Question | Discussion | References | CME Credit

Updated February 3, 2011

Case 4: Fluconazole-Resistant Oropharyngeal Candidiasis

Author: David H. Spach, MD

A 43-year-old HIV-infected woman presents to the clinic with oral candidiasis that is clinically not responding to fluconazole (Diflucan) 200 mg PO once daily. She has advanced immune suppression with a CD4 count of 22 cells/mm3 and HIV RNA of 46,340 copies/ml. She is taking a 5-drug salvage antiretroviral therapy regimen, trimethoprim-sulfamethoxazole (Bactrim, Septra), azithromycin (Zithromax), and fluconazole. She has taken fluconazole on and off for 18 months for recurrent bouts of oropharyngeal candidiasis and the past 3 months she had taken fluconazole 200 mg PO once daily. She currently denies any esophageal symptoms.

Which of the following is true regarding fluconazole-resistant oral candidiasis in HIV-infected patients?

A The most important risk factor identified for the development of fluconazole-resistant oropharyngeal candidiasis is the use of trimethoprim-sulfamethoxazole for longer than 60 days.
B Fluconazole exerts its effect by inhibiting fungal cell wall synthesis. Fluconazole resistance in Candida species occurs primarily through an increase production in cell wall precursors.
C More than 95% of Candida albicans isolates from patients with fluconazole-refractory oropharyngeal candidiasis show resistance to itraconazole (Sporanox). Fewer than 5% of patients with fluconazole-refractory oropharyngeal candidiasis will respond to itraconazole solution at a dose of 200 mg per day.
D Major identified risk factors for the development of fluconazole-resistant candidiasis include low CD4 cell count and cumulative fluconazole use.