Diagnosis and Treatment

The etiologic diagnosis of disorders of food intake can be approached using a diagnostic algorithm (Figure 46-1). One should not conclude that anorexia is due to a medication until other possibilities are ruled out, or the patient responds positively to a supervised trial of medication withdrawal. In an AIDS patient with suspected esophageal candidiasis, it is advisable to treat empirically and only examine patients with persisting symptoms (Rabeneck and Laine, 1994). In contrast, all esophageal ulcerations should be investigated by direct examination and biopsy.

Oral candidiasis responds to a variety of antifungal therapies including the topical therapies, nystatin and clotrima-zole, and the systemically active azole drugs. Esophageal candidiasis is best treated using systemically active compounds, because the organism is invasive. The infection may

Diet history calorie count

Normal

Stop

No offending medication

Offending medication

Discontinue

No local pathology

Local pathology

No CNS disease

CNS disease

Treat

Evaluate for malabsorption, systemic infection

Nontreatable

Nonvolitional feedings

Treatable Treat

FIGURE 46-1. Diagnostic algorithm for disorders of food intake. CNS = central nervous system.

become resistant to azole therapy in some cases, or be due to other yeasts, such as Torulopsis glabrata, for which intravenous (IV) amphotericin B therapy is required. Therapy options for hairy leukoplakia include Acyclovir 800 mg orally 5 times per day for 2 to 3 weeks, then 1.2 to 2 g/d, or Tretinoin (Retin A) 0.025 or 0.05% solution applied 2 to 3 times per day. Herpes simplex virus (HSV) infection responds to oral treatment with acyclovir. Discontinuation of therapy after induction therapy and the use of maintenance therapy only if there are frequent relapses is recommended. Ganciclovir is an effective therapy for CMV esophageal disease (Wilcox et al, 1991). Idiopathic esophageal ulcers not due to identifiable pathogen may respond promptly to corticosteriods, though the danger of worsening immune suppression in patients with AIDS should be kept in mind. The ulcer also may recur after steroid therapy is discontinued. Studies have shown the effectiveness of thalidomide for the treatment of idiopathic esophageal ulcers. The significant neurologic and sedating side effects of thalidomide, as well as teratogenicity in women, have restricted its use to registered physicians and pharmacies.

Salivary gland enlargement frequently complicates AIDS. The concerning manifestations of this entity are cosmetic appearance, pain from distension, and xerostomia. For painful or cosmetically disfiguring cystic lesions, needle aspiration and computed tomography (CT) scan will distinguish cystic and solid lesions. For xerostomia, sugarless gum and artificial saliva may offer some relief. Pilocarpine may be necessary for refractory cases.

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