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Fungal Infections in HIV-patients. Hail M. Al-Abdely, MD Consultant, Infectious Diseases. Fungal Infections in HIV-patients. Cutaneous Seborrheic dermatitis Onychomycosis Skin dermatophyte infection Muco-cutaneous Candidiasis Invasive Cryptococcosis Histoplasmosis Candidiasis

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fungal infections in hiv patients

Fungal Infections in HIV-patients

Hail M. Al-Abdely, MD

Consultant, Infectious Diseases

fungal infections in hiv patients2
Fungal Infections in HIV-patients
  • Cutaneous
    • Seborrheic dermatitis
    • Onychomycosis
    • Skin dermatophyte infection
  • Muco-cutaneous
    • Candidiasis
  • Invasive
    • Cryptococcosis
    • Histoplasmosis
    • Candidiasis
    • Aspergillosis
    • Penicilliosis (Geographically restricted)
    • Coccidioidomycosis
    • Blastomycosis
slide3

Immunologic Status and Fungal Infections

Thrush

Dermatophyte

CD4

Seborrhea

Cryptococcosis

Histoplasmosis

Aspergillosis

Penicilliosis

cutaneous fungal infections
Cutaneous Fungal Infections
  • More common
  • More extensive
  • Relatively more difficult to treat
slide11

Systemic Treatment of Cutaneous Fungal Infections

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 capitis

50 mg qd     3 weeks

3-5 mg/kg/day     4-6 weeks

125 mg qd     (3-6 mg/kg/day)     4 weeks

Onychomycosis

150 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 pedis

150 mg once a week     3-4 weeks

400 mg qd 4 weeks

250 mg qd 6 weeks

Tinea versicolor

400 mg single     dose

200 mg qd     5 or 7 days

Studies ongoing

oro pharyngeal candidiasis
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
Treatment of OPC
  • Topical agents
    • Clotrimazole, nystatin, Ampho B
  • Systemic agents
    • Fluconazole
    • Itraconazole (Capsule, liquid)
    • Ampho B
treatment of opc15
Treatment of OPC
  • 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
esophageal candidiasis
Esophageal Candidiasis
  • Reported in 20% to 40% of all AIDS patients.
  • Characterized by pseudomembranes, erosions and ulcers.
  • Presentation is mainly with odynophagia and dysphagia
esophageal candidiasis18
Esophageal Candidiasis
  • Treatment
    • Commonly empiric therapy.
    • Endoscopy is indicated if the patient is not responding to antifungal therapy
    • Drugs
      • Fluconazole
      • Itraconazole (Capsule, liquid)
      • Ampho B
candidiasis and haart

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
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
Cryptococcosis
  • Cryptococcus neoformansis an encapsulated yeast.
  • 5% of HIV-infected patients in the Western World develop disseminated cryptococcosis
  • CD4+ lymphocyte counts, less than 50 cells/mm3.
cryptococcal meningitis
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.
diagnosis 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
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)
treatment of cryptococcal meningitis27
Treatment of Cryptococcal Meningitis

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 meningitis28
Treatment of Cryptococcal Meningitis

Maintenance

  • fluconazole 200-400 mg daily
  • amphotericin B 1 mg/kg/week (less effective than fluconazole)
  • itraconazole 100-200 mg PO bid (less effective than fluconazole)
  • there is no value to routine measurement of serum cryptococcal antigen
treatment of cryptococcal meningitis29
Treatment of Cryptococcal Meningitis
  • Mild presentation
    • Fluconazole + 5-flucytosine
    • High dose fluconazole 800 mg QD
    • Close monitoring
complications of cryptococcal meningitis
Complications of Cryptococcal Meningitis
  • Acute mortality happens due to cerebral edema, which may be diagnosed by a raised opening pressure of the CSF.
  • Hydrocephalus
dimorphic fungi endemic mycoses
Dimorphic Fungi (Endemic Mycoses)
  • Histoplasmosis
  • Coccidioidomycosis
  • Penicilliosis marnefiei
  • Blastomycosis
  • Sporotrichosis
slide32

Histoplasmosis

Coccidioidomycosis

Penicilliosis

characteristics of the endemic mycoses

Histoplasmosis

Coccidioidomycosis

Penicilliosis

Appearance of organism on biopsy

1-5 mcm round to oval

30-80 mcm round spherules containing 2-5 mcm endospores

1-8 mcm pleomorphic elongated

Method of duplication

Budding

Fission

Fission

Clinical Features:

  Fever

95%

95%

99%

  Weight loss

90%

60%

75%

  Anemia

70%

50%

75%

  Pulmonary disease

50%

90%

50%

  Lymphadenopathy

20%

10%

40-50%

  Skin lesions

5-10%

5%

70%

  Hepatosplenomegaly

25%

10-20%

50%

  Meningitis

<1%

10%

Very rare

Characteristics of the Endemic Mycoses
aspergillosis
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
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.