History

Fact Explanation
Asymptomatic Candida infection is a common opportunistic infection in some patients with HIV. It is due to impaired cell mediated immunity secondary to reduced CD4 cells. Some patients with candidiasis can remain asymptomatic. [1,3]
Symptoms of oropharyngeal candidiasis Oropharyngeal candidiasis is often the earliest sign of HIV infection. Oropharyngeal candidiasis can present in four different forms, prepseudomembranous candidiasis, hyperplastic candidiasis, erythematous candidiasis, and angular cheilitis. Erythematous candidiasis, which is common in patients with HIV infection, presents with erythematous macules over the palate and the dorsum of the tongue. Presence of white plaque like lesions is the complain of pseudomembranous candidiasis which is common in patients with AIDS. Burning sensation of the oral cavity is another presentation of oropharyngeal candidiasis. Angular cheilitis presents with cracked or ulcerated lips. [1,2,3]
Symptoms of esophageal candidiasis Patients with esophageal candidiasis often have co-excisting oropharyngeal candidiasis. Retrosternal chest pain, odynophagia and dysphagia are the usual complains of esophageal candidiasis. [1,3]
Symptoms of onychomycosis [1] Onychomycosis refers to the fungal infection of the nails. Candida infection of the nails causes disfigurement and broken nails. [4]
Symptoms of vulovaginitis [1] Vaginal candidiasis presents with pruritus, vaginal soreness and dysuria. Some females may complain of thick whitish discharge.
Symptoms of candida skin infection [1] Cutaneous infection of the Candida commonly involves the skin folds (intertrigo, groin). Pruritus and the presence of white-yellow, curd-like substance over the affected area are the usual complains.
Symptoms of sepsis [1] Patients with AIDS can present with sepsis. Fever, generalized ill health, postural dizziness and collapse are the presenting complains. [5]
Risk factors People who had unprotected multiple sexual relationships, intravenous drug users who share needles and health care workers who sustain accidental needle prick injuries are at risk of acquiring HIV infection. [1]
References
  1. ANWAR KP, MALIK A, SUBHAN KH. Profile of candidiasis in HIV infected patients Iran J Microbiol [online] 2012 Dec, 4(4):204-209 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3507311
  2. SHETTI ARVIND, GUPTA ISHITA, CHARANTIMATH SHIVYOGI M.. Oral Candidiasis: Aiding in the Diagnosis of HIV—A Case Report. Case Reports in Dentistry [online] 2011 December, 2011:1-4 [viewed 11 August 2014] Available from: doi:10.1155/2011/929616
  3. VAZQUEZ JA. Optimal management of oropharyngeal and esophageal candidiasis in patients living with HIV infection HIV AIDS (Auckl) [online] :89-101 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3218701
  4. ELEWSKI BE. Onychomycosis: Pathogenesis, Diagnosis, and Management Clin Microbiol Rev [online] 1998 Jul, 11(3):415-429 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC88888
  5. PAPPAS PETER G., REX JOHN H., SOBEL JACK D., FILLER SCOTT G., DISMUKES WILLIAM E., WALSH THOMAS J., EDWARDS JOHN E.. Guidelines for Treatment of Candidiasis. CLIN INFECT DIS [online] 2004 January, 38(2):161-189 [viewed 11 August 2014] Available from: doi:10.1086/380796

Examination

Fact Explanation
Examination of the oral mucosa Patients with pseudomembranous candidiasis have white plaque like lesions. The lesions cannot be wiped away. Patients with angular cheilitis have cracked or ulcerated lips, which sometimes peels off. [1,2]
Examination of the genitalia Patients with vulval candidiasis have erythematous labia. Speculum examination shows thick, curd like vaginal discharge.
Nail changes Onycholysis (detachment of the nail from the nail bed) and paronychia (inflammation of the soft tissue around the nail) are common examination findings of candida infection of nails. [3]
Cutaneous manifestations Affected skin is erythematous and inflammed. white-yellow, curd-like substance can be observed in some patients.
Evidence of sepsis Fever, cold clammy extremities and hypotension can be the signs of sepsis.
References
  1. SHETTI ARVIND, GUPTA ISHITA, CHARANTIMATH SHIVYOGI M.. Oral Candidiasis: Aiding in the Diagnosis of HIV—A Case Report. Case Reports in Dentistry [online] 2011 December, 2011:1-4 [viewed 11 August 2014] Available from: doi:10.1155/2011/929616
  2. VAZQUEZ JA. Optimal management of oropharyngeal and esophageal candidiasis in patients living with HIV infection HIV AIDS (Auckl) [online] :89-101 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3218701
  3. ELEWSKI BE. Onychomycosis: Pathogenesis, Diagnosis, and Management Clin Microbiol Rev [online] 1998 Jul, 11(3):415-429 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC88888

Differential Diagnoses

Fact Explanation
Herpetic oesophagitis Herpetic esophagitis is the second most common esophagitis seen in immunecompromised patients. Distal and mid-esophagus are commonly affected. Endoscopic examination reveals friable mucosa, mucosal ulcers, and whitish exudates. [3]
Cytomegalovirus (CMV) esophagitis [1] CMV infection can also cause esophagitis. Biopsy of the esophageal mucosa shows viral inclusions. [4]
Aphthous ulceration Recurrent, painful oral ulcers can be seen in recurrent aphthous ulcers.
HIV oesophagitis HIV itself can cause esophagitis.
Vaginal trichomoniasis Trichomoniasis infection is a sexually transmitted infection. It causes vaginal itching and foul smelling discharge. [5]
Bacterial vaginosis Another sexually transmitted infection, which causes itching and foul smelling of the vagina. [6]
Gastroesophageal reflux disease (GERD) [1] Frequent acid reflux and burning epigastgic pain are seen in patients with GERD.
References
  1. VAZQUEZ JA. Optimal management of oropharyngeal and esophageal candidiasis in patients living with HIV infection HIV AIDS (Auckl) [online] :89-101 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3218701
  2. ELEWSKI BE. Onychomycosis: Pathogenesis, Diagnosis, and Management Clin Microbiol Rev [online] 1998 Jul, 11(3):415-429 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC88888
  3. JAZERON J.-F., BARBE C., FROBERT E., RENOIS F., TALMUD D., BRIXI-BENMANSOUR H., BRODARD V., ANDREOLETTI L., DIEBOLD M.-D., LEVEQUE N.. Virological Diagnosis of Herpes Simplex Virus 1 Esophagitis by Quantitative Real-Time PCR Assay. Journal of Clinical Microbiology [online] December, 50(3):948-952 [viewed 11 August 2014] Available from: doi:10.1128/JCM.05748-11
  4. VENKATARAMANI ARJUN, SCHLUETER ANNETTE J., SPECH THOMAS J., GREENBERG EUGENE. Cytomegalovirus esophagitis in an immunocompetent host. Gastrointestinal Endoscopy [online] 1994 May, 40(3):392-393 [viewed 11 August 2014] Available from: doi:10.1016/S0016-5107(94)70094-X
  5. WENDEL K. A., WORKOWSKI K. A.. Trichomoniasis: Challenges to Appropriate Management. Clinical Infectious Diseases [online] 2007 April, 44(Supplement 3):S123-S129 [viewed 11 August 2014] Available from: doi:10.1086/511425

Investigations - for Diagnosis

Fact Explanation
Full blood count Patients with CD4 T lymphocytes less than 200 cells/µL have a higher risk of acquiring candida infection.
Upper gastrointestinal endoscopy Patients with esophageal candidiasis presents with adherent, whitish curd like mucosal plaques. Superficial mucosal ulcerations and evidence of inflammation can be noted in the presence of esophagitis.
Biopsy or swab from infected areas Biopsies should be obtained from any suspicious lesions. Microscopic examination with 10% KOH smear shows budding yeast and pseudohyphae. Nail scraping of infected nails is used to obtain tissue samples for microscopic examination. [3]
Culture Culture of the biopsy specimens enable isolation of the Candida. Candida albicans is the commonly isolated organism which accounts for about 70%–80% of oral isolates. Candida glabrata and Candida tropicalis are less commonly isolated. Blood culture is helpful in diagnosing Candida sepsis. [2,4]
Enzyme immunoassay (EIA) EIA detects HIV antibodies(IgG) and aids in diagnosing HIV infection. However EIA is not diagnostic of HIV. [5]
Western blot Western blot is the confirmatory rest to diagnose HIV. [5]
References
  1. ANWAR KP, MALIK A, SUBHAN KH. Profile of candidiasis in HIV infected patients Iran J Microbiol [online] 2012 Dec, 4(4):204-209 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3507311
  2. VAZQUEZ JA. Optimal management of oropharyngeal and esophageal candidiasis in patients living with HIV infection HIV AIDS (Auckl) [online] :89-101 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3218701
  3. ELEWSKI BE. Onychomycosis: Pathogenesis, Diagnosis, and Management Clin Microbiol Rev [online] 1998 Jul, 11(3):415-429 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC88888
  4. CHAN‐TACK KIRK M.. Fatal Septicemia in a Patient with AIDS . CLIN INFECT DIS [online] 2005 April, 40(8):1209-1210 [viewed 11 August 2014] Available from: doi:10.1086/428846
  5. CORNETT J. K., KIRN T. J.. Laboratory Diagnosis of HIV in Adults: A Review of Current Methods. Clinical Infectious Diseases [online] December, 57(5):712-718 [viewed 11 August 2014] Available from: doi:10.1093/cid/cit281

Investigations - Fitness for Management

Fact Explanation
Full blood count Regular full blood count tests are necessary to assess the degree of immunosuppression.
Renal profile Patients with sepsis can have multi-organ failure leading to deranged renal function. Abnormal electrolyte profile and elevated serum creatinine are common findings. [1]
Liver function test Sepsis is a cause for acute liver failure. Elevated liver enzymes, PT/INR can be found. [2]
References
  1. MAJUMDAR A. Sepsis-induced acute kidney injury Indian J Crit Care Med [online] 2010, 14(1):14-21 [viewed 11 August 2014] Available from: doi:10.4103/0972-5229.63031
  2. BANKS JG, FOULIS AK, LEDINGHAM IM, MACSWEEN RN. Liver function in septic shock. J Clin Pathol [online] 1982 Nov, 35(11):1249-1252 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC497938

Management - General Measures

Fact Explanation
Health education Patients who are at risk of acquiring HIV infection should be educated about the possible ways of HIV transmission and prevention. Patients with HIV and AIDS should be advised to avoid crowded areas to reduce the risk of acquiring infections.
References

Management - Specific Treatments

Fact Explanation
Highly Active AntiRetroviral Therapy (HAART) HAART in combination with protease inhibitors is known to reduce the incidence of candida infections. [2]
Management of oropharyngeal candidiasis Mild to moderate disease can be treated with topical clotrimazole, nystatin oral suspension, and nystatin pastilles. Severe disease may require systemic antifungals (fluconazole, itraconazole, voriconazole). [1,2]
Treatment of esophageal candidiasis Patients with esophageal candidiasis need systemic antifungal treatment. Fluconazole, itraconazole and ketoconazole are commonly used oral antifungals. Intravenous amphotericin B is used in severe infection. Antifungal resistant mucosal candidiasis is treated with posaconazole, high dose fluconazole and itraconazole. [2]
Treatment of vaginal candidiasis Isoconazole (300 mg), imidazole and tioconazole vaginal tablets are used for topical treatment. Terconazole vaginal tablet is the drug of choice if non-Candida albicans infection is suspected. Patients with recurrent vaginal cadidiasis are given prophylactic antifungal drugs (ketoconazole, clotrimazole). [4]
Management of onychomycosis Onychomycosis is difficult to treat. Routinely used antifungals are fluconazole, itraconazole, and terbinafine. [3]
References
  1. SHETTI ARVIND, GUPTA ISHITA, CHARANTIMATH SHIVYOGI M.. Oral Candidiasis: Aiding in the Diagnosis of HIV—A Case Report. Case Reports in Dentistry [online] 2011 December, 2011:1-4 [viewed 11 August 2014] Available from: doi:10.1155/2011/929616
  2. VAZQUEZ JA. Optimal management of oropharyngeal and esophageal candidiasis in patients living with HIV infection HIV AIDS (Auckl) [online] :89-101 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3218701
  3. ELEWSKI BE. Onychomycosis: Pathogenesis, Diagnosis, and Management Clin Microbiol Rev [online] 1998 Jul, 11(3):415-429 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC88888
  4. RINGDAHL EN. Treatment of recurrent vulvovaginal candidiasis. Am Fam Physician [online] 2000 Jun 1, 61(11):3306-12, 3317 [viewed 12 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10865926