Oct 28, 2007
Recently I have been admitted into the hospital for what appears to be Thrush or Candida. My symptoms include small white spots on the tonsils, white coating of the tongue, a white curd-like spot on the roof of my mouth when easily scraped away bled somewhat, inability to tolerate anything orally due to severe headpain after ingesting food, medications or fluids. Each visit to the hospital they would perform a series of tests to include, MRI, CAT Scan, Blood Culture, LP, EGD, Urinalisys and CBC only to reveal that luckily each test was negative. My suspicion, although never confirmed by any test results is that I have Intestinal Candida because when put on anti-fungal IV, my symptoms improve dramatically. My T-cells are 170 and VL <50.
I am aware that most doctors that are not HIV specialists dont believe that Candida is a disease and dont regard it as something that is potentially life threatening because Candida is found in small amounts in every person and they dont have standardized testing for such for most people. However, with my past diagosis of Ulcer, high sugar diet (ice cream to help ease the ulcer pain), Antibiotic use and a recurant (what seems to be with the research I've done but not concluded by test results) Intestinal Candida, and with anti-fungal treatment dramatically improving my symptoms, I can only gather on my own that what I have is Candida each time. However, no test from the previous three times admitted into the hospital did they conclude I had a fungal infection-because I was not tested for that specifically. On one test from the EGD, it did reveal that I did have Esophogitis though. From what I've read and gathered from literature and online resources is that if the muscosal barrier in the GI tract is comprimised with no protection from certain pathogens, it is possible that those pathogen could potentially penetrate the intestinal wall structure and cause many problems. H. Pylori test was negative as well.
Before being admitted to the hospital as my symptoms get worse, I would start back on a course of Diflucan 200 mg and usually my symptoms would be alleviated. However this last time, my symptoms did not improve and went into the hospital to be treated. I have not been told by my HIV doctors that I should be on anti-fungal maintenance therapy, but have been treated empirically by them but never given a timeframe as to how long I need to continue treatment to keep the supposed Candida and Thrush in check.
My questions are, are there any tests that can be performed to rule out a Candida infection without having to go through the myriad of tests that doctors need to perform? Would a fungal test come back negative if i was already taking an anti-fungal medication? With my diagnosis of Ulcer, is there a probability that my GI tract has become susceptible to various pathogens including Candida? Does a high sugar diet contribute to Candida or Thrush? What is the protocal of most doctors when it comes to testing and treating Candida? Are there any standardized testing for Candida?
I would like to shed light on this very serious situation to better bring a better understanding to myself and the medical community who may not be aware of the potential adverse effects of Candida and initialize through medical advisory boards a standardized protocol testing with respect to certain individuals who are at risk.
Thank you for any information you can share on this very important subject.
Response from Dr. Young
I'm not sure where you get the impression that the medical profession doesn't consider Candida as a pathogen. Candida infection of the throat and esophagus have been part of the staging definitions of HIV disease since the early 90's. Indeed, esophageal candidiasis is a well known and serious AIDS-defining illness. Furthermore, Candidal infections can be very serious and life-threatening, especially when they reach the blood stream. If your doctors tell you otherwise, you need to find new docs.
Now as to your individual situation, if you have esophageal candidiasis demonstrated on upper endoscopy, you should receive therapy with an azole antibiotic, like fluconazole. Typical duration of therapy is 1 week for oral Candida, 14-21 days for esophageal disease. Suppressive therapy is sometimes entertained, but shouldn't be done lightly (especially in persons with low CD4s), since the possibility of selecting drug resistance is present.
To answer your questions; yes, the yield on testing for fungus is lower if one if taking a anti-fungal medicine. Your GI tract is entirely at risk of a variety of pathogenic infections-- you have a quite low CD4 count for now. Hopefully this will improve in the very near future.
Since you appear to have easily sampled Candida from your mouth and throat, a very simple thing to do is to obtain a specimen to verify that it is truly Candida and secondly, to run drug susceptibility tests. (These are standard tests.) In other words, it's possible that the bug is resistant (or partially resistant) to fluconazole (Diflucan). Alternatively, there are species of yeast (non-albicans species of Candida) that are naturally resistant to fluconazole.
There are published guidelines from the US Department of Health and Human Services on the management of this and many other opportunistic infections. I'd suggest looking at this document before suggesting that the medical community needs to reinvent a very important, though well researched wheel.
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