MED-15. Management of fluconazole resistant candidal esophagitis in an HIV-infected patient.

The objectives of this study were to (1) recognize the increasing prevalence of resistant Candida albicans infections in HIV-infected patients. (2) discuss the role of intravenous (IV) Caspofungin as an alternative to IV Amphotericin B, and (3) recognize the role of highly active anti-retroviral therapy (HAART) in the treatment of candidal esophagitis. Our patient was a 36-year-old female treated with fluconazole for several months with persistent severe odynophagia and dysphagia of solid foods. Her CD4 count was 23, with a viral load of >750,000. Exam revealed extensive whitish plaques in the oropharynx. Upper endoscopy revealed severe, disfiguring esophagitis. Pathology and culture revealed C albicans species only. Treatment was initiated with amphotericin B. The patient was unable to tolerate amphotericin B secondary to nephrotoxicity. Therefore, a trial of caspofungin was initiated to avoid any renal complication. Soon thereafter, HAART was initiated. Within 1 week, patient reported significantly less odynophagia and dysphagia. We elected to stop intravenous therapy and discharge patient on nystatin swish and swallow and HAART alone. One month after discharge, patient's CD4 count was 132 and she reported resolution of symptoms. The esophagus appeared normal on repeat endoscopy. The current treatment of candidal esophagitis in HIV-infected persons is frequently oral fluconazole followed by amphotericin B as second line treatment. Nonetheless, recent literature reports increasing frequency of fluconazole and amphotericin B-resistant Candida species. At least two randomized, double-blind trials have suggested IV Caspofungin is a reasonable treatment alternative and we report response in an HIV-infected patient with fluconazole-resistant C albicans esophagitis unable to tolerate amphotericin B. Further, recent data suggests that institution of HAART with improvement of a patient's immunity has led to improvement of Candida infection. The striking resolution of our patient's esophagitis on HAART and nystatin swish and swallow alone supports this approach to treating HIV-associated candidal esophagitis.

Kevin P. Luce, MD. University of Tennessee Chattanooga Unit, Chattanooga, TN.