PRIMARY HIV INFECTION

 Differential Diagnosis

HIV-related candidal infections must be differentiated from a variety of other entities, depending on the site of infection:

Oral Esophageal Vaginal Cytomegalovirus Cytomegalovirus Chlamydial Herpes simplex Herpes simplex Gonococcal Hairy tongue HIV esophagitis Bacterial HIV stomatitis Medication-related ("pill esophagitis")   Kaposi’s sarcoma Mycobacterium avium intracellulare

Emergency Department Treatment and Disposition Poor oral intake secondary to pain associated with severe oral or esophageal candidiasis can cause dehydration and malnutrition, sometimes requiring intravenous hydration and admission. Empiric treatment is appropriate in patients suspected of having esophageal candidiasis. Endoscopy should be performed in those patients whose symptoms do not improve in 3 to 5 days. There is no "standard" treatment for candidiasis in the HIV patient. Both oral and vaginal candidiasis can be treated with standard nystatin or clotrimazole troches. Alternatively, systemic treatment with either ketoconazole or fluconazole is usually effective for oral, vaginal, and esophageal candidiasis. For severe or refractory cases of candidiasis, amphotericin B is the drug of choice.

Clinical Pearls

1. Popular one-dose oral treatments for oral or vaginal candidiasis are associated with a high rate of relapse in HIV patients.

2. Consider possible drug interactions when prescribing antifungal medications. For example, the absorption of ketoconazole is impaired by the simultaneous administration of antacids and cimetidine. Ketoconazole levels are also decreased in patients taking rifampin or isoniazid. Because of these drug interactions, many clinicians favor the use of fluconazole, since lack of gastric acid or the presence of food does not affect its absorption. Fluconazole does raise the serum levels of warfarin, rifabutin, or sulfonylureas.

3. Ensure follow-up in 3 to 5 days when treating empirically for presumptive esophageal candidiasis.

4. Oral candidiasis is a poor prognostic sign, predictive of progression to AIDS in the HIV-positive patient.