Candidiasis oropharyngeal

Inhaled steroids (commonly used are beclomethasone, budesonide, triamcinolone, fluticasone, flunisolide) appear to attenuate the inflammatory response, to reduce bronchial hyperreactivity, to decrease exacerbations and to improve health status they may also reduce the risk of myocar dial infar ction, but they do not modify the longterm decline in lung function. Whether- steroids affect mortality remains unclear. Many patients appear to be resistant to steroids and large, long-term trials have shown only limited effectiveness of inhaled corticosteroid ther apy. Certainly, the benefit from steroids is smaller in COPD than in asthma. Topical side-effects of inhaled steroids are oropharyngeal candidiasis and hoarse voice. At the normal doses systemic side-effects of inhaled steroids have not been firmly established. The current recommendation is that the addition of inhaled gluco-coiticosteroids to bronchodilator treatment is appropriate for patients with severe to veiy sever e COPD. 

Generally, inhaled glucocorticoids have few side effects, the appearance of which depends on the dose, the frequency of administration, and the delivery system used. The most common side effect is dysphonia (hoarseness), which affects approximately one third of treated patients. Oropharyngeal candidiasis (thrush)... 

The most common adverse effects from inhaled corticosteroids include oropharyngeal candidiasis and hoarse voice. These can be minimized by rinsing the mouth after use and by using a spacer device with metered-dose inhalers. Increased bruising and decreased bone density have also been reported the clinical importance of these effects remains uncertain.1,2,19... 

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

Topical agents are first-line therapy for oropharyngeal candidiasis, although oral agents maybe used for severe or unresponsive cases. 

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... 

Oropharyngeal candidiasis remains the most common opportunistic infection in patients with HIV. Eighty to ninety percent of HIV-positive patients develop oropharyngeal candidiasis.27 For 70% of these patients, it is the first manifestation of HIV infection.28 The incidence of oropharyngeal infection increases with decreasing CD4 lymphocyte counts, with an incidence of 60% in patients with a CD4 count less than 200 cells/mm3. 

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. 

Oropharyngeal candidiasis is often a presumptive diagnosis based on signs and symptoms, along with the resolution of them after treatment with antifungal agents. 

Signs vary depending on the type of oropharyngeal candidiasis. 

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. 

Currently, PCP prophylaxis is recommended for all HIV-infected individuals who have already had previous PCP. Prophylaxis is also recommended for all HIV-infected persons who have a CD4 lymphocyte count of less than 200 cells/mm3 (i.e., their CD4 cells are less than 20% of total lymphocytes) or a history of oropharyngeal candidiasis. 

Systemic toxicity of inhaled corticosteroids is minimal with low to moderate inhaled doses, but the risk of systemic effects increases with high doses. Local adverse effects include dose-dependent oropharyngeal candidiasis and dys-phonia, which can be reduced by the use of a spacer device. The ability of spacer devices to enhance lung delivery is inconsistent and should not be relied on. 

Patients with AIDS and cryptococcal meningitis or recurrent oropharyngeal candidiasis usually require maintenance therapy to prevent relapse... 

Oropharyngeal candidiasis 200 mg on the first day, followed by 100 mg once daily. Continue treatment for at least 2 weeks to decrease the likelihood of relapse. 

Oropharyngeal candidiasis - 200 mg/day for 1 to 2 weeks. Vigorously swish the solution in the mouth (10 ml at a time) for several seconds and swallow. For patients with oropharyngeal candidiasis unresponsive/refractory to treatment with fluconazole tablets, the recommended dose of itraconazole is 100 mg twice daily. Expect clinical response in 2 to 4 weeks. Patients may be expected to relapse shortly after discontinuing therapy. Limited data on the safety of long-term use (more than 6 months) of the oral solution are available at this time. 

Esophageal candidiasis 50 mg/day. Because of the risk of relapse of oropharyngeal candidiasis in patients with HIV infections, consider suppressive oral therapy. 

Grim SA, Smith KM, RomaneUi F, Ofotoknn 1. Treatment of azole-resistant oropharyngeal candidiasis with topical amphotericin. Ann Pharmacother 2002 36(9) 1383-6. 

Oropharyngeal candidiasis treatment PO 10 mg 5 times/day for 14 days. Oropharyngeal candidiasis prophylaxis PO 10 mg 3 times/day Dermatophytosis, cutaneous candidiasis Topical 2 times/day. Therapeutic effect may take up to 8 wk. 

Oropharyngeal candidiasis PO,lV 200mgonce, then 100 mg/day for at least Mdays. Esophageal candidiasis PO, IV 200 mg once, then 100 mg/day (up to 400 mg/day) for 21 days and at least 14 days following resolution of symptoms. 

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