1. Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents Microsporidiosis Slide Set
Prepared by the AETC National Resource Center based on recommendations from the CDC, National Institutes of Health, and HIV Medicine Association/Infectious Diseases Society of America

2. About This Presentation
These slides were developed using recommendations published in May The intended audience is clinicians involved in the care of patients with HIV.
Users are cautioned that, because of the rapidly changing field of HIV care, this information could become out of date quickly. Finally, it is intended that these slides be used as prepared, without changes in either content or attribution. Users are asked to honor this intent.
-AETC National Resource Center
May 2013

3. Microsporidiosis: Epidemiology
Protists, related to fungi
Many species, including Enterocytozoon bieneusi, Encephalitozoon cuniculi, Encephalitozoon intestinalis
Ubiquitous, may be zoonotic and/or waterborne
Risk greatest with CD4 count <100 cells/µL
Incidence dramatically lower in areas with widespread use of effective ART
May 2013

4. Microsporidiosis: Clinical Manifestations
Most common: diarrheal illness
Other manifestations: cholangitis, hepatitis, encephalitis, ocular infection, sinusitis, myositis, disseminated infection
Clinical syndromes may vary by species
May 2013

5. Microsporidiosis: Diagnosis
Microscopic identification of stool or tissue samples
Identification requires high magnification (1,000×), selective stains to differentiate spores from cellular debris
Electron microscopy, PCR, Ab-specific stains can determine species
Evaluate 3 stool samples
Small bowel biopsy if stool studies are negative and suspicion is high
Urine examination may be useful if cause is Encephalitozoon or Trachipleistophora spp
May 2013

6. Microsporidiosis: Prevention
Preventing exposure
Handwashing; avoidance of undercooked meat or seafood and exposure to infected animals
Patients with CD4 counts of <200 cells/μL should avoid drinking untreated water
Primary prophylaxis
Appropriate initiation of ART before severe immunosuppression should prevent disease
No chemoprophylaxis known to be effective
May 2013

7. Microsporidiosis: Treatment
ART with immune restoration (to CD4 count >100 cells/µL)
Should be offered to all as part of initial management
If severe dehydration, malnutrition, wasting: hydration, nutritional support (IV therapies may be needed)
Antimotility agents, if needed for diarrhea control
May 2013

8. Microsporidiosis: Treatment (2)
E bieneusi GI infections:
ART and fluid support as above
no specific antimicrobial;
Fumagillin 60 mg PO QD or TNP-470: some evidence of efficacy but not available in United States
Nitazoxanide: limited data; cannot be recommended with confidence
Nonocular infection caused by microsporidial other than E bieneusi and V corneae:
Albendazole 400 mg PO BID
May 2013

9. Microsporidiosis: Treatment (3)
Disseminated disease caused by Trachipleistophora or Anncaliia
Itraconazole 400 mg PO QD + albendazole 400 mg PO BID
Ocular infection: fumagillin (Fumidil B) eye drops 70 mcg/mL + albendazole 400 mg PO BID
May 2013

10. Microsporidiosis: Starting ART
ART should be offered as part of initial management of this infection
May 2013

11. Microsporidiosis: Adverse Events
Albendazole: adverse effects are rare; monitor hepatic enzymes
Fumagillin
Topical: no known substantial side effects
Oral: thrombocytopenia
IRIS: 1 report
May 2013

12. Microsporidiosis: Treatment Failure
Supportive treatment
Optimization of ART
May 2013

13. Microsporidiosis: Prevention of Recurrence
Ocular:
If CD4 >200 cells/µL on ART, consider discontinuing treatment after ocular infection resolves; restart if CD4 drops to <200 cells/µL
Other manifestations:
Safety of treatment discontinuation after immune restoration with ART is not known
Reasonable to discontinue maintenance therapy in asymptomatic patients on ART with increase in CD4 count to >200 cells/µL for ≥6 months (no data to support this approach)
May 2013

14. Microsporidiosis: Considerations in Pregnancy
Initiate ART to restore immune function
Albendazole:
Embryotoxic and teratogenic in animals
Not recommended in 1st trimester, use during later pregnancy only if benefits expected to outweigh risks
Systemic fumagillin: growth retardation in rats: should not be used with pregnant women
Topical fumagillin appears safe
May 2013

15. Microsporidiosis: Considerations in Pregnancy (2)
Itraconazole: avoid in 1st trimester
Loperamide: possible risk of hypospadias with 1st-trimester exposure
Avoid in 1st trimester, unless benefits expected to outweigh risks
Preferred antimotility agent during late pregnancy
Tincture of opium not recommended during late pregnancy
Opiate exposure during late pregnancy associated with neonatal respiratory depression; chronic exposure may result in neonatal withdrawal
May 2013

16. Websites to Access the Guidelines
May 2013

17. About This Slide Set
This presentation was prepared by Susa Coffey, MD, and Oliver Bacon, MD, for the AETC National Resource Center in May 2013
See the AETC NRC website for the most current version of this presentation:
May 2013