factsheet

Bertrand Toulouse & Deirdre Maclean October 31, 1997 Reviewed by Sharon Walmsley, MD, FRCPC

Candidiasis

Summary:
Candidiasis is a very common fungal infection in people living with HIV. It can affect the mouth (thrush), esophagus, vagina (yeast infection), foreskin of the penis, or skin. Rarely, the fungus can infect internal organs and may even be found in the blood. It can be treated with a variety of antifungal drugs.

General:
What is candidiasis?
Candidiasis is most often caused by a fungus called Candida albicans. Less commonly it can be caused by other members of the Candida group of fungi, including Candida glabrata, Candida krusei, and Candida tropicalis. The Candida fungus is normally found in the mouth, gastrointestinal tract, vagina, and on the skin. Its part of the normal flora of bacteria and fungi that live in or on the human body. Candida causes health problems only when there is an overgrowth. Candidiasis is the most common fungal infection in people living with HIV, but it can also flare up in HIV-negative people. Diabetes, false teeth, pregnancy, smoking, steroids, birth control pills, and antibiotics can all encourage the growth of this fungus. develop thrush at CD4+ counts above 200 should consider starting treatment to prevent PCP (Pneumocystis carinii pneumonia). Candidiasis in the esophagus (the tube connecting the mouth to the stomach) can cause difficulty swallowing, a sore throat, and sometimes a feeling of chest pain, just behind the breastbone. Esophageal candidiasis is considered an AIDS-defining illness. Candidiasis of the vulva or the vagina is often called a yeast infection. It can cause an itching or burning feeling of the skin outside the vagina and a thick, white vaginal discharge. Many women get yeast infections, but HIV-positive women may get them more often and they may be more difficult to control. Yeast infections can appear at any CD4+ count, but they may become more severe as the count drops.

Symptoms
Candidiasis of the mouth is often called thrush. It usually appears as white patches on the tongue, the roof of the mouth, insides of the cheeks, or along the gums. The whitish layer can be easily scraped off, revealing a reddish, sore-looking area on the tissue below. Sometimes thrush appears as red, sore spots on the tongue. Less commonly, it can appear as cracks and redness at the corners of the mouth. Thrush can cause discomfort or pain in the mouth and a bad taste or changed sense of taste. Oral candidiasis is considered an early sign of damage to the immune system. People who

Diagnosis
Doctors usually diagnose thrush just by looking at the lesions. Sometimes thrush looks like another mouth infection called oral hairy leukoplakia (OHL). However, OHL lesions cannot be scraped away. The diagnosis of thrush can be confirmed by scraping off a sample from a lesion, staining it, and examining it under the microscope. Esophageal candidiasis is usually, but not always, accompanied by oral thrush. Doctors often
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diagnose it on the basis of symptoms and the patients history, and begin treatment right away. However, there are other conditions that can cause similar symptoms so doctors may also do an endoscopy if the patient does not respond quickly to treatment. The endoscope is a very thin, flexible tube with a viewing device at one end. It is inserted through the mouth and down the esophagus, and allows the lining of the esophagus to be viewed by the physician. A biopsy (the removal of a small sample of tissue) can also be done through the endoscope. Yeast infections may be diagnosed on the basis of symptoms and the patients history. The doctor may also take a swab of the vagina and have the sample examined under a microscope to be certain that Candida is the cause of the symptoms.

prefer to insert yoghurt directly into the vagina in the same way that many pharmaceutical preparations are used.

Treatment
There are many treatments for candidiasis which can be divided into two groups: topical (creams, shampoos, mouthwashes, lozenges) where the drug is in direct contact only with the skin or with the inside of the mouth or vagina, or systemic (pills or injections) where the drug is circulated throughout the body by the blood. Topical treatments are cheap and have almost no side effects. However, they can be messy, they may taste unpleasant, and they may take longer to work than systemic treatments. Although they are convenient, systemic treatments are more expensive, and may cause side effects, or interactions with other drugs. Topical treatments for thrush or yeast infections include: * nystatin (Mycostatin) tablets or clotrimazole (Canesten, Clotrimaderm) troches or amphotericin B lozenges which are dissolved in the mouth and swallowed, 3 to 5 times daily; * nystatin suspension or amphotericin B suspension swished around in the mouth and swallowed, 3 to 5 times daily; * clotrimazole (Canesten, Clotrimaderm, Myclo-Gyne) or nystatin vaginal inserts, tablets or creams. The amount of drug and the length of time its taken varies, depending on the location and severity of the candidiasis. Systemic treatments include: * ketoconazole (Nizoral) tablets (200-400 mg daily) * fluconazole (Diflucan) tablets (100-800 mg daily) * itraconazole (Sporanox) tablets (100-400 mg daily) * itraconazole (Sporanox) oral solution (100200 mg daily) * IV fluconazole or amphotericin B (0.3 mg/kg for 5-7 days)

Prevention
Since the Candida fungus naturally lives in or on our bodies, it is impossible to avoid it. However, there are several ways to help keep it under control. Primary prophylaxis (treatment taken to prevent an infection) with drugs is almost never used. Secondary prophylaxis (treatment taken to prevent an infection from coming back) is used when candidiasis is a recurring problem. Rinsing the mouth with water after eating, drinking, or chewing gum, brushing the teeth after each meal, using dental floss, and visiting a dentist regularly can help maintain oral health. Cutting down on sugars and starchy food has been suggested as a way of helping to control candidiasis, however there have been no controlled clinical trials of a low-sugar or -starch diet with HIV-positive volunteers. Before eliminating sugars or starches, a consultation with a nutrionist can help make sure there are enough calories from proteins, other carbohydrates, and fats in the diet. Unsweetened yoghurt with live bacterial culture (Lactobacillus acidopholus) has been a popular remedy for yeast infections. Hilton and colleagues conducted a one year study of the effect of live yoghurt on yeast infections in a small group of women. The results showed that those who ate 8 ounces of live yoghurt daily had 3 times fewer yeast infections. Some women
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Resistance
Candida strains which are able to resist the effects of fluconazole have been identified and there have been case reports of thrush and yeast infections that do not respond to fluconazole treatment. At the moment, there is no consensus about how to treat such cases. Intravenous amphotericin B is often considered the next step, if fluconazole fails. Despite being a highly effective drug, amphotericin B can cause a variety of side effects and both doctors and patients would prefer another choice. At the 4th Retroviruses Conference in January 1997, Fessel and colleagues reported that 68 of 74 patients were treated successfully with itraconazole oral suspension, after their thrush had not cleared up with fluconazole. Rev Ankar and colleagues reported successful treatment of 151 out of 155 patients with fluconazoleresistant thrush simply by increasing the fluconazole dose (up to as much as 800 mg daily) and the length of time treatment was given. Maximizing anti-HIV treatment may also help to reduce severe candidiasis. At the Canadian Association for HIV Research (CAHR) conference in May 1997, a group of Montreal researchers reported on a small study of 6 male patients who had persistent oral candidiasis, despite daily treatment with high doses of antifungal drugs. After adding a protease inhibitor to their anti-HIV cocktails, 5 of the 6 no longer needed the daily antifungal drugs. Availability of drugs All of the drugs mentioned are available with a prescription, except Amphotericin B lozenges and suspension are not approved for sale in Canada. Physicians may be able to obtain these drugs through Health Canadas Special Access Programme (formerly called the Emergency Drug Release Programme or EDRP).
Canadian Pharmaceutical Association Compendium of Pharmaceuticals and Specialities. 32nd edition. Ottawa: Canadian Pharmaceutical Association,1997. Cohen PT, Sande MA, Volberding PA. The AIDS Knowledge Base. 2nd edition. Toronto: Little, Brown, and Company. 1994. Fessler WJ, Merrill KW, Ward D, et al. Itraconazole oral

solution for the treatment of fluconazole-refractory oropharyngeal candidiasis in HIV-positive patients. [Abstract] 4th Conference on Retroviruses and Opportunistic Infections 1997. Fletcher S, Turner H. Reduction in severe oral candidiasis observed in AIDS patients on triple combination antitretroviral therapy. [Abstract 356] 6th Annual Canadian Conference on HIV/AIDS Research 1997. Hilton E, Isenberg HD, Alperstein P, et al. Ingestion of yogurt containing Lactobacillus acidophilus as prophylaxis for candidal vaginitis. Annals of Internal Medicine 1992;116(5):353-7. Isselbacher KJ, Braunwald E, Wilson JD, Martin JB, Fauci AS, Kasper DL. Harrisons Principles of Internal Medicine. 13th edition. Toronto: McGraw-Hill, 1994. Rev Ankar SG, Dib OP, Kirkpatrick WR, et al. Clinical evaluation and microbiology of fluconazole resistant oropharyngeal candidiasis. [Abstract] 4th Conference on Retroviruses and Opportunistic Infections 1997. Schuman P, Capps L, Peng G, Vazquez J, et al. Weekly fluconazole for the prevention of mucosal candidiasis in women with HIV infection. Annals of Internal Medicine 1997;126:6890696. Tobin MA, Chow FJ, Bowmer MI, Bally GA. A Comprehensive Guide for the Care of Persons with HIV Disease: Module I. Revised edition. Mississauga: The College of Family Physicians of Canada, 1996.

References:

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Decisions about particular medical treatments should always be made in consultation with a qualified medical practitioner knowledgeable about HIV-related illness and the treatments in question. The Community AIDS Treatment Information Exchange (CATIE) in good faith provides information resources to help people living with HIV/AIDS who wish to manage their own health care in partnership with their care providers. Information accessed through or published or provided by CATIE, however, is not to be considered medical advice. We do not recommend or advocate particular treatments and we urge users to consult as broad a range of sources as possible. We strongly urge users to consult with a qualified medical practitioner prior to undertaking any decision, use or action of a medical nature. We do not guarantee the accuracy or completeness of any information accessed through or published or provided by CATIE. Users relying on this information do so entirely at their own risk. Neither CATIE nor Health Canada nor any of their employees, directors, officers or volunteers may be held liable for damages of any kind that may result from the use or misuse of any such information. The views expressed herein or in any article or publication accessed or published or provided by CATIE are solely those of the authors and do not reflect the policies or opinions of CATIE or the official policy of the Minister of Health Canada.

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