Correspondence
Resolution of Refractory AIDS-Related Mucosal Candidiasis after Initiation of Didanosine plus Saquinavir
N Engl J Med 1996; 334:1674-1675June 20, 1996
- Article
To the Editor:
Mucosal candidiasis that is refractory to treatment with fluconazole is an increasingly common complication of human immunodeficiency virus (HIV) infection. In many cases, none of the available oral antifungal agents are effective; in some cases, even intravenous amphotericin B provides only partial relief. We describe a patient with fluconazole-resistant mucosal candidiasis whose infection resolved after the initiation of treatment with an antiretroviral agent combined with a protease inhibitor.
A 34-year-old man with HIV infection had CD4 counts of 4 to 10 cells per cubic millimeter from November 1991 to January 1996. He received didanosine from January 1992 to April 1995, after which he stopped taking the medication for a “drug holiday.” From 1990 to 1993, his oral thrush responded to treatment with fluconazole (50 to 100 mg per day) as needed. In December 1993, daily therapy with fluconazole (100 mg orally each day) was started; within several months, oral candidiasis developed and persisted despite the administration of fluconazole (maximal dose, 400 mg per day for 14 days) plus nystatin solution. Itraconazole (200 mg per day orally for two weeks) was also not effective. In October 1995, the patient entered an AIDS Clinical Trials Group study of amphotericin B oral suspension for resistant thrush. A throat culture grew 3+ Candida albicans. After only a partial response at four weeks, the therapy was stopped. Thrush persisted despite the administration of fluconazole (200 to 400 mg per day) and nystatin (four times per day). In December 1995, disseminated Mycobacterium avium complex infection was diagnosed and treated with clarithromycin plus ethambutol.
Subsequently, treatment with didanosine (125 mg twice a day) plus saquinavir (600 mg three times a day) was initiated. Two weeks later, the thrush was moderately improved. At the end of February 1996, complete resolution of the oral plaques was noted; the patient had stopped taking fluconazole and was taking nystatin only once per week. His CD4 count was 20 cells per cubic millimeter on two occasions. When seen at the end of March, his weight had increased by 16 lb (7.3 kg), and he reported improved well-being, full compliance with antiretroviral treatment, and no use of antifungal medications in the previous three weeks.
A number of potent antiretroviral drugs have recently been approved for use in the United States. This case report suggests that some previously refractory HIV complications may resolve after treatment is begun with a protease inhibitor. Improving immune function with antiretroviral drugs may be a worthwhile approach to the prevention or treatment of refractory or difficult-to-treat HIV-related diseases. Studies of treatments for HIV-related complications should account for the initiation or termination of antiretroviral medications before concluding that a therapy is effective or ineffective.
Barry S. Zingman, M.D.
Montefiore Medical Center, Bronx, NY 10467- Citing Articles (38)
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