Common Opportunistic Infections
in HIV Patients, Part 2
Chris Farnitano, MD
Thursday, October 8, 2009
Noon Conference
Objectives
 Discuss most common opportunistic
infections (OIs): Dx and Rx
 Discuss immune reconstitution disease
 Review primary OI prophylaxis
Forms
Case Study SP
 27 yo male seen in clinic in June 2009
 Meds: unboosted atazanavir + Truvada
since 1/09; ranitidine
 T cells 5; viral load 30,000
 Why is his anti-HIV cocktail failing?
Case Study SP
 Ritonavir added to boost atazanavir
 Patient instructed to take ranitidine in
AM only and antivirals in PM
 Blood Cx for AFB, HIV genotype
ordered
Case Study SP
 Admitted to Kaiser August, 2009 with
diffuse warm, tender lymphadenopathy
 Biopsy performed, read as suspicious
for lymphoma
 Transferred to CCRMC after 7 days on
clarithromycin, ethambutol, rifabutin
 T Cells 209, viral load 726
 What is patient’s diagnosis?
What are the most common
OI’s?
 Cohort Studies in pre-triple therapy era:
 Candida
 Pneumocystis Carinii
 Cytomegalovirus
 Mycobacterium Avium Complex
 Pneumocystis - second episode
 Toxoplasmi gondii
 Herpes zoster
Causes of death, PHC HIV
clinic
 2007-9
 RH: Crypto meningitis
 TW: street drug overdose
 SA: sepsis, pneumonia and massive hemoptysis
 DW: metastatic prostate ca
 RP: CVA, laryngeal ca
 VA: PML (progressive multifocal
leukencephalopathy)
 AM: bacterial pneumonia, ETOH cirrhosis, wasting
OIs diagnosed, PHC HIV clinic
 2005-9
 PCP pneumonia
 Esophageal Candidiasis
 Herpes Simplex
 Herpes Zoster
 M. Kansasii immune reconstitution pneumonia
 Mycobacterium Avium Complex (MAC)
 Cryptococcal Fungemia, meningitis
 Histoplasmosis
 PML
Effect of HAART on
Opportunistic Infection
Incidence
 Most OI’s have declined 80-90%
 OI’s seen now mostly in 3 groups
 undiagnosed
HIV+
 not in care or not adhering to therapy
 long time “battle-scarred warriors” failing
after a long history of multiple regimens
50-200 T Cells:
 Pneumocystis Carinii Pnuemonia
 Toxoplasmosis
 Cryptococcus
Toxoplasmosis
<50 T Cells
 CMV Retinitis
 Mycobacterium Avium Complex
 Cryptosporidiosis
 Progressive Multifocal
Leukencephalopathy
PML
Ockham's razor does not
apply for advanced AIDS
 -often multiple diagnoses present
simultaneously
 ie
PCP, CMV, KS, Cocci
 12% of bacterial pneumonias also have
PCP
 10% of PCP pneumonia complicated by
bacterial infection
 search for second etiology if patient not
improving
Immune reconstitution
diseases
(HAART attacks)
 MAC adenitis
 CMV
 TB
 PCP
Case Study SP
 Diagnosis: Immune Reconsitution MAC
 AFB
blood culture from June grew out
MAC on 8/12 (hospital day #13)
 Also:
 Perianal
herpes
 Squamous cell carcinoma-in-situ, buttock
 Vancomycin-resistant enterococcus, groin
Primary OI prophylaxis
 PCP -T cells <200 or thrush
 Toxo -T cells <100 and +Toxo titer
 MAC - Tcells <50
 TB – INH x 9 months if PPD >5mm or
quantiferon-TB positive
Toxo prophylaxis
 Septra SS or DS qd or DS TIW
 Septra Desensitisation:
 1cc
qd x 3d, then 2cc qd x 3d, then 5ccqd
x 3d, then one SS tab qd
 Dapsone 100mg qd +pyramethamine
50mg qweek + leukovorin 25mg qweek
 Atovaquone 1500mg qd
MAC prophylaxis
 Zithromax 600mg x 2 tabs qweek
reduces infection rate 59%
 Also seems to reduce risk of PCP
Cytomegalovirus Retinitis Who Gets It?
 Rare above 50 T Cells
 Reactivation disease: most HIV patients
CMV IgG+ (90% of gay HIV+ men)
 90% of CMV disease is retinitis
Cytomegalovirus Retinitis Symptoms
 painless, progressive visual loss
 unilateral blurry vision
 floaters
Cytomegalovirus Retinitis Signs
 coalescing white perivascular exudates
 surrounded by hemorrhage
 brushfire pattern or tomato and cheese
pizza
Cytomegalovirus Retinitis
Cytomegalovirus Retinitis
Cytomegalovirus Retinitis Diagnosis
 if you suspect it, obtain ophthalmologist
confirmation within 24-48 hrs.
Cytomegalovirus Retinitis Treatment
 Valgancyclovir 900mg PO BID x 21
days, then qd
 Adverse effects:
 neutropenia
ANC<500 in 15%
 thrombocytopenia
 anemia
 50%: nausea, vomiting, abdominal pain or
diarrhea
Gangcyclivir intraocular
implant
 Consider in addition to systemic
therapy:
 Surgically
implanted depo device
 Effective for 6 months
 Replace at 6 months if still not immune
reconstituted
 Consider for sight threatening lesions near
the central visual field
Mycobacterium avium
Complex - Who gets it?
 T Cells <50
 screen with blood culture for AFB x 1 q
3 months to detect subclinical disease
Mycobacterium avium
Complex - Symptoms
 fever, night sweats
 weight loss
 diarrhea
Mycobacterium avium
Complex - Signs
 anemia
 Neutropenia
 Fever
 Diarrhea
 wasting
Mycobacterium avium
Complex - Diagnosis
 Blood culture usually positive if symptomatic
but takes weeks to grow
 If need to know sooner then do bone marrow
Bx
 Positive sputum culture usually colonization,
not active disease
 Positive stool culture may be colonization, not
active disease, mucosal bx more indicative of
disease
MAC-filled macrophages in
spleen
Mycobacterium avium
Complex - Treatment
 Clarithromycin 500mg BID +
 Ethambutol 15mg/kg/d +/-
 Rifabutin 300mg qd
 Treatment failure rate is high without
immune reconstitution
 drug
toxicity
 development of resistance
Case Study SP
 After 4 months of anti-MAC therapy + potent
anti-HIV therapy:
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




T Cells 71 viral load <48
Patient still hospitalized
Large effusions persist
Dubhoff tube required for feeding
Diffuse chest/abdominal adenopathy persists
MAC Cx’s show partial/complete resistance to all
MAC drugs except clofazamine
Prognosis?
Forms
Summary:
 Pyramid approach
 Prophylaxis simple: Septra and
Zithromax
 Rule out TB in pneumonia with T Cells
<200
 Avoid treating PCP empirically
 An ounce of prevention pills is worth a
pound of Treatment pills
An ounce of prevention pills is
worth a pound of Treatment
pills