Oesophageal candidiasis in HIV — DTM&H MCQ
Instant feedback + full explanation. One question, done properly.
Educational content. Not a substitute for clinical judgement or local policy.
Reveal the answer and explanation
Correct answer: D — Oral fluconazole 200 mg daily for 14-21 days
Oral fluconazole 200 mg daily for 14-21 days (D) is correct. The clinical picture of dysphagia with white adherent plaques that scrape off on endoscopy is classic for oesophageal candidiasis, which despite CD4 350 and virological control on ART can still occur, particularly with any residual mucosal immune deficit. BHIVA guidance on the clinical management of candidiasis in HIV states that oesophageal disease requires systemic (not topical) azole therapy because topical agents cannot achieve adequate mucosal penetration along the oesophagus. Fluconazole 200 mg once daily for 14 to 21 days is the recommended systemic regimen, reserving higher doses or alternative agents for azole-refractory disease. Why the other options are wrong: C. Oral nystatin 14 days: nystatin is a topical, non-absorbed polyene effective only for oropharyngeal thrush; it does not achieve therapeutic tissue levels in the oesophagus, so it is inadequate for oesophageal candidiasis. E. Oral aciclovir 400 mg five times daily: this treats HSV oesophagitis, which typically produces multiple small shallow or punched-out ulcers on endoscopy, not adherent white plaques. A. IV caspofungin 14 days: an echinocandin reserved for fluconazole-refractory or azole-resistant oesophageal candidiasis, or when oral therapy is not tolerated; it is not first-line in a straightforward, treatment-naive presentation. B. Oral valganciclovir 21 days: this is used for CMV oesophagitis, which classically causes a large, deep, solitary ulcer rather than plaques, and would need biopsy evidence of CMV inclusion bodies. Key point: Endoscopic white plaques that scrape off in an HIV-positive patient with dysphagia indicate oesophageal candidiasis, which mandates systemic fluconazole (200 mg daily, 14-21 days) rather than topical antifungal therapy.
Reference: BHIVA Guidelines on the Management of Opportunistic Infection in People Living with HIV: Candidiasis (2019, updated), bhiva.org