Oral plaques and dysphagia in a young man
FEATURES AND DIAGNOSIS OF ORAL CANDIDIASIS
Lesions of oral candidiasis can vary in their appearance. The pseudomembranous form is the most characteristic, with white adherent “cottage-cheese-like” plaques that wipe away, causing minimal bleeding.1,7 The erythematous or atrophic form is associated with denture use and causes a “beefy” appearance on the dorsum of the tongue or on the mucosa that supports a denture.1,7 A third form affects the angles of the mouth, causing angular cheilitis (perlèche).7,8 Chronic infection appears as localized, firmly adherent plaques with an irregular surface similar to hyperkeratosis caused by chronic frictional irritation.7
Oral candidiasis can occur in different forms at the same time. Patients often describe minimal symptoms such as dysgeusia or dry mouth.1,7 Infections causing dysphagia or odynophagia warrant suspicion for involvement of the esophagus.
,The diagnosis is made empirically if the lesions resolve with anticandidal therapy. A more definitive diagnosis can be made by microscopy with a potassium hydroxide preparation showing pseudohyphae. Formal culture can also determine the yeast’s susceptibility to medication in recurrent or resistant cases.2
Oral candidiasis may be the manifesting symptom of HIV infection, and more than 90% of patients with adult immunodeficiency syndrome have an episode of thrush.8 When candidiasis is diagnosed without obvious cause, HIV testing should be offered, regardless of a patient’s lack of obvious risk factors. Other oral lesions in HIV patients are oral hairy leukoplakia, Kaposi sarcoma, periodontal and gingival infections, aphthous ulcers, herpes simplex stomatitis, and xerostomia.2 With highly active antiretroviral therapy, the incidence of oral candidiasis has decreased by about 50%.2
Our patient was diagnosed with HIV when screened after this initial presentation. Lower CD4 counts and higher viral loads increase the patient’s risk for oral candidiasis and other lesions. This patient’s initial CD4 count was 524 cells/μL, and his viral load was 11,232 copies/mL.
TREATMENT
In HIV-negative patients or in HIV-positive patients with a CD4 count greater than 200 cells/μL, the treatment of oral candidiasis involves topical antifungal agents, including a nystatin suspension (Nystat-Rx) or clotrimazole (Mycelex) troches.3,7,9 Treatment should be continued for at least 7 days after resolution of the infection. If resolution does not occur, oral fluconazole (Diflucan) 200 mg daily should be given.
For HIV patients with CD4 counts below 200 cells/μL, oral fluconazole or itraconazole (Sporanox) is recommended, with posaconazole (Noxafil) as an alternative for refractory disease.3,9 Giving fluconazole prophylactically to prevent oral candidiasis is not recommended because of the risk of adverse effects, lack of survival benefit, associated cost, and potential to develop antifungal resistance.3,9
