Oral Candida infections are often seen in individuals with HIV/AIDS, with the severity of infection correlating with the degree of immunosuppression. Oral candidiasis can occur at all stages of HIV disease. The usual causative agent is Candida albicans, but other Candida species have been isolated. Oral candidiasis, or “thrush,” can be classified as pseudomembranous, angular, or erythematous. Pseudomembranous candidiasis can be diagnosed by identifying removable whitish plaques on the tongue, uvula, and buccal mucosa. Erythematous or atrophic candidiasis appears as smooth red patches along the soft and hard palate. Although isolated oral candidiasis is not an AIDS-defining illness (although esophageal candidiasis is), oral candidiasis is an indication for pneumocystis prophylaxis regardless of CD4+ cell count.
Vaginal candidiasis is common in HIV-positive patients and can cause a severe whitish discharge with vulvar erythema.
Management and Disposition
Patients presenting to the ED for dysphagia or odynophagia thought to be due to candidiasis should be evaluated for dehydration and may require inpatient admission. Most cases of minimally symptomatic oral candidiasis respond well to nystatin suspension or clotrimazole troches. More symptomatic oral or esophageal candidiasis usually responds to fluconazole. Rare cases of resistant candidiasis may require intravenous echinocandin therapy and consultation with an infectious disease physician.
Symptomatic oral and esophageal candidiasis is still a common ED presentation in HIV patients who are not receiving or are not compliant with effective ART.
The diagnosis of oral candidiasis in a patient not already diagnosed with HIV infection should lead to a discussion of risk factors and should prompt HIV screening.
Mildly symptomatic oral, esophageal, or vaginal candidiasis usually responds to a one-time oral dose of fluconazole. Close clinical follow-up should be arranged.
Oral Candidiasis. Removable whitish plaques on the palate are seen in this HIV infected patient with pseudomembranous candidiasis. (Photo contributor: Thea James, MD.)
Esophageal Candidiasis. Endoscopy demonstrating esophageal candidiasis in this HIV-infected patient. (Photo contributor: Edward C. Oldfield III, MD.)
Oral Thrush. Typical plaque lesions are seen on the palate and uvula of this HIV patient. (Photo contributor: Seth W. Wright, MD.)