9Cutaneous candidiasis involving the moist skinfolds under the breasts Cutaneous candidiasis involving the moist skinfolds under the breasts. The lesions are very red, and there are small red satellite lesions surrounding the main area of involvement. The typical location and the presence of satellite lesions make the gross image highly suggestive of cutaneous candidiasis. There is little tendency for deep tissue invasion with this type of lesion. (From Fitzpatrick et al.
11Systemic Treatment of Cutaneous Fungal Infections Fluconazole (Diflucan)Itraconazole (Sporanox)Terbinafine (Lamisil)Tinea corporis and cruris150 mg once a week 3-4 weeks200 mg qd 1-2 weeks250 mg qd 2 weeksTinea capitis50 mg qd 3 weeks3-5 mg/kg/day 4-6 weeks125 mg qd (3-6 mg/kg/day) 4 weeksOnychomycosis150 mg once a week 9 months200 mg qd Fingernails -6 weeks Toenails - 12 weeks Pulse dosing 200 mg bid-- 1 week on, 3 weeks off, Toenails 3-4 months, Fingernails 2-3 months250 mg qd Fingernails 6 weeks Toenails 12 weeksTinea pedis150 mg once a week 3-4 weeks400 mg qd 4 weeks250 mg qd 6 weeksTinea versicolor400 mg single dose200 mg qd 5 or 7 daysStudies ongoing
12Extensive pharyngeal candidiasis involving the soft palette and uvula of a patient with AIDS. Oral pharyngeal candidiasis can be a marker of T-cell immunosuppression. T cells are required to control candida growth on the mucosal surfaces. However, adequate neutrophil number and function are enough to prevent deep invasion, and there is surprisingly little tendency to develop disseminated candidiasis in patients who are T-cell deficient. (From Fitzpatrick et al.
13Oro-pharyngeal Candidiasis 90% of HIV-patients develop OPC during their lifetime.Candida appears as part of the mouth flora in more than 80% of HIV-positive patients.Actual predisposing factors for progression from colonization to disease are not well characterized.
14Treatment of OPC Topical agents Systemic agents Clotrimazole, nystatin, Ampho BSystemic agentsFluconazoleItraconazole (Capsule, liquid)Ampho B
15Treatment of OPC Systemic treatment Strategies Fluconazole is the most common agent.Faster action and less relapse than topical Rx.Major problem with increasing resistance.Higher dose.Switch to other agents.StrategiesTreat each episodeContinuous therapy
16Esophageal Candidiasis Reported in 20% to 40% of all AIDS patients.Characterized by pseudomembranes, erosions and ulcers.Presentation is mainly with odynophagia and dysphagia
18Esophageal Candidiasis TreatmentCommonly empiric therapy.Endoscopy is indicated if the patient is not responding to antifungal therapyDrugsFluconazoleItraconazole (Capsule, liquid)Ampho B
19Candidiasis and HAARTSince the advent of HAART, the incidence of new Candida infections has decreased by as much as 60% to 80%
20Vaginal CandidiasisVulvo-vaginal candidiasis occurs in approximately 30% to 40% of HIV-infected women.? Candidiasis more common in women with HIV infection when other important risk factors for vaginal infection (sexual activity, racial and ethnic background).HIV infection influences the severity and persistence of vulvo-vaginal Candida infection.
21Cryptococcosis Cryptococcus neoformans is an encapsulated yeast. 5% of HIV-infected patients in the Western World develop disseminated cryptococcosisCD4+ lymphocyte counts, less than 50 cells/mm3.
22Cryptococcal Meningitis Cryptococcosis typically presents as a subacute meningitisCryptococcal meningitis rarely presents as an obvious meningitis.Initial symptoms are commonly more subtle and may just include fever and headache.
25Diagnosis of Cryptococcal Meningitis Symptoms and Signs.70% of patients with cryptococcal meningitis have positive blood culturesSerum cryptococcal antigen is a useful screening test. 1:8 is regarded as evidence of cryptococcal infection.India ink (CSF): 50% sensitive, needs experience.CSF cryptococcal antigen is rapid, sensitive and specific.Histopathological stainsCSF culture.
26Treatment of Cryptococcal Meningitis Inductionamphotericin B, 0.7 mg/kg IV daily for 14 days or equivalentconsider 5-flucytosine (5-FC) 25 mg/kg PO q6 hoursmeasure opening pressure; consider means to reduce pressure if raised (>25 cms/water)
27Treatment of Cryptococcal Meningitis Consolidationfluconazole, 400 mg PO bid for 2 days, then daily for 8 weeks; oritraconazole, 200 mg PO tid for 3 days, then bid for 8 weeks (appears to be slightly less active)repeat lumbar puncture, with measurement of opening pressure, if patients remain symptomatic (especially persistent headache)
28Treatment of Cryptococcal Meningitis Maintenancefluconazole mg dailyamphotericin B 1 mg/kg/week (less effective than fluconazole)itraconazole mg PO bid (less effective than fluconazole)there is no value to routine measurement of serum cryptococcal antigen
35AspergillosisTends to occur in the very late stages of HIV infection, typically in patients with a history of other AIDS-defining illnesses.Two main presentationsrespiratory tract diseasecentral nervous system infection
40ConclusionFungal infections remain an important cause of morbidity and mortality in patients with HIV disease.Epidemiology is changing with the advent of HAART.High index of suspicion is important to make a diagnosis of some of the invasive mycoses.Multiple opportunistic fungal infections can exist in the same patient on presentation.