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compromised immune system. ulcerations from these disorders may increase the risk of transmission in the woman who is HIV negative.

The location of Candida infection indicates the state of the immune system. Vaginal candidiasis may precede oral candidiasis (thrush) and may be the first sign of immune dysfunction. As immune suppression becomes worse, the primary site of the Candida infection may change from the vagina to the mouth and pharynx and later to the esophagus and gastrointestinal tract in severely immunocom-promised women. Vaginal candidiasis may be accompanied by generalized lymphadenopathy, localized herpes simplex, depletion of t-helper cells, and anergy.

Despite the presence of oral lesions, patients are often asymptomatic during early stages of a candi-dal infection. Some complain of oral discomfort, a burning sensation when eating or an altered sense of taste. Oral candidiasis is commonly seen as whitish furry or cheesy exudates on the buccal mucosa, gingiva, tongue, or palate. There may be an erythematous (reddish) base noted after scraping the lesion. Occasionally, the typical white exudate is absent and the only finding is inflamed or atrophic oral mucosa. Diagnosis is made by scraping the lesion and examining the collected material under a microscope. Mycelia will be evident. Several therapies are available for oral candidiasis: clotrimazole and nystatin are commonly recommended topical therapies. Systemic therapy with

KETOCONAZOLE, FLUCONAZOLE, or ITRACONAZOLE is also available. Many clinicians are quick to institute therapy with fluconazole hoping that there may be some additional prophylactic effect against other fungal infections.

Esophageal candidiasis typically presents as odynophagia or dysphagia. Many patients complain of anterior chest pain exacerbated by swallowing. Oral thrush may or may not be present. Esophageal candidiasis may occur in patients taking topical therapy for oral candidiasis. A presumptive diagnosis may be made in patients with odynophagia that responds to empiric treatment. Barium swallow may reveal esophageal ulcerations suggestive of candida, but it is not diagnostic. Definitive diagnosis is made by endoscopy with biopsy and pathologic or cytologic evidence of Candida. For most patients with odynophagia or dys-

phagia, fluconazole or ketoconazole are the treatments of choice. Patients who have had esophageal candida may relapse after treatment and may require continuous systemic low-dose prophylaxis.

Vaginal yeast infections can usually be treated topically, with a cream or suppository that is inserted into the vagina before bed nightly for three to seven nights. Several are available over the counter (without prescription) such as Monistat-7 or Gyne-Lotrimin. If such treatments fail to relieve the symptoms and eradicate signs of infection, women should be checked for the possibility of a different infection. If no other infection exists, and yeast infection is confirmed, the oral azole agents (such as ketoconazole or fluconazole) may be required. Frequent use of the azole agents for treatment in women with very low T-cell counts, however, is problematic. Research has shown that these women are at risk for development of infection with a resistant strain of Candida species. These so-called resistant infections will fail to respond to treatment with azole drugs and may require treatment with topical or intravenous amphotericin b, a drug with multiple and sometimes severe side effects. For this reason, it is felt that it is best to use topical treatment for vaginal candidiasis first and to limit the use of azole drugs as much as possible to prevent development of resistant strains. For vaginal candidiasis, exams every six months are warranted. Studies indicate that the acidophilus bacteria found in yogurt may reduce candidal infection in the vagina.

Candida species resistant to ketoconazole and fluconaxole have been reported. Amphotericin is required for treatment of resistant strains.

cannabinoids Components of cannabis, including tetrahydrocannabinol (THC). See cannabis.

cannabis A plant that contains tetrahydrocannabinol (THC), the active ingredient in marijuana. Medical uses of cannabis, or THC, include stimulation of appetite and reduction of nausea.

capitation A method used by managed care plans to reimburse providers. Unlike the traditional fee-for-service system, which pays providers per service, the capitation system pays a fixed

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