Oral and Oesophageal Candidiasis

Oral and oesophageal candidiasis are fungal infections caused by an overgrowth of Candida yeast in the mouth or food pipe. They occur more frequently and severely in people with weakened immunity, particularly those with advanced HIV infection, and oesophageal involvement is considered an AIDS-defining illness.

• Oral candidiasis (thrush): creamy white patches on the tongue, inner cheeks, or roof of the mouth, which can often be scraped off, sometimes leaving a red or slightly bleeding surface underneath
• Soreness or altered taste in the mouth
• Oesophageal candidiasis: pain or difficulty swallowing, chest discomfort behind the breastbone, often occurring together with oral thrush

• Caused by overgrowth of Candida yeast, which is normally present in small amounts in the mouth and gut.
• Risk is increased by weakened immunity, particularly advanced HIV infection with a low CD4 count, as well as recent antibiotic use, inhaled corticosteroid use without rinsing the mouth afterward, diabetes, and infancy.

• Oral candidiasis is usually diagnosed clinically based on the characteristic white patches.
• Oesophageal candidiasis is suspected when someone with oral thrush also has pain or difficulty swallowing; it is often diagnosed presumptively and treated based on this clinical picture, particularly in people with known advanced HIV infection.
• Recurrent, severe, or oesophageal candidiasis should prompt HIV testing if HIV status is not already known.

Uncomplicated oral candidiasis is treated with a topical antifungal, such as nystatin oral suspension or miconazole gel, used several times daily for about a week to two weeks.

Oesophageal candidiasis, or oral candidiasis that does not respond to topical treatment, requires an oral antifungal medicine such as fluconazole for a longer course, typically 14–21 days for oesophageal involvement.

For people living with HIV, starting or optimising antiretroviral therapy is essential for longer-term control, as improving immune function greatly reduces recurrence.

Recurrent or severe candidiasis, especially oesophageal involvement, should prompt assessment of HIV status and level of immune suppression if not already known.

• Ensure good oral hygiene, including rinsing the mouth after using inhaled corticosteroids.
• Manage underlying conditions such as diabetes well.
• Seek HIV testing if oral thrush is recurrent, severe, or extends to cause swallowing difficulty.
• For people living with HIV, adherence to antiretroviral therapy is the most effective way to prevent recurrent candidiasis.