Community case study of long-term survival with oesophageal candidiasis: a primary healthcare nursing study of support for a patient receiving home self-administered intravenous amphotericin

HIV infection predisposes a person to fungal infections because of failure in the host's cell-mediated immunity, which may result in a variety of fungal infections (1,2). Candidiasis is commonly caused by Candida albicans which can become a multi-system problem affecting the patient's nails, mouth, oesophagus, lower gastrointestinal tract, genitalia and rectum. Candida oesophagitis is a condition diagnostic of AIDS and characterised by erythematous lesions, pseudomembranous areas and/or ulcerations of the oesophagus. The condition may cause difficulty in swallowing, retrosternal pain, nausea and vomiting. Significant weight loss may also develop secondary to the characteristic symptoms of oesophageal candidiasis (3).
Reports to date suggest therapy failure, incomplete response and decreasing susceptibility to azole medications such as ketoconazole, fluconazole and itraconazole (4). Whilst amphotericin remains the standard treatment for systemic or resistant mycoses (1), hospital experience with amphotericin toxicity may be a limiting factor against initiating homebased therapy (1).
We report the outcomes for a clinically responding patient with a falling CD4 count diagnosed with oesophageal candidiasis receiving intravenous amphotericin at home for a continuous seventeen month period. This case fulfils current definitions of long-term survival (5,6).
The patient initially presented over three years previously with HIV-related thrombocytopenia, a diagnosis made after counselling and HIV antibody testing showed HIV infection.
Over successive years the patient received out-patient follow up including quarterly CD4 monitoring, treatment with Zidovudine, prophylaxis with Cotrimoxazole against Pneumocystis carinii pneumonia, psychological counselling, oral and dental, care and social welfare interventions. The out-patient service included written information for the patient's General Medical Practitioner after each out-patient visit, on patient request.
On presentation with oesophageal candidiasis due to Candida albicans three years later, the patient requested homebased care in association with the General Medical Practitioner (GP) and the rest of the primary healthcare team. The patient wished to keep hospital stays and out-patient visits to a minimum.
The blood results for the patient's serum creatinine, urea and potassium are shown in Figures 1-3, respectively, for a total period of seventeen months during which amphotericin was administered. The data covers both the two week period of hospital based induction therapy and the following seventeen months of homebased maintenance therapy.