Dr. Penchilaprasad Kandikattu
Internal Medicine
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hi doctor,
I need some advice on behalf of my mother who is 67 years old.
For the past 12 days my mother has been experiencing pain in the throat area, feels like something is stuck, vomiting mucous, weakness, body aches, white tongue, difficulty swallowing, and vomiting feeling while talking and eating. She vomits about twice a day. She consulted an ENT and internal medicine doctor. ENT dismissed her after nothing found in throat using a camera but the internal medicine doctor did some investigations. Results showed UTI (epithelial cells 20-25/HPF and pus cells 30-35) and TSH (13.5) raised as well as Candida Albicans growth from a throat swab. She has had this issue every few months and normally clears up on its own, but this time it is very severe and not going away.
Current medication: Cefotil (Cefuroxime 500 mg and Clavulanic acid 125 mg), Gelora gel for oral thrush (Miconazole BP 2%), Motigut for vomiting 10mg), Thyroxine (50 mcg currently but internal medicine doctor asked to increase the dose to 1.5 tablets due to high TSH).
Urine culture was done and it was normal. My query is, whether this is a bad infection, not bacterial but growth of esophageal candidiasis can be treated by antifungal therapy Fluconazole? No improvements are seen with many antibiotics. Oral thrush candida was found on initial appointments and also candida in throat swab.
Is there any harm in trying a course of Fluconazole? She had a history of fungal infections in the throat which normally clear up on its own. This time it seems much more serious. If it is fine, what dosage would you recommend and for what period?
Hello,
Welcome to icliniq.com.
Yes, your mother is suffering from 1. Hypothyroidism. 2. Oral candidiasis. 3. UTI (urinary tract infection). 4. Dysphagia.
Oral candidiasis or oral thrush if not improved within five days after starting local antifungals then you may start oral antifungal medication.
You may use tablet AF (Fluconazole) 150 mg once a day for one week. But in case of old age, people may feel nausea or vomiting for this drug then you can give iv Fluconazole (Forcan 100 ml) once a day for five days.
In old age, vitamin B12 deficiency is also common, so it may present like glossitis with pharyngitis. Take vitamin B12 injection weekly once. You can give Neurobion injection also. Use Candid B mouth paint for local application.
Use tablet Levosulfuride 25 mg twice a day for nausea and vomiting. At the same time check for serum electrolytes levels which may be altered in old age lead to vomiting. You may give probiotics like capsule Gut ok or Sporulac sachets to increase the immunity levels and also prevent gut growth of fungus.
Remaining medications you continue the same. Response to the treatment may take four to five days. Diabetic patients are more prone to oral candidiasis so check for blood sugar.
Patient's Query
Thank you doctor,
Her infectious disease specialist has agreed to Fluconazole but to take only 50 mg for 21 days. I want to ask, in your opinion, is this dose too low to treat a severe fungal infection in the throat and esophagus? Secondly, if she tolerates 50 mg for a few days, is there any harm in increasing the dose to 150 mg?
He also said not to stop the antibiotics. Strangely, she has a UTI as the urine report shows pus cells but urine culture was negative with zero growth. Is there any explanation for this? Could it be the candida causing this too? She vomits five times today and says it feels like something is stuck in her throat, which means she is struggling to eat and thus getting very weak. She also has lot of body pain. She just takes chicken soup for the last 10 days.
Finally based on her symptoms please let me know if there are any other tests you would recommend to get done, either blood, or scans, etc, apart from the endoscopy which I have noted.
Hello,
Welcome back to icliniq.com.
You may get an endoscopy to rule out esophageal candidiasis if she is cooperative. If you observe any curdy white patches in her mouth it may be due to candidiasis only.
Yes, you may get it done a complete blood picture to see for elevated leukocyte count. It is possible that pus cells occur with fungal infection. Is she complaining of any white discharge? In case of vomiting, you may give tablet Vomikind or Perinorm or Levosulfuride. If she is not taking orally means you have to start intravenous antiemetics, antifungal, and antibiotics which may give fast relief.
Ultrasound abdomen may give a clue to diagnose any abdominal or renal infection may present like pus cells in urine.
Yes, Fluconazole 50 mg is a low dose so you have to increase the dose. Blood culture may give a clue to diagnose the unknown pathogen like bacteroides fragilis, or pseudomonas or klebsiella. My advice is better to start intravenous medication under your physician's guidance.
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Internal Medicine
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