Candidiasis esophageal

Explain the underlying pathophysiology of vulvovaginal candidiasis, oropharyngeal candidiasis, esophageal candidiasis, and fungal skin infections. 

The occurrence of oropharyngeal and esophageal candidiasis is an indicator of immune suppression, often developing in infants, the elderly, and the immunocompromised. 

Representing a severe form of extension of oropharyngeal candidiasis, esophageal candidiasis requires oral antifungal therapy. 

Oropharyngeal candidiasis (OPC) is a common fungal infection, usually associated with immune suppression. If left untreated, it will progress to more serious oral disease. Esophageal candidiasis, representing a serious progression of oropharyngeal candidiasis, is associated with increased morbidity. 

The prevalence of HIV infection plays a significant role in the incidence of oropharyngeal and esophageal candidiasis. In the 1980s, the incidence of oropharyngeal candidiasis increased fivefold, in association with the spread of HIV infections.25 Although HIV infection remains a risk factor for candidiasis, the introduction of highly active antiretroviral therapy precipitated a decline in the incidence of both infections by 50% to 60%.26... 

Although esophageal candidiasis represents the first manifestation of HIV infection in less than 10% of cases, it is the second most common acquired immunodeficiency syndrome (AIDS)-defining disease.29 As with oropharyngeal candidiasis, the incidence of esophageal candidiasis increases with decreasing CD4 counts. 

Candida albicans accounts for 80% of cases of OPC and esophageal candidiasis. Over the last 20 years, an increasing incidence of C. albicans resistance has been accompanied by an increased incidence of non-albicans species infections, including Candida glabrata, Candida tropicalis, Candida krusei, and Candida parapsilosis. In patients with cancer, non-albicans Candida species account for almost half of all cases.29... 

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. 

TABLE 80-4. Risk Factors for Oropharyngeal and Esophageal Candidiasis... 

Since oropharyngeal and esophageal candidiasis are signs of immunocompromise, the immune status of the patient should be considered in the therapeutic care plan. For HIV-infected patients, this should also include an evaluation of the patient s antiretroviral therapy since fungal infections may represent deterioration in immune status. 

Two to three weeks of fluconazole or itraconazole solution are highly effective and demonstrate similar clinical response rates.32 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 amphotericin B for 10 days. Although echinocandins and voriconazole are effective in treatment of esophageal candidiasis, experience remains limited. 

Assess the patient s symptoms to determine if symptoms are consistent with oropharyngeal or esophageal candidiasis. All patients with suspected oropharyngeal or esophageal candidiasis should be referred to a practitioner or physician since no antifungal products appropriate for oral use are available without a prescription. 

If the patient has had oropharyngeal or esophageal candidiasis previously, determine what treatments were helpful to the patient in the past. 

Provide patient education pertaining to oropharyngeal or esophageal candidiasis and antifungal therapy. 

Twenty percent of HIV-infected patients develop fluconazole-resistant Candida albicans isolates after repeated exposure to fluconazole.33 To treat fluconazole-resistant oropharyngeal candidiasis, daily itraconazole for 2 to 4 weeks may be used. Oral itraconazole solution exhibits a mycological cure rate of 88% and a clinical cure rate of 97% in immunocompromised patients.34 Fluconazole-resistant esophageal candidiasis should be treated with intravenous amphotericin B or caspofungin. 

If immunocompromised patients experience frequent or severe recurrences, particularly of esophageal candidiasis, chronic maintenance therapy with fluconazole 100 to 200 mg daily should be considered. In patients with infrequent or mild cases, secondary prophylaxis is not recommended. The rationale for not giving prophylaxis includes availability of effective treatments for acute episodes, risk of developing resistant organisms, potential for drug interactions, and the cost of therapy. 

Although more invasive, esophageal candidiasis does not typically evolve into a life-threatening infection. However, topical therapy is ineffective. Azoles (fluconazole, itraconazole solution, or voriconazole), echinocandins, or intravenous amphotericin B (in cases of unresponsive infections) are effective treatment options. Parenteral therapy should be used in patients who are unable to take oral medications.20... 

Blastomycosis, histoplasmosis, aspergillosis 200 mg bid. Oropharyngeal, esophageal candidiasis 100 mg qd. Onychomycosis 200 mg bid x 7 days each month x 3 months. 

Dowell JA, Stogniew M, Krause D, Henkel T. (2003) Anidulafungin (ANID) pharmacokinetic (PK)/Pharmacodynamic (PD) correlation Treatment of esophageal candidiasis. 43rd Interscience Conference of Antimicrobial Agents and Chemotherapy Abstract A-1578. 

Use primarily for treatment of patients with progressive and potentially fatal fungal infections. Do not use to treat noninvasive forms of fungal disease such as oral thrush, vaginal candidiasis, and esophageal candidiasis in patients with normal neutrophil counts. 

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