Fever

• Odynophagia

• Retrosternal pain Signs

• Hyperemic or edematous white plaques

• Ulceration of esophagus

• Increased mucosal friability

• Narrowing of lumen Diagnostic Testing

Unlike OPC, diagnosis of esophageal candidiasis is not based solely on clinical presentation, instead requiring endoscopic visualization of lesions and culture confirmation. Due to the invasive nature of these procedures, most practitioners opt to treat the infection presumptively, reserving endoscopic evaluation for patients who fail therapy.

• Cytology and culture to identify species of yeast or presence of resistance

• Barium esophagogram

• Endoscopy revealing whitish plaques with progression to superficial ulceration of the esophageal mucosa

• Mucosal biopsy Patient Encounter 2

A 35-year-old woman presents to your clinic complaining of "burning and soreness in my mouth" along with a metallic taste and "this funny white stuff." On initial examination, she has white patches on her tongue, gums, and buccal mucosa. These patches are easily removed, revealing erythematous tissue underneath.

This is the woman's first visit to your clinic, therefore no medical history is available in her chart.

What additional information do you need to know before creating a treatment plan for this patient?

What underlying medical conditions might make her susceptible to fungal infections?

How is the treatment care plan altered if the patient has a history of frequent and severe OPC? If the patient is HIV-positive? If the patient is neutropenic?

For non-HIV-infected patients who have suppressed immune systems, the practitioner must consider the patient's risk of dissemination. Patients with cell-mediated immune deficiency but near-normal granulocyte function, such as patients with diabetes, solid organ transplant, or solid tumors, are at low-risk for dissemination. The risk of dissemination is higher for patients who develop neutropenia, including patients with leukemia or bone marrow transplant. These patients should be treated aggressively to prevent invasive fungal infection.

For the treatment of OPC in HIV-infected individuals, initial episodes can be adequately controlled with topical agents, such as clotrimazole troches, so long as symp-

toms are not severe and no esophageal involvement is suspected. Topical nystatin is

the least effective agent, especially in severely immunocompromised patients. Topical clotrimazole appears to be the most effective topical antifungal, exhibiting clinical responses equivalent to oral fluconazole and itraconazole solution, but mycological cure rates are lower and relapse rates higher with clotrimazole.31

® Representing a severe extension of OPC, esophageal candidiasis requires systemic antifungal therapy. The significant morbidity associated with esophageal can-didiasis warrants aggressive treatment. The diagnosis of esophageal candidiasis requires endoscopic evaluation, but rather than employing invasive procedures, patients can be treated with an appropriate course of antifungal based on clinical presentation. If patients do not respond, endoscopy should be considered.

Two to three weeks of fluconazole or itraconazole solution are highly effective and demonstrate similar clinical response rates.34 Oral doses of 100 to 200 mg are effective in immunocompetent patients but doses up to 400 mg are recommended for immunocompromised patients. Due to variable absorption, ketoconazole and itraconazole capsules should be considered second-line therapy. In severe cases, oral azoles may prove ineffective, warranting the use of IV amphotericin B for 10 days. Although echinocandins and voriconazole are effective in treatment of esophageal candidiasis, experience remains limited.

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