Esophageal candidiasis in pediatric acquired immunodeficiency syndrome: clinical manifestations and risk factors

Background. Little is known about the epidemiology and clinical features of esophageal candidiasis (EC) in pediatric AIDS. We therefore investigated t he clinical presentation and risk factors of EC in a large prospectively mo nitored population of HIV-infected children at the National Cancer Institut e. Patients and methods. We reviewed the records of all HIV-infected children (N = 448) followed between 1987 and 1995 for a history of esophageal candid iasis to characterize the epidemiology, clinical features, therapeutic inte rventions and outcome of esophageal candidiasis. To understand further the risk factors for EC in pediatric AIDS, we then performed a matched case-con trol analysis of 25 patients for whom control cases were available. Results. There were 51 episodes of EC documented in 36 patients with 23 mal e and 13 female patients (0.2 to 17 years; median CD4, count 11/mu l), repr esenting a frequency of EC of 8.0%, Concurrent oropharyngeal candidiasis (O PC) was the most common clinical presentation of EC (94%); other signs and symptoms included odynophagia (80%), retrosternal pain (57%), fever (29%), nausea/vomiting (24%), drooling (12%), dehydration (12%), hoarseness (6%) a nd upper gastrointestinal bleeding (6%), The causative organism documented in 36 episodes (18 from OPC, 17 from endoscopic biopsy and 1 from autopsy) was Candida albicans in all cases, Patients received treatment for EC with amphotericin B (63%), fluconazole (29%), ketoconazole (4%) or itraconazole (1%), A clinical response was documented in all 45 evaluable episodes. In 6 other cases, EC was a final event without contributing to the cause of dea th, By a conditional logistic regression model for matched data, the best p redictor of EC was the presence of prior OPC (P < 0.0001), followed by CD4 count and CD4 percentage (P = 0.0002) and use of antibacterial antibiotics (P = 0.0013), The risks associated with low CD4 count were independent of t hat of prior OPC. Conclusion, EC in pediatric AIDS is a debilitating infection, which develop s in the setting of prior OPC, low CD4 counts and previous antibiotics.