What medication should be started for a patient with Human Immunodeficiency Virus (HIV) presenting with severe throat pain, painful swallowing, and oral candidiasis?

Fluconazole is the Medication of Choice

For this HIV patient with severe oropharyngeal and likely esophageal candidiasis (given the severe throat pain and painful swallowing), fluconazole should be started immediately as the first-line systemic antifungal therapy. 1

Clinical Reasoning

Why Systemic Therapy is Required

• The presentation of severe throat pain with painful swallowing (odynophagia) in an HIV patient with oral candidiasis strongly suggests esophageal involvement 1, 2
• Systemic antifungal therapy is always required for esophageal candidiasis—topical agents cannot reach therapeutic concentrations in the esophageal mucosa and will fail 1, 2
• Even for isolated oropharyngeal candidiasis in immunocompromised HIV patients, systemic therapy with fluconazole provides superior outcomes compared to topical agents 1, 3

Specific Dosing Recommendations

For presumed esophageal candidiasis:

• Fluconazole 200-400 mg (3-6 mg/kg) orally daily for 14-21 days 1
• If the patient cannot swallow, intravenous fluconazole 400 mg (6 mg/kg) daily is recommended 1
• A diagnostic trial of fluconazole is appropriate before performing endoscopy, as most patients with esophageal candidiasis will have symptom resolution within 7 days 1

For oropharyngeal candidiasis alone:

• Fluconazole 100 mg daily for at least 7 days would be sufficient 1

Why NOT the Other Options

Clotrimazole Troches - Inadequate for This Patient

• While clotrimazole troches can treat mild oropharyngeal candidiasis, they are completely ineffective for esophageal involvement 2
• Topical agents result in faster symptomatic relapses compared to fluconazole in HIV patients 2, 3
• Given the severity of symptoms and likely esophageal involvement, topical therapy would be inappropriate 1

Nystatin - Inferior Efficacy

• Nystatin is less effective than fluconazole for oropharyngeal candidiasis 1, 3
• Topical agents including nystatin should not be used for oropharyngeal candidiasis in HIV patients due to suboptimal tolerability (bitter taste, frequent dosing) and lower efficacy 1
• Like clotrimazole, nystatin cannot treat esophageal disease 2

Acyclovir - Wrong Indication

• Acyclovir is an antiviral medication used for herpes simplex virus (HSV) esophagitis, not fungal infections
• The clinical presentation of scrapable white plaques is pathognomonic for candidiasis, not HSV
• This patient requires antifungal, not antiviral therapy

Critical Additional Management

Antiretroviral Therapy Must Be Restarted

• Antiretroviral therapy should be initiated or restarted as soon as possible, as this is the most effective long-term strategy for reducing mucosal candidiasis 1
• Effective antiretroviral therapy decreases oral Candida carriage rates and reduces symptomatic oropharyngeal candidiasis frequency 1
• The patient's non-adherence to antiretroviral medications for several months has directly contributed to this opportunistic infection 1

Common Pitfalls to Avoid

• Do not use topical therapy when esophageal involvement is suspected—it will fail 1, 2
• Do not assume topical agents are "safer" to prevent resistance—resistance develops with both topical and systemic therapy 1, 2
• Do not delay treatment waiting for endoscopy—empiric fluconazole therapy is cost-effective and appropriate 1
• Monitor for hepatotoxicity if therapy exceeds 21 days by checking liver function tests periodically 1, 4

If Treatment Fails

• Treatment failure is defined as persistent symptoms after 7-14 days of appropriate therapy 1
• For fluconazole-refractory disease, switch to itraconazole solution 200 mg daily (64-80% response rate) 1
• Alternative options include posaconazole 400 mg twice daily, voriconazole 200 mg twice daily, or an echinocandin 1