CD4 Cryptococcosis Histoplasmosis Aspergillosis Penicilliosis Thrush Dermatophyte Seborrhea Immunologic Status and Fungal Infections
Cutaneous Fungal Infections More common More extensive Relatively more difficult to treat
Fluconazole (Diflucan) Itraconazole (Sporanox) Terbinafine (Lamisil) Tinea corporis and cruris 150 mg once a week 3-4 weeks 200 mg qd 1-2 weeks 250 mg qd 2 weeks Tinea capitis50 mg qd 3 weeks 3-5 mg/kg/day 4-6 weeks 125 mg qd (3-6 mg/kg/day) 4 weeks Onychomycosis150 mg once a week 9 months 200 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 months 250 mg qd Fingernails 6 weeks Toenails 12 weeks Tinea pedis150 mg once a week 3-4 weeks 400 mg qd 4 weeks 250 mg qd 6 weeks Tinea versicolor400 mg single dose 200 mg qd 5 or 7 days Studies ongoing Systemic Treatment of Cutaneous Fungal Infections
Oro-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.
Treatment of OPC Topical agents –Clotrimazole, nystatin, Ampho B Systemic agents –Fluconazole –Itraconazole (Capsule, liquid) –Ampho B
Systemic treatment –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. Strategies –Treat each episode –Continuous therapy Treatment of OPC
Esophageal Candidiasis Reported in 20% to 40% of all AIDS patients. Characterized by pseudomembranes, erosions and ulcers. Presentation is mainly with odynophagia and dysphagia
Treatment –Commonly empiric therapy. –Endoscopy is indicated if the patient is not responding to antifungal therapy –Drugs Fluconazole Itraconazole (Capsule, liquid) Ampho B Esophageal Candidiasis
Candidiasis and HAART Since the advent of HAART, the incidence of new Candida infections has decreased by as much as 60% to 80%
Vaginal Candidiasis Vulvo-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.
Cryptococcosis Cryptococcus neoformans is an encapsulated yeast.Cryptococcus neoformans 5% of HIV-infected patients in the Western World develop disseminated cryptococcosis CD4+ lymphocyte counts, less than 50 cells/mm 3.
Cryptococcal Meningitis Cryptococcosis typically presents as a subacute meningitis Cryptococcal meningitis rarely presents as an obvious meningitis. Initial symptoms are commonly more subtle and may just include fever and headache.
Symptoms of Cryptococcal Meningitis
Diagnosis of Cryptococcal Meningitis Symptoms and Signs. 70% of patients with cryptococcal meningitis have positive blood cultures Serum 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 stains CSF culture.
Treatment of Cryptococcal Meningitis Induction amphotericin B, 0.7 mg/kg IV daily for 14 days or equivalent consider 5-flucytosine (5-FC) 25 mg/kg PO q6 hours measure opening pressure; consider means to reduce pressure if raised (>25 cms/water)
Consolidation fluconazole, 400 mg PO bid for 2 days, then daily for 8 weeks; or itraconazole, 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) Treatment of Cryptococcal Meningitis
Maintenance fluconazole mg daily amphotericin 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 Treatment of Cryptococcal Meningitis
Characteristics of the Endemic Mycoses HistoplasmosisCoccidioidomycosisPenicilliosis Appearance of organism on biopsy 1-5 mcm round to oval mcm round spherules containing 2-5 mcm endospores 1-8 mcm pleomorphic elongated Method of duplicationBuddingFission Clinical Features: Fever95% 99% Weight loss90%60%75% Anemia70%50%75% Pulmonary disease50%90%50% Lymphadenopathy20%10%40-50% Skin lesions5-10%5%70% Hepatosplenomegaly25%10-20%50% Meningitis<1%10%Very rare
Aspergillosis Tends to occur in the very late stages of HIV infection, typically in patients with a history of other AIDS-defining illnesses. Two main presentations –respiratory tract disease –central nervous system infection
Conclusion Fungal 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.