Medicine chapters
Oral and oesophageal candidiasis
Who gets Candida infection of the mouth and oesophagus, the different clinical forms, how it is confirmed, and when to use topical versus systemic antifungals.
- Candida albicans is a normal mouth commensal that causes thrush when local or systemic defences fall: antibiotics, inhaled or systemic steroids, diabetes, dentures, extremes of age, HIV, chemotherapy.
- Oral thrush gives creamy white plaques that wipe off leaving a red base; oesophageal candidiasis causes odynophagia and is an AIDS-defining illness.
- Treat mild oral disease with topical nystatin or miconazole; use oral fluconazole for oesophageal, severe or immunocompromised cases.
On this page
Overview
Candidiasis is the fungal infection people get most often. Candida species are yeasts that normally live in the mouth and gut without causing harm. They cause disease when the local flora or the immune system is disturbed.
In the mouth this is called thrush. In the oesophagus it causes painful swallowing and is an important marker of immune suppression, especially HIV.
Organism
- Candida albicans causes most infections.
- Non-albicans species (C. glabrata, C. krusei, C. tropicalis) are increasing; they are often resistant to azoles. C. krusei is intrinsically fluconazole-resistant.
- C. auris is a newer, multi-drug-resistant species that spreads in hospitals.
- Candida grows as budding yeasts and forms pseudohyphae when it invades tissue.
Risk factors
| Local factors | Systemic factors |
|---|---|
| Broad-spectrum antibiotics (kill normal flora) | HIV infection (low CD4 count) |
| Inhaled corticosteroids (asthma, COPD) | Diabetes mellitus |
| Dentures (especially worn at night) | Systemic steroids, chemotherapy, transplant drugs |
| Dry mouth (Sjögren syndrome, radiotherapy, anticholinergic drugs) | Leukaemia, lymphoma, neutropenia |
| Smoking | Extremes of age (neonates, elderly) |
| Iron, folate or B12 deficiency; serious illness |
Thrush in a young adult with no obvious cause (no antibiotics, steroids or diabetes) should prompt an HIV test.
Oral candidiasis: clinical forms
| Form | Appearance | Typical setting |
|---|---|---|
| Pseudomembranous (classic thrush) | Creamy-white curd-like plaques on the tongue, palate and cheeks; wipe off to leave a red, sometimes bleeding base | Infants, antibiotics, steroids, HIV |
| Erythematous (atrophic) | Red, sore patches on the palate or a smooth red tongue | Antibiotics, inhaled steroids, HIV |
| Denture stomatitis | Red mucosa under an upper denture, usually painless | Denture wearers |
| Angular cheilitis | Painful cracks at the corners of the mouth | Dentures, iron or B vitamin deficiency, HIV |
| Chronic hyperplastic candidiasis | Firm white plaque that does not wipe off, often inside the corners of the mouth | Smokers; premalignant |
Symptoms: soreness, burning, altered taste; many patients notice little.
White plaque wipes off → thrush. White plaque does not wipe off → leukoplakia, chronic hyperplastic candidiasis, lichen planus, or oral hairy leukoplakia (EBV, sides of the tongue in HIV).
Oesophageal candidiasis
Who gets it
- HIV/AIDS (most typical), chemotherapy, high-dose steroids, transplant recipients, poorly controlled diabetes.
- Occasionally after antibiotics or inhaled steroids in otherwise well people.
Clinical features
- Odynophagia (pain on swallowing), retrosternal discomfort.
- Dysphagia.
- Oral thrush may be absent, so a normal mouth does not exclude it.
Diagnosis
- Upper GI endoscopy: multiple white or yellow adherent plaques on a red mucosa.
- Brushings or biopsy showing yeasts and pseudohyphae; culture for species and drug sensitivity if the infection does not settle.
- In HIV patients with typical symptoms, treatment is often started empirically and endoscopy is kept for those who do not improve.
Differential diagnosis of infective oesophagitis
| Cause | Endoscopy |
|---|---|
| Candida | White plaques |
| Herpes simplex | Small, shallow, punched-out ulcers |
| Cytomegalovirus | Large, deep linear ulcers, often in the lower third |
| Tuberculosis | Deep ulcers with mediastinal nodes |
In a patient with HIV and painful swallowing, the most likely cause is Candida oesophagitis, even if the mouth looks normal.
Infections may be mixed, so biopsies and culture are important if the picture is not clear.
Oesophageal candidiasis (and Candida of the trachea, bronchi or lungs) is an AIDS-defining condition. Oral thrush alone is not, though it signals immune damage.
Management
Treat the cause
- Stop or reduce unnecessary antibiotics or steroids.
- Control diabetes; correct iron, folate or B12 deficiency.
- Remove dentures at night and clean and soak them.
- HIV: start effective antiretroviral therapy, the best long-term way to prevent recurrence.
- Inhaled steroids: use a spacer and rinse the mouth with water after each dose.
Antifungal drugs
| Situation | Treatment |
|---|---|
| Mild oral thrush | Topical nystatin suspension or miconazole oral gel |
| Moderate or severe oral thrush, or immunocompromised | Oral fluconazole |
| Oesophageal candidiasis | Systemic fluconazole (first-line); itraconazole as an alternative |
| Azole-resistant species (C. krusei, many C. glabrata) | Amphotericin B or an echinocandin (e.g. caspofungin) |
| Invasive / disseminated candidiasis | IV echinocandin, fluconazole or amphotericin according to species and sensitivity |
- Topical treatment does not work for oesophageal disease.
- Prophylaxis with nystatin, fluconazole or amphotericin is often given to patients on heavy immunosuppression.
Miconazole and fluconazole inhibit liver enzymes. They raise warfarin (higher INR and bleeding) and can cause hypoglycaemia with sulfonylureas. Check the drug list before prescribing.
"ABCDE of thrush risk": Antibiotics, Breathing steroids (inhalers), Chemotherapy/CD4 low, Diabetes and Dentures, Extremes of age.
Complications
- Spread to the oesophagus in immunocompromised patients.
- Invasive candidiasis (candidaemia) with central lines and profound neutropenia: endophthalmitis, abscesses, endocarditis.
- Chronic hyperplastic candidiasis can undergo malignant change; biopsy plaques that persist after treatment.
Expect: risk factors for oral thrush (antibiotics, inhaled steroids, diabetes, dentures, HIV), wipe-off white plaques versus leukoplakia and hairy leukoplakia, odynophagia as the presenting symptom of oesophageal candidiasis, endoscopic white plaques, its status as an AIDS-defining illness, topical nystatin for mild oral disease and systemic fluconazole for oesophageal disease, fluconazole-resistant C. krusei, and mouth rinsing after inhaled steroids.
Quick revision
- Commensal yeast; thrush follows antibiotics, steroids, diabetes, dentures, HIV.
- Thrush wipes off; leukoplakia and hairy leukoplakia do not.
- Oesophageal candidiasis: odynophagia; oral thrush may be absent.
- Endoscopy: white adherent plaques; confirm with brushings or biopsy.
- Oesophageal candidiasis = AIDS-defining.
- Mild oral: topical nystatin or miconazole. Oesophageal: oral fluconazole.
- C. krusei is fluconazole-resistant: use amphotericin or an echinocandin.
- Inhaled steroids: spacer and mouth rinse.
Written by The House Job from standard references (Kumar and Clark's Clinical Medicine; Bailey & Love's Short Practice of Surgery).
FAQ
Why does oral thrush occur after antibiotics?
Broad-spectrum antibiotics kill the normal mouth bacteria that keep Candida in check, allowing the yeast to overgrow.
Is oral thrush an AIDS-defining illness?
No. Oesophageal candidiasis and candidiasis of the trachea, bronchi or lungs are AIDS-defining; oral thrush alone is a sign of immune suppression but not AIDS-defining.
Can nystatin treat oesophageal candidiasis?
No. Topical agents do not reach the oesophagus effectively, so systemic fluconazole is the first-line treatment.
How do you prevent thrush in a patient using a steroid inhaler?
Use a spacer device and rinse the mouth with water after each dose.