FUNGAL DISEASES

Oral Manifestations of HIV infection
By Drs. Deborah Greenspan and John S. Greenspan

Oral Candidiasis

Like hairy leukoplakia, oral candidiasis is highly prevalent in HIV-infected individuals. Approximately 30% of otherwise asymptomatic gay men have one or both of these lesions, and they are often the first clinical expression of HIV disease. Three presentations of oral candidiasis are seen in association with HIV infection: pseudomembranous candidiasis (thrush), erythematous candidiasis, and angular cheilitis.
Pseudomembranous candidiasis appears as creamy, white, removable plaques that can be found anywhere in the mouth or pharynx. These plaques are caused by overgrowth of fungal hyphae mixed with desquamate epithelium and inflammatory cells.
Erythematous candidiasis presents as flat, subtle, red patches of varying sizes on any mucosal surface, commonly the palate and dorsal surface of the tongue. These two forms of oral candidiasis are equally predictive of the development of AIDS. Angular cheilitis involves fissuring and cracking at the corners of mouth. Occasionally, all three types appear in the same individual. The diagnosis of oral candidiasis is usually made from the appearance of the lesions, but the presence of hyphae and blastospores, seen on smears examined with potassium hydroxide or Gram stain, can help confirm the diagnosis.
Oral candidiasis may be treated with either topical or systemic antifungal agents. The choice of medication depends on a variety of factors, including other, concomitant medications, evidence of abnormal liver function, patient preference and compliance, and the sugar content of topical preparations. Topical agents include nystatin oral pastille, one or two pastilles dissolved slowly four to five times a day; clotrimazole oral troche, 10 mg, one troche dissolved five times a day; and nystatin oral suspension. Nystatin oral suspension has a high sugar content and its relatively short time in contact with the oral mucosa makes it less effective. If used for a long time, the oral topical agents that contain sweetening agents may promote caries, so daily topical fluoride rinses should be used in conjunction with long-term therapy. Other preparations that can be used topically for oral candidiasis include some vaginal preparations: nystatin vaginal troche 100,000 units, one troche dissolved in the mouth three times a day; or clotrimazole vaginal troche, one dissolved in the mouth daily.
Oral candidiasis can be treated systemically with ketoconazole, fluconazole, and itraconazole. Ketoconazole is used as one or two 200-mg tablets taken daily with food. However, since ketoconazole depends on normal levels of gastric acidity for its absorption and many HIV-infected patients have hypochlorhydria, caution should be exercised. Fluconazole is used as one 100-mg tablet taken once daily. Itraconazole is used as two 100-mg capsules taken daily. Oral candidiasis outbreaks often recur and maintenance therapy may be needed.

Angular Cheilitis

Angular Cheilitis can be treated with topical agents such as nystatin, clotrimazole, and ketoconazole creams or ointments. Some cases of oral candidiasis may be resistant to treatment with fluconazole and to other orally administered systemic and topical agents. Amphotericin B solution has been reported to be helpful in some of these cases. Amphotericin B as an oral solution is prescribed as 0.1 mg/ml; 5 to 10 ml are used to rinse the mouth and are then expectorated, three to four times a day.

Histoplasmosis

Histoplasmosis has been reported to present as oral ulcers that may be the first presentation or may be part of disseminated disease.

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