An infection frequently underestimated in HIV infected women, is Candida esophagitis, (a yeast infection in the esophagus). It is closely related to thrush (a yeast infection in the throat) and Candida vaginitis (a yeast infection in the vagina) and the only difference is it's location in the esophagus--the tube that connects the mouth with the stomach.
In one study, patients at risk for AIDS were found to have Candida esophagitis as the only initial opportunistic infection. Another study demonstrated that Candida esophagitis was the most common AIDS-defining diagnosis in those women, occurring more frequently than PCP. Yet, another study showed that women were more likely than men to have Candida esophagitis (19% vs. 9.7% respectively).
Candida albicans is the most common fungus (yeast) in people with AIDS. These yeast or fungi live normally in the gastrointestinal tract, the mouth, & the female genital tract. Infection usually results from suppression of the immune system, which can be the result of antibiotics, immune suppressing drugs, or HIV infection itself.
Common symptoms of overgrowth and dissemination of Candida in the esophagus are: painful swallowing, pain behind the breast bone, a sensation of food sticking in the chest, and nausea. The majority of women with esophageal candidias also have oral thrush. Yet, a study of 110 people with esophageal symptoms showed that the presence of oral thrush was not a good indication of underlying esophagitis. While 77% of patients with oral thrush had Candida esophagitis, 40% of patients with Candida esophagitis had no thrush, and 27% had viral (CMV or herpes) esophagitis. The results show that the cause of esophagitis cannot be predicted by symptoms alone, or the presence of thrush.
The most accurate way to diagnose Candida is to get samples or cultures. One method is by direct endoscopy. This utilizes a fiber optic scope which acts as a light source and a telescope. The scope is passed through the mouth and into the esophagus, where direct viewing of the esophagus is possible, and samples are taken for evaluation.
Another test called a barium swallow is often used to aid in making the diagnosis. This involves drinking a white, chalky-like substance, which outlines the walls of the esophagus under simple x-ray. Often the barium pattern is irregular, shaggy, or cobblestone in appearance. Unfortunately, the pattern is not specific for Candida. Furthermore, mild infections can go undetected by the barium swallow.
Once the diagnosis of Candida esophagitis is made, there are a few basic medications used to treat the infection. The first, and least effective, is the anti-fungal swish and swallow suspensions, or lozenges, which work well against oral thrush, but do not seem to be as effective in the esophagus.
The next step after topical anti-fungals, are the oral systemic anti-fungals, such as Nizoral or Diflucan. Both drugs are fairly well tolerated, though they commonly can cause elevations in liver function tests. Studies have shown that Diflucan works better than Nizoral in people with AIDS.
In patients who do not respond to the oral agents, there is an intravenous medication used to treat many different kinds of fungal infections, called Amphotericin B, also known as Ampho-terrible. Ampho B has many more side effects than the other drugs, such as fevers, chills, sweats, nausea, and kidney dysfunction. A new preparation of Ampho B is being tried which mixes the drug in a solution of lipids or fats, instead of sugar. A British Medical Journal study showed that the side effects of Amphotericin are reduced when the drug is prepared in fat emulsion.
There is a national debate going on over whether there is an emerging resistance to antifungals, especially orals, from using medications like Diflucan, too early in the course of HIV. It is not clear whether using Diflucan and others, for fungal prevention, actually improves or increases one's life, or if it creates greater problems.
This brings up an interesting dilemma, which researchers in France have been trying to address. They proposed that patients were not resistant to Diflucan, but that the blood levels of Diflucan were inadequate, despite appropriate dosing. They proposed that patients were metabolizing the drug too rapidly. Blood levels of Diflucan were measured at the point when therapeutic levels should have been achieved. They found that the blood level of Diflucan was 0! They then increased the dose until adequate blood concentrations were reached, and the Candida improved. There were no reported adverse side effects from the higher doses of Diflucan, sometimes as high as 1.5-2 grams. It should be cautioned that this is only a theory and more extensive and controlled testing needs to be done to determine the efficacy and safety of this trial.
Prevention, therefore, becomes a difficult question to answer. Should patients be treated only when they are symptomatic, should they take oral medications three times a week, or every day to prevent reoccurrence? No definitive answers exist, but I think given that, the consideration of herbal/natural remedies should be mentioned. Many patients have found that regular use of garlic pills, have helped to control their yeast infections. It is not clear whether it works in an acute infection, but it seems to have value in an adjunctive role. More research and consideration needs to be made in this regard. There are many other nontoxic, natural remedies that are being used successfully by many persons with AIDS.
In conclusion, Candida is a fungal infection that is causing significant discomfort and disease to HIV+ patients, and to women specifically. Candida esophagitis is just one manifestation of the fungus which also causes thrush and vaginitis. There is growing awareness of the need for improvements in diagnosis and treatment. Prevention and resistance continue to be an issue, but as more is known about the disease, especially in women, more effective treatment regimes can be developed.
Lisa Mark PA-C is the co-director of the Pacific Oaks Women's Education & Resource (P.O.W.E.R.) Center in Sherman Oaks, California. #818-906-6279.