Cardiovascular Complications

1

Management of AIDS-Related Opportunistic
Infections
Judith A. Aberg, MD
JA Aberg, MD. Presented at IASUSA/RWCA Clinical
Conference, August 2004.
The International AIDS SocietyUSA
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Pneumocystis jiroveci pneumonia

• Pneumocystis is a fungi that produces pneumonia
  in immunosuppressed patients
• Wide range of severity
• It is the most frequent form of presentation of
  AIDS
• Usually CD4 count less than 200 cells/mm3
• Diagnosis clinical, induced sputum, BAL

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PCP Prophylaxis

• CD4 T cell count lt 200 H/O oral candidiasis
  Unexplained fever gt 2 weeks Previous episode of
  PCP
• TMP/SMX DS 1 tablet po daily
• Dapsone 50 mg po b.i.d. or 100 mg daily
• Atovaquone 1500 mg po daily
• Pentamidine aerosol 300 mg monthly

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Treatment

• TMP/SMX for 21 days
• Pentamidine
• TMP plus dapsone
• Clindamycin plus primaquine
• Atovaquone
• Trimetrexate plus leucovorin
• Corticosteroids pO2 lt 70 mm/Hg or A-a gradient
  gt 35 mm Hg

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Disseminated Mycobacterium avium

• Usually late in the course of AIDS (CD4 lt50)
• Persistent fevers, night sweats, fatigue, weight
  loss, and anorexia
• Hepatosplenomegaly, lymphadenopathy, and (rarely)
  jaundice
• Anemia, leukopenia, elevated alkaline phosphatase
  levels are common

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Mycobacterium avium complex

• Improved survival with 3 drugs vs 2
• CLR 500 mg po bid (AZ 500 mg daily)
• EMB 15 mg/kg po qd
• RBT 300 mg po qd (adjust for ART)
• Failure to response/relapse
• Susceptibility testing
• Ciprofloxacin 500-750 mg po bid or levofloxacin
  500 mg qd
• Amikacin 10-15 mg/kg IV qd

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Toxoplasmosis

• Standard therapy is pyrimethamine plus
  sulfadiazine
• Sulfadiazine may not be available
• Pyrimethamine 200 mg load the 50 mg daily plus
  clindamycin 600 mg qid plus leucovorin 10 mg
  daily.
• SMX/TMP (based on 5 mg/kg TMP) bid
• If no clinical/radiographic improvement in 2
  weeks or clinical decline in one week BIOPSY

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Differential for Toxo Chagas

• USA has second largest Latino population
• Southern US, Latin America to central Argentina
• Trypanosoma cruzi
• Transmitted by kissing (reduviid) bugs, blood
  transfusions
• 1500 blood donors in LA positive
• 1600 donors positive in 3 SW states
• Chagoma portal of entry
• Cardiac, GI, CNS
• 16-18 million infected and 50,000 die annually

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Chagas Disease

• Diagnosis
• Serological limited, not standardized
• Buffy coat, GMS
• Biopsy
• ? Role of T. cruzi IgG look for chronic
  carriers. Reactivation similar to toxo
• PCR?
• Treatment Nifurtimox 8-10 mg/kg daily

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Leishmaniasis

• Asia, Mid-East, India, Africa, Brazil, Spain,
  France, Italy
• Sandflies
• Weight loss, F/S, anemia, leukopenia,
  hepatosplenomegaly weeks to months
• Diagnosis Liver, spleen or BM Biopsy (liver bx
  least helpful), Buffy coat, EIA and IFA
• Treatment Liposomal AMB drug of choice in HIV.
  Pentavalent antimonial drugs associated with high
  relapse and failure

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Cytomegalovirus

• Immediate vision-threatening GCV implant plus
  VGCV 900 mg po qd
• Peripheral non-vision threatening GCV implant
• Duration of therapy continue until immune
  reconstitution
• GI VGCV for 14-21 days
• Neuro Combined IV FOS and GCV

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Fungal Infections

• Cryptococcosis and Histoplasmosis Safe to stop
  secondary prophylaxis if CD4 gt150
• Coccidioidomycosis Do not stop prophylaxis
• Penicilliosis
• Asia particularly Thailand
• Similar to Histo
• AMB ? ITZ 400 mg

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Human papillomavirus

• Genital warts usually type 6 or 11
• Podofilox 0.5 solution or gel, apply bid for 3
  days, cycle q 4 weeks (50 response)
• Imiquimod 5 cream. Apply at bedtime and wash off
  in am. Apply 3 non-consecutive nights per week up
  to 16 weeks (response variable)
• Cryotherapy, Surgical Excision, TCA
  cauterization, cidofovir topical, podophyllin

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Anogenital dysplasia

• Anal and cervical PAP smears
• Colposcopsy indications
• Visible lesion on cervix regardless of PAP
  results
• ASCUS (atypical squamous cells-undetermined
  significance). Treat for infectious etiology. F/U
  PAP 2-3 month after treatment. If no infection,
  repeat PAP q 4-6 months until 3 negative PAP over
  2 year period. If second report of ASCUS, do
  colpo
• ASCUS-H (cannot rule out high-grade disease)
• ASCUS and previous h/o abnormal
• LSIL or HSIL (squamous intraepithelial lesion)
• High-resolution anoscopy (HRA) if LSIL or HSIL on
  anal PAP. Consider ASCUS or ASCUS-H. Biopsy

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Effect of ART on OIs

• Multiple studies show reduction in OIs on ART
• Decreased morbidity/mortality
• Improvement in pathogen specific immunity
• Parodoxical reactions
• Immune reconstitution syndromes
• Atypical manifestations

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What should we do with ART-naïve?

• Risk vs benefit
• First line treat OI
• Consider ART
• Drug interactions
• Drug toxicities
• Risk of immune reconstitution syndrome
• Consider wait
• Consider steroids
• If sub-optimal CD4 response??