Candidiasis and HIV

BACKGROUND

Mucocutaneous candidiasis is an opportunistic infection caused by the fungus Candida albicans that can affect the mouth (oral candidiasis, oral thrush), esophagus (esophageal candidiasis) or vagina (vulvovaginal candidiasis, yeast infections). Opportunistic infections occur in individuals who are immunocompromised (weakened immune systems), such as patients infected with the human immunodeficiency virus (HIV).

HIV primarily destroys CD4 T-cells, which are a type of lymphocyte (white blood cell that helps coordinate the immune system's response to infection and disease). The patient's CD4 cell count is used as a marker to determine how far the disease has progressed. Individuals with a CD4 cell count lower than 200 cells per microliter of blood have progressed to AIDS. Since the virus weakens the immune system, HIV patients are more vulnerable than the general population to developing diseases and infections, including mucocutaneous candidiasis.

The Candida albicans fungus, which is responsible for the development of candidiasis, is found almost everywhere in the environment. Most people have small amounts of Candida albicans present in their mouths and/or vagina at any given time, but healthy individuals are able to prevent the fungus from multiplying and causing an infection. Candidiasis does not usually affect individuals with healthy immune systems, but when it does, symptoms are usually minor. In contrast, immunocompromised patients, such as HIV patients, often suffer from severe symptoms, including painful lesions in the mouth that make it difficult to eat.

Oral candidiasis, commonly known as oral thrush, usually develops in HIV patients once their CD4 cell count drops below 350. While oral thrush is the least serious of the fungal infections associated with HIV, it may indicate that a patient's HIV condition is worsening. The oral infection can progress to esophageal candidiasis, which occurs when thrush spreads to the esophagus. Esophageal candidiasis typically occurs when the HIV patient's CD4 cell counts are 200 or less. Esophageal candidiasis is the only type of candidiasis that is considered an AIDS-defining illness. This means that when HIV-infected patients develop esophageal candidiasis, their condition has progressed to AIDS.

Vaginal candidiasis (yeast infection) is common in both immunocompetent and immunocompromised individuals. Researchers estimate that about 75% of all women are likely to have at least one vaginal Candida infection during their lifetime, and up to 45% experience two or more. Individuals who become pregnant, take high-estrogen oral contraceptives (like birth control pills), have uncontrolled diabetes mellitus, wear tight-fitting clothes, receive antibiotic therapy and individuals who have sexually transmitted diseases have an increased risk of developing yeast infections.

Candidiasis infections are treatable. HIV patients who have candidiasis infections usually receive treatment with antifungals to clear the infection. Some of these medications may cause liver damage. Therefore, blood tests should be performed regularly during treatment to monitor liver function. Treatment generally lasts about 10 to 14 days.

CAUSES

This opportunistic infection occurs in individuals who have weakened immune systems, such as HIV patients. HIV infects and destroys the body's immune cells, especially the CD4 cells. The patient's CD4 cell count is used as a marker to determine how far the HIV has progressed. Individuals with a CD4 cell count lower than 200 cells per microliter of blood have progressed to AIDS.

Candida albicans is present in most people's mouths. HIV patients who carry the fungus typically develop oral thrush once their CD4 cell count drops below 350.

Esophageal candidiasis occurs when oral thrush spreads into the esophagus. This infection typically occurs when the HIV patient's CD4 cell counts are 200 or less. According to the U.S. Centers for Disease Control and Prevention (CDC), esophageal candidiasis is considered an AIDS-defining illness. This means that the infection is often a sign that the patient's condition has progressed from HIV to AIDS.

Vaginal candidiasis (yeast infection) is common in both immunocompetent and immunocompromised individuals. Small amounts of Candida albicans are present in most women's vaginas. The fungus can overgrow if the environment in the vagina changes. For instance, vaginal candidiasis is associated with pregnancy, high-estrogen oral contraceptives (like birth control pills), uncontrolled diabetes mellitus, tight-fitting clothes, antibiotic therapy, dietary factors, intestinal colonization, and sexually transmitted diseases.

SYMPTOMS

Oral thrush: Symptoms of oral thrush may develop suddenly. Oral thrush typically causes creamy white lesions on the tongue, inner cheek, and sometimes the gums, tonsils, and roof of the mouth. These lesions are often painful in HIV patients, and they may bleed slightly when they are rubbed.

Esophageal candidiasis: Severe cases of oral thrush may spread into the esophagus. This is most likely to occur if oral thrush is left untreated or if the patient is extremely immunocompromised. Common symptoms of esophageal candidiasis include pain or difficulty swallowing and sensation of food sticking to the throat. The pain may be so severe that it is difficult to eat. A fever may indicate that the infection has spread beyond the esophagus.

Vulvovaginal candidiasis (yeast infection): Symptoms of vulvovaginal candidiasis (yeast infection) generally worsen during menstruation because the hormonal changes provide a suitable environment for fungal growth. Common symptoms include itching, watery or curd-like vaginal discharge that is white in color, vaginal erythema (reddening of the skin), dyspareunia (pain during sexual intercourse), external dysuria (painful urination), swollen labia and vulva, and vaginal lesions.

DIAGNOSIS

General: In most cases, diagnoses of candidiasis infections can be determined after a physical examination. If a diagnosis is uncertain, the physician may scrape surface cells of the mouth, esophagus or vagina (depending on where symptoms are) or culture a tissue sample to determine whether the fungus is present.

Throat culture: A throat culture is often used to diagnosis oral candidiasis. During the procedure, a physician swabs the back of the patient's throat with a sterile cotton swab. The tissue sample is then cultured on a special medium to determine the bacteria or fungi that may be causing the symptoms. If Candida albicans is present, a positive diagnosis for candidiasis is made.

Endoscopic examination: An endoscopic examination may be conducted to diagnosis esophageal candidiasis. During the procedure, an endoscope (thin, flexible tube with a camera attached to it) is inserted into the throat. The doctor then takes a sample of tissue (either a biopsy or brushing) from the esophagus to be examined in a laboratory for the presence of fungus. The procedure generally takes between 30 and 60 minutes. Patients are typically given a sedative and a local anesthetic.

Barium swallow: A barium swallow test may be conducted to diagnosis esophageal candidiasis. During the test, the patient drinks one or two barium "milkshakes." Barium is a chalky liquid that coats the internal organs so that they are more visible on the X-ray. This substance helps the radiologist see the esophagus and stomach during an X-ray. Esophageal candidiasis may be indicated if lesions appear in the esophagus.

Vaginal discharge tests: Vaginal discharge can be analyzed under a microscope or cultured to determine whether the fungus is present. During a microscopic evaluation, a sample of vaginal discharge is placed on a microscope slide with a drop of 10% potassium hydroxide (KOH) solution. The KOH solution dissolves all of the cells except for fungus cells. If the Candida albicans fungus is present in high numbers, candidiasis is strongly suspected

During a culturing procedure, a swab is rubbed on the infected skin surface. The sample is then placed on a sterile Petri dish and allowed to grow in a laboratory to determine the bacteria or fungi that may be causing the symptoms.

TREATMENT

General: Patients should tell their healthcare providers if they are taking any drugs (prescription or over-the-counter), herbs, or supplements. Patients should always take medications exactly as prescribed by their healthcare providers. HIV patients who have candidiasis infections usually receive treatment with antifungals. However, some antifungal medications may cause liver damage. Therefore, blood tests should be performed regularly during treatment to monitor liver function.

Oral thrush: Oral antifungals are typically used to treat oral thrush. The drug of choice is usually oral nystatin suspension (Mycostatin©), Nilstat©, or Nystex©). Other antifungals that may be used to treat oral thrush include amphotericin B (Fungizone©), fluconazole (Diflucan©), and ketoconazole (Nizoral©). Treatment generally lasts 10 to 14 days.

Ketoconazole and amphotericin B are the most likely to cause liver damage. Patients who experience nausea, vomiting, weakness, fatigue, abdominal pain (especially near the liver), dark urine, or jaundice (yellowing of the skin and eyes) should consult their healthcare providers.

Esophageal candidiasis: The most effective antifungal medication for esophageal candidiasis in HIV patients is the antifungal fluconazole (Diflucan©). This medication is taken orally, either as a tablet or liquid suspension. Other medications in the same family, including ketoconazole (Nizoral©) and itraconazole (Sporanox©), have also been used. Treatment duration varies from several days to several weeks or longer, depending on the severity of the infection.

Ketoconazole is the most likely to cause liver damage. Patients who experience nausea, vomiting, weakness, fatigue, abdominal pain (especially near the liver), dark urine, or jaundice (yellowing of the skin and eyes) should consult their healthcare providers.

Itraconazole may cause congestive heart failure. Patients who experience shortness of breath, coughing up white or pink phlegm, weakness, fatigue, fast heartbeat, sudden weight gain, or swelling of the feet, ankles, or legs should consult their healthcare providers.

Vulvovaginal candidiasis (yeast infection): Vaginal yeast infections have been treated with antifungal medications that are inserted directly into the vagina as suppositories, ingested as tablets, or applied to the skin as creams or ointments. Treatment generally lasts about one to seven days, depending on the severity of the symptoms. Common over-the-counter medications used include butoconazole (Femstat©), clotrimazole (Gyne-Lotrimin©), miconazole (Monistat 3©), tioconazole (Vagistat©, Trosyd©), and terconazole (Vagistat-1©). While these medications are available without a prescription, women who have never experienced a yeast infection before should consult their healthcare providers before self-medicating. This ensures that the symptoms are caused by Candida albicans and not sexually transmitted infections like ghonorrhea or chlamydia.

INTEGRATIVE THERAPIES

Unclear or conflicting scientific evidence :

Bitter orange : Clinical study has found promising results using the oil of bitter orange as a therapy for fungal infections. However, due to methodological weakness of the trial, further evidence is needed to confirm these results.

Avoid if allergic or hypersensitive to bitter orange or any members of the Rutaceae family. Avoid with heart disease, narrow-angel glaucoma, intestinal colic, and long QT interval syndrome. Avoid if taking anti-adrenergic agents, beta-blockers, QT-interval prolonging drugs, monoamine oxidase inhibitors (MAOIs), stimulants, or honey. Use cautiously with headache, hyperthyroidism (overactive thyroid), or if fair-skinned. Avoid if pregnant or breastfeeding.

Cinnamon : There is a lack of available evidence to support the use of cinnamon for candidiasis in advanced AIDS. More study is needed in this area. Avoid if allergic or hypersensitive to cinnamon, its constituents, members of the Lauraceae family, or Balsam of Peru. Use cautiously if prone to atopic reactions or if taking cytochrome P450 metabolized agents, anticoagulants (blood thinners), insulin or blood sugar-altering medications, antibiotics, or cardiovascular agents. Avoid if pregnant or breastfeeding.

Cranberry : Limited laboratory research has examined the antifungal activity of cranberry. Reliable human studies supporting this use are currently lacking.

Avoid if allergic to cranberries, blueberries, or other plants of the Vaccinium genus. Sweetened cranberry juice can affect blood sugar levels. Use cautiously with history of kidney stones. Pregnant and breastfeeding women should avoid cranberry in higher amounts than what is typically found in foods.

Garlic : Several studies describe the application of garlic topically to the skin as an anti-fungal infection treatment, including yeast infections. Garlic may cause severe burns and rash when applied to the skin of sensitive individuals. Avoid if allergic or hypersensitive to garlic or other members of the Lilaceae (lily) family (like hyacinth, tulip, onion, leek, chive). Avoid with a history of bleeding problems, asthma, diabetes, low blood pressure, or thyroid disorders. Stop using supplemental garlic two weeks before dental/surgical/diagnostic procedures and avoid using immediately after such procedures to avoid bleeding problems. Avoid in supplemental doses if pregnant or breastfeeding.

Pomegranate : An extract of pomegranate was shown to be as effective as a commonly used oral (by mouth) gel when used topically (applied on the skin) to treat candidiasis associated with denture stomatitis (mouth sores). Additional study is needed to confirm pomegranate's antifungal effects.

Avoid if allergic or hypersensitive to pomegranate. Avoid with diarrhea or high or low blood pressure. Avoid taking pomegranate fruit husk with oil or fats to treat parasites. Pomegranate root/stem bark should only be used under the supervision of a qualified healthcare professional. Use cautiously with liver damage or disease. Pomegranate supplementation may be unsafe during pregnancy if taken by mouth. The bark, root, and fruit rind may cause menstruation or uterine contractions. Avoid if breastfeeding due to a lack of scientific data.

Seaweed, kelp, bladderwrack : Limited laboratory research has examined the antifungal activity of bladderwrack, a type of seaweed called kelp. Reliable human studies supporting this use are currently lacking.

Avoid if allergic or hypersensitive to Fucus vesiculosus and iodine. Avoid with history of thyroid disease, bleeding, acne, kidney disease, blood clots, nerve disorders, high blood pressure, stroke, or diabetes. Avoid if pregnant or breastfeeding.

Tea tree oil : Early studies report that tea tree oil may have activity against several fungal species. In laboratory studies, tea tree oil has been shown to kill fungus and yeast such as thrush (oral Candida albicans). However, at this time, there is not enough information available from human studies to make recommendations for or against this use of tea tree oil. Tea tree oil can be toxic when taken by mouth and therefore should not be swallowed. Avoid allergic or hypersensitive to tea tree oil (Melaleuca alternifolia), any of its constituents, balsam of Peru, benzoin, colophony (rosin) tinctures, eucalyptol, or other members of the Myrtle (Myrtaceae) family. Avoid if taking antineoplastic agents. Avoid if pregnant or breastfeeding.

Thyme : Thyme essential oil and thymol have been shown to have antifungal effects. Currently, there is insufficient evidence to recommend for or against thyme/thymol as a treatment for fungal infections.

Avoid with a known allergy/hypersensitivity to members of the Lamiaceae (mint) family or to any component of thyme, or to rosemary (Rosmarinus officinalis). Avoid oral ingestion or non-diluted topical application of thyme oil due to potential toxicity. Avoid topical preparations in areas of skin breakdown or injury, or in atopic patients, due to multiple reports of contact dermatitis. Use cautiously in patients with gastrointestinal irritation or peptic ulcer disease due to anecdotal reports of gastrointestinal irritation. Use cautiously in patients with thyroid disorders due to observed anti-thyrotropic effects in animal research of the related species Thymus serpyllum. Avoid if pregnant or breastfeeding.

PREVENTION

Mucocutaneous candidiasis infections are less likely to develop in individuals who have healthy immune systems. Therefore, patients who have HIV/AIDS should receive highly active antiretroviral therapy (HAART), which suppresses HIV and subsequently boosts the body's immune system. Research has shown that HAART dramatically slows the progression of opportunistic infection in HIV/AIDS patients.

Decreasing or avoiding alcohol consumption may reduce the risk of developing mucocutaneous candidiasis. The body converts alcohol into sugar, which promotes the growth of Candida albicans.

Wear loose fitting clothes to help prevent vaginal candidiasis (yeast infections) because this provides better ventilation and allows areas of the body to dry out.

Maintain good oral hygiene by brushing the teeth daily, gargling with antiseptic mouthwash, and flossing the teeth.

AUTHOR INFORMATION

This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

• AIDS InfoNet. www.aidsinfonet. Accessed March 3, 2009.
• HIV InSite. http://hivinsite.ucsf.edu. Accessed March 3, 2009.
• Natural Standard: The Authority on Integrative Medicine. www.naturalstandard.com. Copyright © 2009. Accessed March 3, 2009.
• The Body: The Complete HIV/AIDS Resource. www.thebody.com. Accessed March 3, 2009.