
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for treatment is appropriate, and b
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contact with the patient. Patients
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tablet daily of trimethoprim-sulfam
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Opportunistic Infection Prophylaxis
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Discontinuing Primary Prophylaxis P
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Latent Tuberculosis Background Late
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INH may cause liver toxicity and it
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Patient Education ♦ ♦ ♦ ♦
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Reducing Maternal-Infant HIV Transm
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Some states require written informe
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contraindicated during pregnancy be
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Section 3—Antiretroviral Therapy
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Nelfinavir (Viracept) Adequate drug
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Section 4—Complications of Antire
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♦ ♦ ♦ Toronto General Hospita
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Adverse Reactions to HIV Medication
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♦ ♦ ♦ ♦ ♦ Vital signs: No
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egimen, symptoms of fatigue could i
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Recreational Drugs and Antiretrovir
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Section 4—Complications of Antire
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LSD, Mescaline, Psilocin, and Methy
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Immune Reconstitution Syndrome Back
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A: Assessment In the appropriate cl
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♦ ♦ ♦ ♦ ♦ Navas E, Martin
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Page 202 and 203: Eye Problems Background The immunos
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Page 210 and 211: Fever Background Although fever may
Page 212 and 213: Headache Background Headache may ha
Page 214 and 215: Lymphadenopathy Background Lymphade
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Page 226 and 227: Pulmonary Symptoms Background Short
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Page 240: Maintenance therapy Use caution whe
Page 246 and 247: Cervical Dysplasia Background Cervi
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Page 254 and 255: Cryptosporidiosis Background Crypto
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Page 266 and 267: Gonorrhea and Chlamydia Background
Page 268 and 269: Treatment of Gonorrhea Treatment op
Page 270 and 271: Hepatitis B Infection Background He
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Page 274 and 275: Hepatitis C Infection Background He
Page 276 and 277: pregnancy. Ribavirin is teratogenic
Page 278 and 279: Herpes Simplex, Mucocutaneous Backg
Page 280: References ♦ ♦ ♦ ♦ ♦ Cent
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Kaposi Sarcoma Background Kaposi sa
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Treatment Treatment of KS is not co
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Molluscum Contagiosum Background Mo
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Mycobacterium avium Complex Backgro
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Table 1. Interactions between Rifab
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Mycobacterium tuberculosis: Treatme
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P: Plan Diagnostic Evaluation Durin
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Table 1. Regimens for Treatment of
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Rifabutin may be substituted for ri
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Non-Hodgkin Lymphoma Background Non
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Patient Education ♦ ♦ ♦ ♦ S
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Toxoplasmosis Background Toxoplasma
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♦ Atovaquone 1,500 mg orally twic
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Linear Gingival Erythema Background
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Background Necrotizing ulcerating p
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Oral Health Background Examination
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Maxillary Tori; Mandibular Tori S:
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Periodontal Disease Background The
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Oral Hairy Leukoplakia Background O
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Oral Ulceration Background Oral ulc
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Oral Warts Background Oral warts ar
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Anxiety Disorders Background Anxiet
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Patient Education ♦ ♦ Behaviora
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Insomnia Background Insomnia is a c
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Suicidal Ideation Background Transi
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Section 8—Neuropsychiatric Disord
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P: Plan ♦ ♦ ♦ ♦ ♦ Check t
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Correctional Settings Background Ca
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Adherence Adherence is one of the m
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Karnofsky Performance Scale Backgro
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