Candidiasis in Immune-Compromised Women

Candidiasis refers to any infection caused by a group of yeast-like fungi called Candida. Candida albicans is the most common type and is normally found in the mouth, digestive tract, vagina and skin of a healthy person. The presence of Candida does not always lead to a flare-up, but in some people can cause recurrent, difficult-to-treat infections. Candidiasis is a frequent complication for HIV-positive individuals. Candida can infect the lining of the mucous membranes in the esophagus, intestines, vagina, throat and lungs. Oral candidiasis (thrush) or recurrent vaginal candidiasis (vaginitis, yeast infection) is an early sign of weakening of the immune system. The prevalence of vaginitis increases as CD4 cell counts decline, especially below 200 (Duerr A et al. Obstetrics and Gynecology. August 1997; 90(2) 253-56). The symptoms of oral and vaginal candidiasis include pain, itching, redness and white patches at the sites of infection.

Esophageal candidiasis is the most common AIDS-defining condition and is associated with poorly recognized morbidity. It is more common in women than in men. At the National Conference on Women and HIV held this Spring, Paula Schuman, M.D., of Wayne State University in Detroit, presented data from CPCRA study 010, which tested 200 mg of fluconazole per week as prophylaxis for mucosal candidiasis in 323 HIV-positive women (abstract 103.2). Use of fluconazole cut in half the incidence of oral/throat and vaginal yeast infections (see also Treatment Issues, June/July 1996). The effect of fluconazole on esophageal candidiasis could not be determined because of its low incidence in the study.

After a median follow-up of 29 months, Candida albicans did not usually develop resistance to fluconazole. However, women on fluconazole were more likely to become colonized with less pathogenic non-albicans strains of Candida that were prone to fluconazole resistance.

Other studies have shown that low CD4 count is a risk factor in the emergence of fluconazole resistance by C. albicans. Women with fewer than 50 CD4 cells and a treatment history with azole drugs are more likely to develop resistant strains. A Johns Hopkins University study observed that women with the lowest CD4 counts (a median of 11 in this case) and a history of extensive prior fluconazole use tended to harbor fluconazole-resistant yeast (Maenza JR et al. Journal of Infectious Diseases. January 1996; 173(1):219-25). The Johns Hopkins study concluded that for women at risk for fluconazole resistance, topical treatments might be used as a first choice, with fluconazole reserved as a back-up.

A second presentation at the National Conference on Women and HIV, by Wafaa El-Sadr, M.D., of New York's Harlem Hospital, looked at predictors of new and recurrent candidiasis in a cohort of women drawn from the CPCRA 010 study (abstract 103.3). Dr. El-Sadr stated that the main risk factor for recurrence was a prior history of candidiasis at the same site. PCP prophylaxis was associated with a higher incidence of oral and a lower incidence of vaginal candida. Baseline CD4 cell count was not an independent predictor of mucosal candidiasis in this study.

The Grace Study at the Yale School of Nursing was presented as a poster (number 38). The study found that self-reporting on the part of the 184 participants did not adequately identify disease, confirming the importance of comprehensive gynecological exams. Since vaginitis can be misdiagnosed, it is important that health care providers perform the necessary examinations and tests to make an accurate diagnosis of the cause of the symptoms.