HIV AIDS opportunistic infections: Difference between revisions

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__NOTOC__
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{{CMG}}; {{AOEIC}}, [[User:Ujjwal Rastogi|Ujjwal Rastogi, MBBS]] [mailto:urastogi@perfuse.org]
{{AIDS}}
{{CMG}}; {{AE}} {{AL}}; {{JH}}
 
==Overview==
==Overview==
Before the widespread use of potent combination antiretroviral therapy (ART), opportunistic infections (OIs), which have been defined as infections that are more frequent or more severe because of immunosuppression in HIV-infected persons, were the principal cause of morbidity and mortality in this population. In the early 1990s, the use of chemoprophylaxis, immunization, and better strategies for managing acute OIs contributed to improved quality of life and improved survival.<ref name="pmid16741877">{{cite journal |author=Walensky RP, Paltiel AD, Losina E, Mercincavage LM, Schackman BR, Sax PE, Weinstein MC, Freedberg KA |title=The survival benefits of AIDS treatment in the United States |journal=J. Infect. Dis. |volume=194 |issue=1 |pages=11–9 |year=2006 |month=July |pmid=16741877 |doi=10.1086/505147 |url=http://www.jid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=16741877 |accessdate=2012-04-05}}</ref>  However, the widespread use of ART starting in the mid-1990s has had the most profound influence on reducing OI-related mortality in HIV-infected persons in those countries in which these therapies are accessible and affordable.
It is important to recognize that the relationship between opportunistic infections (OIs) and HIV infection is bi-directional. HIV causes the immunosuppression that allows opportunistic pathogens to cause disease in HIV-infected persons. OIs, as well as other co-infections that may be common in HIV-infected persons, such as sexually transmitted infections (STIs), can adversely affect the natural history of HIV infection by causing reversible increases in circulating viral load that could accelerate HIV progression and increase transmission of HIV. The widespread use of ART starting in the mid-1990s has had the most profound influence on reducing OI-related mortality in HIV-infected persons in those countries in which these therapies are accessible and affordable. Major OIs characteristic of AIDS include viral infections such as [[CMV retinitis]], mucosal [[HSV]], and [[varicella zoster]], bacterial infections such as [[bacillary angiomatosis]], [[tuberculosis]], [[mycobacterium avium complex]], and [[syphilis]], and fungal infections such as [[cryptococcosis]], mucocutaneous [[candidiasis]], [[coccidiomycosis]], and [[pneumocystis jirovecii]] pneumonia.


==Etiology==
==Opportunistic Infections==
Despite the availability of ART in the United States and other industrialized countries, OIs continue to cause considerable morbidity and mortality for three primary reasons:
===Bacteria===
{| style="border: 0px; font-size: 85%; margin: 3px; width:1000px;" align=center
|valign=top|
|+
! style="background: #4479BA; color:#FFF;  width: 100px;" | Disease
! style="background: #4479BA; color:#FFF;  width: 200px;" | Description
! style="background: #4479BA; color:#FFF;  width: 250px;" | Clinical Findings
! style="background: #4479BA; color:#FFF;  width: 200px;" | Diagnosis
! style="background: #4479BA; color:#FFF;  width: 200px;" | Prevention / Prophylaxis
! style="background: #4479BA; color:#FFF;  width: 200px;" | Treatment
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" | [[Mycobacterium avium complex]] (MAC)
| style="padding: 5px 5px; background: #F5F5F5;" |
*''[[M. avium]]'' is the etiologic agent in 95% of patients with MAC disease
*The greatest risk of disease occurs among patients with a [[CD4]]+ <50 cells/µL
| style="padding: 5px 5px; background: #F5F5F5;" | [[Fever]], night sweats, weight loss, [[fatigue]], [[diarrhea]], and [[abdominal pain]].


*Many patients are unaware of their HIV infection and seek medical care when an OI becomes the initial indicator of their disease.
| style="padding: 5px 5px; background: #F5F5F5;" |  Isolation of MAC from cultures of blood, lymph node or bone marrow.
*Certain patients are aware of their HIV infection, but do not take ART because of psychosocial or economic factors.
| style="padding: 5px 5px; background: #F5F5F5;" | Prophylaxis is indicated when [[CD4]] < 50 cells/µL
*Certain patients are prescribed ART, but fail to attain adequate virologic and immunologic response because of factors related to adherence, pharmacokinetics, or unexplained biologic factors.<ref name="pmid16011527">{{cite journal |author=Perbost I, Malafronte B, Pradier C, Santo LD, Dunais B, Counillon E, Vinti H, Enel P, Fuzibet JG, Cassuto JP, Dellamonica P |title=In the era of highly active antiretroviral therapy, why are HIV-infected patients still admitted to hospital for an inaugural opportunistic infection? |journal=HIV Med. |volume=6 |issue=4 |pages=232–9 |year=2005 |month=July |pmid=16011527 |doi=10.1111/j.1468-1293.2005.00282.x |url=http://onlinelibrary.wiley.com/resolve/openurl?genre=article&sid=nlm:pubmed&issn=1464-2662&date=2005&volume=6&issue=4&spage=232 |accessdate=2012-04-05}}</ref><ref name="pmid16494634">{{cite journal |author=Palacios R, Hidalgo A, Reina C, de la Torre M, Márquez M, Santos J |title=Effect of antiretroviral therapy on admissions of HIV-infected patients to an intensive care unit |journal=HIV Med. |volume=7 |issue=3 |pages=193–6 |year=2006 |month=April |pmid=16494634 |doi=10.1111/j.1468-1293.2006.00353.x |url=http://onlinelibrary.wiley.com/resolve/openurl?genre=article&sid=nlm:pubmed&issn=1464-2662&date=2006&volume=7&issue=3&spage=193 |accessdate=2012-04-05}}</ref>
*[[Azithromycin]] 1200 mg PO once weekly, OR
*[[Clarithromycin]] 500 mg PO BID
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Clarithromycin]] 500 mg PO twice daily + [[ethambutol]] 15 mg/kg PO daily , OR
*[[Azithromycin]] 500–600 mg + [[ethambutol]] 15 mg/kg PO daily
:<small>(Testing of susceptibility to [[clarithromycin]] or [[azithromycin]] is recommended)</small>
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" | Respiratory Disease
| style="padding: 5px 5px; background: #F5F5F5;" |
* Atypical bacterial pathogens such as [[Legionella pneumophila]], [[Mycoplasma pneumoniae]], and [[Chlamydophila]] species have been reported as infrequent causes of community-acquired bacterial pneumonia in HIV-infected individuals
*The frequency of [[Pseudomonas aeruginosa]] and [[Staphylococcus aureus]] as community-acquired pathogens is higher in HIV-infected individuals
| style="padding: 5px 5px; background: #F5F5F5;" | [[Fever]], [[chills]], rigors, [[chest pain]] or [[pleurisy]], productive [[cough]], and [[dyspnea]]
| style="padding: 5px 5px; background: #F5F5F5;" | Diagnosis is the same as in HIV-negative patients ([[chest X-ray]], [[sputum]] analysis)
| style="padding: 5px 5px; background: #F5F5F5;" | Pneumococcal and influenza [[vaccination]] is recommended for all HIV patients. <br> <small>Note: Live attenuated influenza vaccine is contraindicated in HIV-infected persons </small>
| style="padding: 5px 5px; background: #F5F5F5;" |
*Treatment should be pathogen specific.
*Empiric therapy:
:*[[Amoxicillin/clavulanate]] + [[azithromycin]] or [[clarithromycin]], OR
:*[[Levofloxacin]] 750 mg PO once daily
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" | Enteric Infections
| style="padding: 5px 5px; background: #F5F5F5;" |
*The most common routinely cultured enteric bacteria among HIV-infected adults in the United States are [[Salmonella]], [[Shigella]], and [[Campylobacter]].
*Other pathogens include [[E. coli]] and [[C. difficile]].
| style="padding: 5px 5px; background: #F5F5F5;" | Severe and prolonged [[diarrheal]] disease, potentially associated with fever, bloody diarrhea, and weight loss.
| style="padding: 5px 5px; background: #F5F5F5;" |
*The diagnosis of Gram-negative bacterial enteric infection is established through cultures of stool and blood.  
*Stool sample for [[C. difficile]] toxin or [[polymerase chain reaction]] assay (if recent antibiotic use)
| style="padding: 5px 5px; background: #F5F5F5;" |Antimicrobial prophylaxis to prevent bacterial enteric illness usually is not recommended.
| style="padding: 5px 5px; background: #F5F5F5;" |
*Treatment should be pathogen specific.
*Empiric therapy: [[Ciprofloxacin]]  500–750 mg PO q12h
* Oral or IV hydration therapy as appropriate.
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" | [[Bacillary Angiomatosis]]
| style="padding: 5px 5px; background: #F5F5F5;" |
*B. henselae and B. quintana infections have been identified in HIV- infected patients
*The greatest risk of disease occurs among patients with a CD4+ <50 cells/µL
| style="padding: 5px 5px; background: #F5F5F5;" | Cutaneous lesions (red, globular and non-blanching, with a vascular appearance), sub-cutaneous nodules.
| style="padding: 5px 5px; background: #F5F5F5;" | Histopathologic examination of biopsied tissue
| style="padding: 5px 5px; background: #F5F5F5;" | Primary chemoprophylaxis for Bartonella-associated disease is not recommended
| style="padding: 5px 5px; background: #F5F5F5;" |
*Doxycycline 100 mg PO or IV q12h, OR
*Erythromycin 500 mg PO or IV q6h 
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" | [[Syphilis]]
| style="padding: 5px 5px; background: #F5F5F5;" |  
*Treponema pallidum is the causative pathogen.
*Early syphilis in HIV-infected patients may cause a transient decrease in CD4 count and increase in HIV viral load.
| style="padding: 5px 5px; background: #F5F5F5;" |
*Primary: Single painless nodule that ulcerates (chancre) or multiple atypical chancres may be seen.
*Secondary: More rapid progression or severity in HIV patients.  Manifestations include maculopapular skin lesions, condyloma lata, lymphadenopathy, fever, malaise, anorexia, arthralgias, and headache. 
*Terciary:  Manifestations of neurosyphilis, such as concomitant uveitis and meningitis, may be more common in HIV-infected persons.  Other manifestations include cardiovascular syphilis and gummatous syphilis.
| style="padding: 5px 5px; background: #F5F5F5;" |
*Serologic tests: VDRL, RPR, FTA-ABS, TP-PA
*Darkfield microscopy and tests to detect T. pallidum in lesion exudates or tissue (biopsy with silver stain) are definitive for diagnosing early syphilis
| style="padding: 5px 5px; background: #F5F5F5;" |
*Routine serologic screening for syphilis is recommended at least annually for all HIV- infected patients who are sexually active.
*Prophylaxis is indicated in patients who were exposed sexually within 90 days preceding the diagnosis of primary, secondary, or early-latent syphilis in a sex partner or exposed >90 days before syphilis diagnosis in a sex partner, if serologic test results are not available immediately and the opportunity for follow-up is uncertain.
| style="padding: 5px 5px; background: #F5F5F5;" |
*Primary: Benzathine penicillin G 2.4 million units IM for 1 dose
*Secondary and terciary: Benzathine penicillin G 2.4 million units IM weekly for 3 doses
|-
| style="padding: 5px 5px; background: #F5F5F5;" colspan=6| Table adapted from Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents<ref name="Guidelines"> {{cite web| title=Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the
prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Accessed Oct 2014| url=http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf }} </ref>
|}


Thus, although hospitalizations and deaths have decreased since the implementation of ART, OIs remain a leading cause of morbidity and mortality in HIV-infected persons.<ref name="pmid16116306">{{cite journal |author=Gebo KA, Fleishman JA, Reilly ED, Moore RD |title=High rates of primary Mycobacterium avium complex and Pneumocystis jiroveci prophylaxis in the United States |journal=Med Care |volume=43 |issue=9 Suppl |pages=III23–30 |year=2005 |month=September |pmid=16116306 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0025-7079&volume=43&issue=9&spage=III23 |accessdate=2012-04-05}}</ref><ref name="pmid16089023">{{cite journal |author=Bonnet F, Lewden C, May T, Heripret L, Jougla E, Bevilacqua S, Costagliola D, Salmon D, Chêne G, Morlat P |title=Opportunistic infections as causes of death in HIV-infected patients in the HAART era in France |journal=Scand. J. Infect. Dis. |volume=37 |issue=6-7 |pages=482–7 |year=2005 |pmid=16089023 |doi= |url= |accessdate=2012-04-05}}</ref><ref name="pmid17304464">{{cite journal |author=Teshale EH, Hanson DL, Wolfe MI, Brooks JT, Kaplan JE, Bort Z, Sullivan PS |title=Reasons for lack of appropriate receipt of primary Pneumocystis jiroveci pneumonia prophylaxis among HIV-infected persons receiving treatment in the United States: 1994-2003 |journal=Clin. Infect. Dis. |volume=44 |issue=6 |pages=879–83 |year=2007 |month=March |pmid=17304464 |doi=10.1086/511862 |url=http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17304464 |accessdate=2012-04-05}}</ref>
===Virus===
{| style="border: 0px; font-size: 85%; margin: 3px; width:1000px;" align=center
|valign=top|
|+
! style="background: #4479BA; color:#FFF;  width: 100px;" | Disease
! style="background: #4479BA; color:#FFF;  width: 200px;" | Description
! style="background: #4479BA; color:#FFF;  width: 250px;" | Clinical Findings
! style="background: #4479BA; color:#FFF;  width: 200px;" | Diagnosis
! style="background: #4479BA; color:#FFF;  width: 200px;" | Prevention / Prophylaxis
! style="background: #4479BA; color:#FFF;  width: 200px;" | Treatment
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" | [[Cytomegalovirus]] Infection
| style="padding: 5px 5px; background: #F5F5F5;" |
*The greatest risk of disease occurs among patients with a CD4+ <50 cells/µL
| style="padding: 5px 5px; background: #F5F5F5;" |
*Retinitis is the most common clinical manifestation of CMV end-organ disease
*Colitis occurs in 5% to 10% of patients with AIDS and CMV end-organ disease, clinical manifestations include weight loss, anorexia, abdominal pain, diarrhea, and malaise.
*Esophagitis occurs in a small percentage of patients
| style="padding: 5px 5px; background: #F5F5F5;" |CMV viremia can be detected by PCR, antigen assays, or culture
| style="padding: 5px 5px; background: #F5F5F5;" |
* CMV end-organ disease is best prevented by using ART to maintain CD4 count >100 cells/uL
* Ganciclovir or valganciclovir primary prophylaxis is not recommended.
* Some specialists recommend yearly funduscopic examination in patients with CD4 < 50 cells/uL
| style="padding: 5px 5px; background: #F5F5F5;" |
*Preferred Regimen: Valganciclovir 900 mg PO daily
*For sight threatening lesions: Add intravitreal injections of ganciclovir or foscarnet to normal regimen.
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" | [[Herpes Simplex Virus]] Infection
| style="padding: 5px 5px; background: #F5F5F5;" |
*Approximately 70% of HIV-infected persons are HSV-2 seropositive and 95% are seropositive for either HSV-1 or HSV-2.
*The greatest risk of disease occurs among patients with a CD4+ <100 cells/µL
| style="padding: 5px 5px; background: #F5F5F5;" |
*HSV-1: Orolabial herpes (cold sores, fever blisters).
*HSV-2: Genital herpes (papules, vesicles or ulcers).
*Non-mucosal HSV infections, such as HSV keratitis, HSV encephalitis, HSV hepatitis, and herpetic whitlow, are similar in presentation to manifestations observed in HIV-seronegative individuals
| style="padding: 5px 5px; background: #F5F5F5;" |Viral culture, HSV DNA PCR, and HSV antigen detection are available methods for diagnosis of mucocutaneous lesions.
| style="padding: 5px 5px; background: #F5F5F5;" |Prophylaxis with antiviral drugs to prevent primary HSV infection is not recommended.
| style="padding: 5px 5px; background: #F5F5F5;" |  
<u>Genital lesions</u> (for 5-14 days): 
*Valacyclovir 1 g PO BID, or
*Famciclovir 500 mg PO BID, or
*Acyclovir 400 mg PO TID
<u>Oral lesions</u> (for 5-10 days): 
*Valacyclovir 1 g PO BID, or
*Famciclovir 500 mg PO BID, or
*Acyclovir 400 mg PO TID
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" | [[Varicella-Zoster Virus]] (VZV) Infection
| style="padding: 5px 5px; background: #F5F5F5;" |
*The greatest risk of herpes zoster occurs among patients with a CD4+ <200 cells/µL
*Because most HIV-infected adults in the United States are VZV seropositive, primary varicella is an uncommon.
| style="padding: 5px 5px; background: #F5F5F5;" |
*Varicella rash tends to have a central distribution with lesions first appearing on the head, then trunk, and finally the extremities, evolving through stages of macules, papules, vesicles, pustules, and crusts
*Herpes zoster manifests as a painful cutaneous eruption in a dermatomal distribution, often preceded by prodromal pain.
| style="padding: 5px 5px; background: #F5F5F5;" |
*Diagnosis is made clinically.
*History of varicella or VZV exposure, a rash that began with a dermatomal pattern, and VZV serologic testing to assess prior VZV infection may be helpful.
| style="padding: 5px 5px; background: #F5F5F5;" |
*Avoid exposure to individuals with varicella or herpes zoster.
*Prophylaxis with antiviral drugs to prevent varicella is not recommended.
*Varicella vaccination is recommended for patients with CD4 > 200 cells/µL.
*Post-exposure prophylaxis: VariZIG 125 IU/10 kg IM
| style="padding: 5px 5px; background: #F5F5F5;" |
*Valacyclovir 1000 mg PO TID, OR
*Famciclovir 500 mg PO TID
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" | Human Herpesvirus-8 Infection
| style="padding: 5px 5px; background: #F5F5F5;" |
*The greatest risk of herpes zoster occurs among patients with a CD4+ <200 cells/µL
| style="padding: 5px 5px; background: #F5F5F5;" |
*Most patients are asymptomatic
*Kaposi Sarcoma:  nontender, purplish, indurated skin lesions.
*Multicentric Castleman’s disease: generalized adenopathy and fever and can progress to multi-organ failure.
*Primary effusion lymphoma characteristically presents with effusions of the pleural, pericardial, or abdominal spaces


==Pathophysiology==
| style="padding: 5px 5px; background: #F5F5F5;" |Diagnosis is made with cytologic and immunologic cell markers
Recognizing that the relation between OIs and HIV infection is bidirectional is important. HIV leads to immunosuppression that allows opportunistic pathogens to cause disease in HIV-infected persons. OIs and other coinfections that might be common in HIV-infected persons, such as sexually transmitted infections, can also have adverse effects on the natural history of HIV infection. Certain OIs are associated with reversible increases in circulating viral load and these increases could lead to accelerated HIV progression or increased transmission of HIV. Thus, although chemoprophylaxis and vaccination directly prevent pathogen-specific morbidity and mortality, they might also contribute to reduced rate of progression of HIV disease. For instance, randomized trials using [[trimethoprim]]-[[sulfamethoxazole]] (TMP-SMX) have documented that [[chemoprophylaxis]] can both decrease OI-related [[morbidity]] and improve [[survival]].
| style="padding: 5px 5px; background: #F5F5F5;" |Screening is not recommended
| style="padding: 5px 5px; background: #F5F5F5;" |
*Kaposi Sarcoma: Start or adjust ART
*Multicentric Castleman’s disease: Valganciclovir 900 mg PO BID for 3 weeks, or Ganciclovir 5 mg/kg IV q12h for 3 weeks, or Valganciclovir 900 mg PO BID + zidovudine 600 mg PO q6h for 7–21 days.
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" | [[Human Papillomavirus]] Infection
| style="padding: 5px 5px; background: #F5F5F5;" |
*HPV 16 and 18 are associated with cervical malignancy.
*HPV 6 and 11 cause 90% of genital warts.
| style="padding: 5px 5px; background: #F5F5F5;" |
*Oral, genital, and anal warts (condyloma acuminata) are usually flat, papular, or pedunculated growths on the mucosa or epithelium.
*Cervical cancer can be asymptomatic or may manifest with bleeding, pain, or a palpable mass.
| style="padding: 5px 5px; background: #F5F5F5;" |
*Diagnosis of genital and oral warts is made by visual inspection and can be confirmed by biopsy.
*Cytology (Pap test) and colposcopic techniques with biopsy are used to detect CIN.


==Historical Perspective==
| style="padding: 5px 5px; background: #F5F5F5;" |
The first guidelines for Prophylaxis against Pneumocystis carinii Pneumonia for persons infected with the human immunodeficiency virus became the first HIV-related treatment guideline published by the U.S. Public Health Service in 1989. This report was followed by guideline on prevention of Mycobacterium avium complex (MAC) disease in 1993.
*HPV vaccination is recommended in HIV infected patients
| style="padding: 5px 5px; background: #F5F5F5;" |
*Podophyllotoxin or Imiquimod self-application to warts.
*Cryotherapy, surgical excision, laser surgery.
|-
| style="padding: 5px 5px; background: #F5F5F5;" colspan=6| Table adapted from Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents <ref name="Guidelines"> {{cite web| title=Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the
prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Accessed Oct 2014| url=http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf }} </ref>
|}


==Treatment==
===Fungus===
===Initiation of ART in the Setting of an Acute OI (Treatment-Naïve Patients)===
{| style="border: 0px; font-size: 85%; margin: 3px; width:1000px;" align=center
When an acute OI is present, initiation of ART is usually expected to improve immune function and contribute to faster resolution of the OI.
|valign=top|
|+
! style="background: #4479BA; color:#FFF;  width: 100px;" | Disease
! style="background: #4479BA; color:#FFF;  width: 200px;" | Description
! style="background: #4479BA; color:#FFF;  width: 250px;" | Clinical Findings
! style="background: #4479BA; color:#FFF;  width: 200px;" | Diagnosis
! style="background: #4479BA; color:#FFF;  width: 200px;" | Prevention / Prophylaxis
! style="background: #4479BA; color:#FFF;  width: 200px;" | Treatment
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" | [[Pneumocystis pneumonia|Pneumocystis Pneumonia]] <br> <br><small>[[HIV opportunistic infection pneumocystis pneumonia: prevention and treatment guidelines|(Click here for more information)]]</small>
| style="padding: 5px 5px; background: #F5F5F5;" |
*Caused by the fungus ''Pneumocystis jirovecii''.
*90% of cases occurred among patients with CD4+ <200
*Incidence among HIV patients: 2-3 cases per 100 person-year
| style="padding: 5px 5px; background: #F5F5F5;" |Subacute onset of progressive [[dyspnea]], [[fever]], nonproductive [[cough]], and chest discomfort that worsens within days to weeks. [[Tachypnea]], [[tachycardia]], and diffuse dry rales are found in the physical examination. 
| style="padding: 5px 5px; background: #F5F5F5;" |
*Clinical presentation, blood tests, or chest x-rays are not pathognomonic for PCP. <br>  [[BAL]] or induced sputum samples are required for a definite diagnosis.
| style="padding: 5px 5px; background: #F5F5F5;" | Start [[TMP-SMX]] prophylaxis when [[CD4]]+ <200 cells/µL or history of oropharyngeal [[candidiasis]].  <br> Discontinue prophylaxis when  CD4+ is >200 cells/µL for >3 month.
| style="padding: 5px 5px; background: #F5F5F5;" |
*TMP-SMX
*Administer adjunctive corticosteroids in patients with pO2 <70 mm Hg or arterial-alveolar O2 gradient >35 mm Hg
*In patients not on ART, ART should be initiated, when possible, within 2 weeks of diagnosis of PCP
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |  [[Candidiasis|Mucocutaneous Candidiasis]]
| style="padding: 5px 5px; background: #F5F5F5;" |
*''Candida albicans'' is the causative agent.
*Oropharyngeal and esophageal candidiasis are common in HIV-infected patients
*The greatest risk of disease occurs among patients with a [[CD4]]+ <200 cells/µL
| style="padding: 5px 5px; background: #F5F5F5;" |
*Oropharyngeal:  Painless, creamy white, plaque-like lesions that can occur on the buccal surface, hard or soft palate, oropharyngeal mucosa, or tongue surface.
*Esophageal: retrosternal burning pain or discomfort along with [[odynophagia]].
| style="padding: 5px 5px; background: #F5F5F5;" |
*Usually diagnosed clinically based on the characteristic appearance of lesions (can be scraped off)
*Definitive diagnosis of esophageal candidiasis requires direct endoscopic visualization of lesions with histopathologic demonstration of characteristic Candida yeast
| style="padding: 5px 5px; background: #F5F5F5;" |Routine primary prophylaxis is not recommended
| style="padding: 5px 5px; background: #F5F5F5;" |
<u>Oropharyngeal</u>: 
*[[Fluconazole]] 100 mg PO once daily
<u>Esophageal</u>: 
*[[Fluconazole]] 100 mg (up to 400 mg) PO or IV daily, OR<br>
*[[Itraconazole]] oral solution 200 mg PO daily
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |  [[Cryptococcosis]]
| style="padding: 5px 5px; background: #F5F5F5;" |
*''Cryptococcus neoformans'' is the causative pathogen.
*The greatest risk of disease occurs among patients with a [[CD4]]+ <100 cells/µL
| style="padding: 5px 5px; background: #F5F5F5;" |
*Subacute meningitis or meningoencephalitis with fever, malaise, and headache.
*Other symptoms such as lethargy, altered mental status, personality changes, and memory loss may be present.
| style="padding: 5px 5px; background: #F5F5F5;" |
*CSF analysis shows mildly elevated levels of protein, low-to-normal glucose, and pleocytosis consisting mostly of lymphocytes
* Opening pressure in the CSF may be elevated
* Diagnosed through culture of blood or CSF, CSF microscopy with India ink staining, or cryptococcal antigen (CrAg) detection
| style="padding: 5px 5px; background: #F5F5F5;" |
*Primary prophylaxis or screening for serum CrAg in asymptomatic patients is not recommended in the US
*Prophylactic fluconazole or itraconazole can reduce the frequency of primary cryptococcal disease in patients who have CD4 cell counts <100 cells/mm according to prospective RCT.
| style="padding: 5px 5px; background: #F5F5F5;" |
<u>Induction Therapy</u>:
*Liposomal amphotericin B 3–4 mg/kg IV daily + flucytosine 25 mg/kg PO QID
<u>Consolidation Therapy</u>:
*Fluconazole 400 mg PO or IV once daily
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |  [[Histoplasmosis]]
| style="padding: 5px 5px; background: #F5F5F5;" |
*''Histoplasma capsulatum'' is the causative pathogen.
*The greatest risk of disease occurs among patients with a [[CD4]]+ <150 cells/µL
| style="padding: 5px 5px; background: #F5F5F5;" |
Fever, fatigue, weight loss, hepatosplenomegaly, cough, chest pain, and dyspnea.
| style="padding: 5px 5px; background: #F5F5F5;" |
*Detection of Histoplasma antigen in blood, urine or [[BAL]] is a sensitive method for rapid diagnosis of disseminated histoplasmosis and acute pulmonary histoplasmosis.
| style="padding: 5px 5px; background: #F5F5F5;" |
*Avoid activities known to be associated with increased risk (areas contaminated of bird or bat droppings)
*Start prophylaxis with [[Itraconazole]] 200 mg PO once daily when [[CD4]]+ <150 cells/µL and the patients is at high risk of exposure.
| style="padding: 5px 5px; background: #F5F5F5;" |
<u>Induction Therapy</u>: 
*Liposomal amphotericin B 3 mg/kg IV daily (for 2 weeks)
<u>Consolidation Therapy</u>:
*Itraconazole 200 mg PO TID for 3 days, then BID for > 12 months
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |  [[Coccidioidomycosis]]
| style="padding: 5px 5px; background: #F5F5F5;" |
*Caused by a soil-dwelling fungus that consists of two species, ''Coccidioides immitis'' and ''Coccidioides posadasii''.
*The greatest risk of disease occurs among patients with a [[CD4]]+ <250 cells/µL
| style="padding: 5px 5px; background: #F5F5F5;" |
Focal pneumonia (most common in patients with [[CD4]] >250 cells/µL), diffuse [[pneumonia]], cutaneous disease, [[meningitis]], liver or lymph node involvement.
| style="padding: 5px 5px; background: #F5F5F5;" |
*Diagnosis is confirmed by culture.
*Serology (IgM and IgG) is useful
| style="padding: 5px 5px; background: #F5F5F5;" |
* Avoid activities involving exposure to infection while living in or visiting areas in which Coccidioides spp. are endemic.
*Chemoprophylaxis is not recommended.
| style="padding: 5px 5px; background: #F5F5F5;" |
<u>Mild infections</u>:
*Fluconazole 400 mg PO once daily (BII), OR
*Itraconazole 200 mg PO twice daily
<u>Severe infection</u>
*Amphotericin B deoxycholate 0.7–1.0 mg/kg IV daily, OR
*Lipid formulation amphotericin B 4–6 mg/kg IV daily


Initiation of ART has been documented to be effective for OIs for which effective therapy does not exist; [[cryptosporidiosis]], [[microsporidiosis]], and [[progressive multifocal leukoencephalopathy ]](PML) might resolve or at least stabilize after the institution of effective ART. For [[kaposi's sarcoma]] (KS), initiation of ART has been documented to lead to resolution of lesions in the absence of specific therapy for the sarcoma.<ref name="pmid11807324">{{cite journal |author=Murdaca G, Campelli A, Setti M, Indiveri F, Puppo F |title=Complete remission of AIDS/Kaposi's sarcoma after treatment with a combination of two nucleoside reverse transcriptase inhibitors and one non-nucleoside reverse transcriptase inhibitor |journal=AIDS |volume=16 |issue=2 |pages=304–5 |year=2002 |month=January |pmid=11807324 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0269-9370&volume=16&issue=2&spage=304 |accessdate=2012-04-06}}</ref>
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |  Aspergillosis
| style="padding: 5px 5px; background: #F5F5F5;" |
*Aspergillus fumigatus is the most common causative agent.
*The greatest risk of disease occurs among patients with a [[CD4]]+ <100 cells/µL
| style="padding: 5px 5px; background: #F5F5F5;" | Symptoms of pneumonia include [[fever]], [[cough]], [[dyspnea]], chest pain, [[hemoptysis]], and hypoxemia
| style="padding: 5px 5px; background: #F5F5F5;" |
*Lung CT: Halo of low attenuation surrounding a pulmonary nodule or a cavity.
* Bronchoscopic examination demonstrates ulcerative or plaque-like lesions adherent to the tracheal wall
* Isolation of Aspergillus spp. from respiratory secretions or the finding of septate hyphae consistent with Aspergillus spp. in respiratory samples in association with typical CT findings
| style="padding: 5px 5px; background: #F5F5F5;" | Antifungal therapy is not recommended for prevention.
| style="padding: 5px 5px; background: #F5F5F5;" | [[Voriconazole]] 6 mg/kg IV q12h for 1 day, then 4 mg/kg IV q12h , followed by [[voriconazole]] PO 200 mg q12h after clinical improvement.  
|-
| style="padding: 5px 5px; background: #F5F5F5;" colspan=6| Table adapted from Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents <ref name="Guidelines"> {{cite web| title=Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the
prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America.  Accessed Oct 2014| url=http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf }} </ref>
|}


'''Benefits of ART in preventing OI:'''
===Parasite===
{| style="border: 0px; font-size: 85%; margin: 3px; width:1000px;" align=center
|valign=top|
|+
! style="background: #4479BA; color:#FFF;  width: 100px;" | Disease
! style="background: #4479BA; color:#FFF;  width: 200px;" | Description
! style="background: #4479BA; color:#FFF;  width: 250px;" | Clinical Findings
! style="background: #4479BA; color:#FFF;  width: 200px;" | Diagnosis
! style="background: #4479BA; color:#FFF;  width: 200px;" | Prevention / Prophylaxis
! style="background: #4479BA; color:#FFF;  width: 200px;" | Treatment
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" | [[Toxoplasma gondii]] Encephalitis<br> <br><small>[[HIV opportunistic infection toxoplasma gondii encephalitis: prevention and treatment guidelines|(Click here for more information)]]</small>
| style="padding: 5px 5px; background: #F5F5F5;" |
* Caused by the protozoan ''Toxoplasma gondii''
* The greatest risk of disease occurs among patients with a CD4+ <50 cells/µL
* Primary infection occurs after eating undercooked meat containing tissue cysts or ingesting oocysts that have been shed in cat feces and have sporulated in the environment
| style="padding: 5px 5px; background: #F5F5F5;" | Focal encephalitis with headache, confusion, or motor weakness and fever
| style="padding: 5px 5px; background: #F5F5F5;" |
*Diagnosis is done with IgG antibodies.
*CT scan or MRI of the brain will typically show multiple contrast-enhancing lesions, often with associated edema. 
*Definite diagnosis requires a brain biopsy.
*PET is helpful to distinguish between toxoplasmosis and primary CNS lymphoma.
| style="padding: 5px 5px; background: #F5F5F5;" |
*Start [[TMP-SMX]] prophylaxis when [[CD4]]+ <100 cells/µL <br> Discontinue prophylaxis when  CD4+ is >200 cells/µL for >3 month.
| style="padding: 5px 5px; background: #F5F5F5;" | Administer:
* [[Pyrimethamine]], PLUS 
* [[Sulfadiazine]], PLUS
* [[Leucovorin]]
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" | [[Cryptosporidiosis]] <br> <br><small>[[HIV opportunistic infection cryptosporidiosis: prevention and treatment guidelines|(Click here for more information)]]</small>
| style="padding: 5px 5px; background: #F5F5F5;" |
*Caused by the protozoan ''Cryptosporidium <small>(C. hominis, C. parvum, and C. meleagridis)</small>''
*The greatest risk of disease occurs among patients with a CD4+ <100 cells/µL
| style="padding: 5px 5px; background: #F5F5F5;" | Acute or subacute onset of watery diarrhea, nausea, vomiting, lower abdominal pain. Fever is seen in 1/3 of patients.
| style="padding: 5px 5px; background: #F5F5F5;" | Microscopic examination of oocysts in stool with direct immunofluorescence.
| style="padding: 5px 5px; background: #F5F5F5;" |
*Initiate ART
*Education of possibles ways of transmission (infected patients, diapers, animals)
*Avoid direct contact of pet stool
*Scrupulous handwashing is recommended.
| style="padding: 5px 5px; background: #F5F5F5;" |
*Initiate or optimize ART for immune restoration to CD4 count >100 cells/mm3


The initiation of ART in the setting of an acute OI also has preventive benefit; a second OI is less likely to occur if ART is started promptly rather than delaying the initiation of ART.
*Aggressive oral and/or IV rehydration and replacement of electrolyte loss, and symptomatic treatment of diarrhea with anti- motility agent.
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" | Microsporidiosis
| style="padding: 5px 5px; background: #F5F5F5;" |
*The microsporidia reported as pathogens in humans include ''Encephalitozoon cuniculi, Encephalitozoon hellem, Encephalitozoon intestinalis, Enterocytozoon bieneusi, Trachipleistophora hominis, Trachipleistophora anthropophthera, Pleistophora species, P. ronneafiei, Vittaforma corneae, Microsporidium sp, Nosema ocularum, Anncaliia connori, Anncaliia vesicularum, and Anncaliia algerae''.
*The greatest risk of disease occurs among patients with a CD4+ <100 cells/µL
| style="padding: 5px 5px; background: #F5F5F5;" |


'''Disadvantages:'''
Clinical syndromes can vary by infecting species. The most common manifestation is diarrhea. <small>
*E. bieneusi is associated with malabsorption, diarrhea, and cholangitis.
*E. cuniculi is associated with hepatitis, encephalitis, and disseminated disease.
*E. intestinalis is associated with diarrhea, disseminated infection, and superficial keratoconjunctivitis.
*E. hellem is associated with superficial keratoconjunctivitis, sinusitis, respiratory disease, prostatic abscesses, and disseminated infection.
*Anncaliia and Trachipleistophora are associated with keratoconjunctivitis.
*Nosema, Vittaforma, and Microsporidium are associated with stromal keratitis following trauma in immunocompetent hosts.
*Pleistophora, Anncaliia, and Trachipleistophora are associated with myositis.
*Trachipleistophora is associated with encephalitis and disseminated disease.</small>
| style="padding: 5px 5px; background: #F5F5F5;" | Examination of 3 stool samples with chromotrope and chemofluorescent stains
| style="padding: 5px 5px; background: #F5F5F5;" |
*Patients who have CD4 counts <200 cells/µL should avoid untreated water sources.
*No specific chemoprophylactic regimens are known to be effective in preventing microsporidiosis.


Starting ART in the setting of an acute OI has several potential disadvantages.
| style="padding: 5px 5px; background: #F5F5F5;" |
*Severely ill patients might not absorb ART drugs, leading to subtherapeutic serum levels and the development of antiretroviral drug resistance.
*Initiate or optimize ART with immune restoration to CD4 count >100 cells/mm3
*[[Antiretroviral drug#Adverse effects|ART toxicities]] might be confused with disease manifestations or toxicities associated with drugs used for treating patients with an OI. Drug-drug interactions among ART and anti-OI drugs might be difficult to manage.
*Severe dehydration, malnutrition, and wasting should be managed by fluid support and nutritional supplements
*Renal or hepatic dysfunction during acute OIs might make dosing of ART drugs difficult to estimate.
*[[Immune reconstitution inflammatory syndrome|IRIS]] events can occur and cause manifestations that are difficult to distinguish from other clinical conditions.


'''When to start the therapy?'''
|-
| style="padding: 5px 5px; background: #F5F5F5;" colspan=6| Table adapted from Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents <ref name="Guidelines"> {{cite web| title=Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the
prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America.  Accessed Oct 2014| url=http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf }} </ref>
|}


For above mentioned reasons, no consensus has been reached concerning the optimal time to start ART in the setting of a recently diagnosed OI. However, one recently completed randomized clinical trial has demonstrated a clinical and survival benefit of starting ART early, within the first 2 weeks, of initiation of treatment for an acute OI, excluding TB.<ref name="pmid9164318">{{cite journal |author=Jacobson MA, Zegans M, Pavan PR, O'Donnell JJ, Sattler F, Rao N, Owens S, Pollard R |title=Cytomegalovirus retinitis after initiation of highly active antiretroviral therapy |journal=Lancet |volume=349 |issue=9063 |pages=1443–5 |year=1997 |month=May |pmid=9164318 |doi=10.1016/S0140-6736(96)11431-8 |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(96)11431-8 |accessdate=2012-04-06}}</ref>
==Gallery==
<gallery>
Image:Oral Candidiasis.jpg|'''Oral Candidiasis''' <br> <small> Image obtained from U.S. Department of Veterans Affairs - Image Library [http://www.hiv.va.gov/provider/image-library] (Pediatric AIDS Pictoral Atlas, Baylor International Pediatric AIDS Initiative) </small>
Image:Candida esophagitis.jpg|'''Candida esophagitis''' <br> <small> Image obtained from U.S. Department of Veterans Affairs - Image Library [http://www.hiv.va.gov/provider/image-library] (Paul A. Volberding, MD, University of California San Francisco) </small>
Image:CMV Retinitis.jpg|'''CMV Retinitis''' <br> <small> Image obtained from U.S. Department of Veterans Affairs - Image Library [http://www.hiv.va.gov/provider/image-library] (Paul A. Volberding, MD, University of California San Francisco) </small>
Image:CMV Colitis.jpg|'''CMV Colitis''' <br> <small> Image obtained from U.S. Department of Veterans Affairs - Image Library [http://www.hiv.va.gov/provider/image-library] (Paul A. Volberding, MD, University of California San Francisco) </small>
Image:Herpes simplex.jpg|'''Oral Herpes Simplex''' <br> <small> Image obtained from U.S. Department of Veterans Affairs - Image Library [http://www.hiv.va.gov/provider/image-library] (Arthur Ammann, MD, Global Strategies for HIV Prevention) </small>
Image:Genital herpes simplex.jpg|'''Genital Herpes Simplex''' <br> <small> Image obtained from U.S. Department of Veterans Affairs - Image Library [http://www.hiv.va.gov/provider/image-library] (Paul A. Volberding, MD, University of California San Francisco) </small>
Image: Condyloma acuminatum anogenital warts.jpg|'''Condyloma Acuminatum: Anogenital Warts  ''' <br> <small> Image obtained from U.S. Department of Veterans Affairs - Image Library [http://www.hiv.va.gov/provider/image-library] (Paul A. Volberding, MD, University of California San Francisco) </small>
Image: HPV cutaneous warts.jpg|'''HPV Cutaneous Warts ''' <br> <small> Image obtained from U.S. Department of Veterans Affairs - Image Library [http://www.hiv.va.gov/provider/image-library] (Pediatric AIDS Pictoral Atlas, Baylor International Pediatric AIDS Initiative) </small>
Image: Kaposi Sarcoma HHV-8.jpg|'''Kaposi Sarcoma/ HHV-8''' <br> <small> Image obtained from U.S. Department of Veterans Affairs - Image Library [http://www.hiv.va.gov/provider/image-library] (Paul A. Volberding, MD, University of California San Francisco) </small>
Image:Kaposi sarcoma angiomatous nodule.jpg|'''Kaposi Sarcoma: Angiomatous Nodule ''' <br> <small> Image obtained from U.S. Department of Veterans Affairs - Image Library [http://www.hiv.va.gov/provider/image-library] (Toby A. Maurer, MD, Timothy G. Berger, MD, University of California San Francis ) </small>
Image:PCP X-ray.jpg|'''Pneumocystis jiroveci Pneumonia <br> X-ray shows bilateral, diffuse granular opacities''' <br> <small> Image obtained from U.S. Department of Veterans Affairs - Image Library [http://www.hiv.va.gov/provider/image-library] (Laurence Huang, MD, University of California San Francisco) </small>
Image:Herpes zoster HIV.jpg|''' Herpes Zoster''' <br> <small> Image obtained from U.S. Department of Veterans Affairs - Image Library [http://www.hiv.va.gov/provider/image-library] (Paul A. Volberding, MD, University of California San Francisco) </small>
Image:Herpes zoster - HIV.jpg|'''Herpes Zoster''' <br> <small> Image obtained from U.S. Department of Veterans Affairs - Image Library [http://www.hiv.va.gov/provider/image-library] (Susanne Theresia Duerr, MD; University of Regensburg, Germany; provided courtesy of the Hôpital de Shyria, Rwanda) </small>
Image:Toxoplasma gondii retinal lesions.jpg|'''Toxoplasma gondii Retinal Lesions  ''' <br> <small> Image obtained from U.S. Department of Veterans Affairs - Image Library [http://www.hiv.va.gov/provider/image-library] (Paul A. Volberding, MD, University of California San Francisco) </small>
Image:Toxoplasma gondii CT scan showing cerebral abscess.jpg|'''Toxoplasma gondii: CT scan showing cerebral abscess''' <br> <small> Image obtained from U.S. Department of Veterans Affairs - Image Library [http://www.hiv.va.gov/provider/image-library] (Paul A. Volberding, MD, University of California San Francisco) </small>
Image:Bacillary Angiomatosis HIV.jpg|'''Bacillary Angiomatosis''' <br> <small> Image obtained from U.S. Department of Veterans Affairs - Image Library [http://www.hiv.va.gov/provider/image-library] (Paul A. Volberding, MD, University of California San Francisco) </small>
Image:Bacillary Angiomatosis HIV 2.jpg|'''Bacillary Angiomatosis''' <br> <small> Image obtained from U.S. Department of Veterans Affairs - Image Library [http://www.hiv.va.gov/provider/image-library] (Paul A. Volberding, MD, University of California San Francisco) </small>


===Management of Acute OIs in Patients Receiving ART===
OIs that occur after patients have been started on ART can be categorized into three groups.
*The '''first group''' includes OIs that occur shortly after initiating ART (within 12 weeks).
**These cases might be subclinical infections that have been unmasked by early immune reconstitution or simply OIs that occurred because of advanced immunosuppression and are not considered to represent early failure of ART. Many of these cases represent IRIS.<ref name="pmid12126821">{{cite journal |author=Egger M, May M, Chêne G, Phillips AN, Ledergerber B, Dabis F, Costagliola D, D'Arminio Monforte A, de Wolf F, Reiss P, Lundgren JD, Justice AC, Staszewski S, Leport C, Hogg RS, Sabin CA, Gill MJ, Salzberger B, Sterne JA |title=Prognosis of HIV-1-infected patients starting highly active antiretroviral therapy: a collaborative analysis of prospective studies |journal=Lancet |volume=360 |issue=9327 |pages=119–29 |year=2002 |month=July |pmid=12126821 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0140673602094114 |accessdate=2012-04-06}}</ref><ref name="pmid9457095">{{cite journal |author=Race EM, Adelson-Mitty J, Kriegel GR, Barlam TF, Reimann KA, Letvin NL, Japour AJ |title=Focal mycobacterial lymphadenitis following initiation of protease-inhibitor therapy in patients with advanced HIV-1 disease |journal=Lancet |volume=351 |issue=9098 |pages=252–5 |year=1998 |month=January |pmid=9457095 |doi=10.1016/S0140-6736(97)04352-3 |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(97)04352-3 |accessdate=2012-04-06}}</ref>
**When an OI occurs within 12 weeks of starting ART, treatment for the OI should be started and ART should be continued.
*The '''second group''' includes OIs that occur >12 weeks after initiation of ART among patients with suppressed HIV ribonucleic acid. levels and sustained CD4+ counts >200 cells/µL<ref name="pmid11015162">{{cite journal |author=Currier JS, Williams PL, Koletar SL, Cohn SE, Murphy RL, Heald AE, Hafner R, Bassily EL, Lederman HM, Knirsch C, Benson CA, Valdez H, Aberg JA, McCutchan JA |title=Discontinuation of Mycobacterium avium complex prophylaxis in patients with antiretroviral therapy-induced increases in CD4+ cell count. A randomized, double-blind, placebo-controlled trial. AIDS Clinical Trials Group 362 Study Team |journal=Ann. Intern. Med. |volume=133 |issue=7 |pages=493–503 |year=2000 |month=October |pmid=11015162 |doi= |url=http://www.annals.org/cgi/pmidlookup?view=long&pmid=11015162 |accessdate=2012-04-06}}</ref><ref name="pmid10722436">{{cite journal |author=Cinti SK, Kaul DR, Sax PE, Crane LR, Kazanjian PH |title=Recurrence of Mycobacterium avium infection in patients receiving highly active antiretroviral therapy and antimycobacterial agents |journal=Clin. Infect. Dis. |volume=30 |issue=3 |pages=511–4 |year=2000 |month=March |pmid=10722436 |doi=10.1086/313705 |url=http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=10722436 |accessdate=2012-04-06}}</ref> Determining whether these represent a form of IRIS rather than incomplete immunity with the occurrence of a new OI is difficult.
**When an OI occurs despite complete virologic suppression (i.e., late OI), therapy for the OI should be initiated and ART should be continued.
**If the CD4+ response to ART has been suboptimal, modification of the ART regimen may be considered, although no evidence exists to indicate that changing the ART regimen in this setting will improve the CD4+ response.
*The '''third group''' includes OIs that occur among patients who are experiencing virologic and immunologic failure while on ART. These represent clinical failure of ART.
**When an OI occurs in the setting of virologic failure, OI therapy should be started, antiretroviral resistance testing should be performed, and the ART regimen should be modified, if possible, to achieve better virologic control.
===Treatment Failure===
Clinical failure is defined as lack of improvement or worsening of respiratory function documented by [[arterial blood gases]] (ABGs) after at least 4--8 days of anti-PCP treatment. Treatment failure attributed to treatment-limiting toxicities occurs in up to one third of patients.<ref name="pmid8610948">{{cite journal |author=Safrin S, Finkelstein DM, Feinberg J, Frame P, Simpson G, Wu A, Cheung T, Soeiro R, Hojczyk P, Black JR |title=Comparison of three regimens for treatment of mild to moderate Pneumocystis carinii pneumonia in patients with AIDS. A double-blind, randomized, trial of oral trimethoprim-sulfamethoxazole, dapsone-trimethoprim, and clindamycin-primaquine. ACTG 108 Study Group |journal=Ann. Intern. Med. |volume=124 |issue=9 |pages=792–802 |year=1996 |month=May |pmid=8610948 |doi= |url= |accessdate=2012-04-07}}</ref>


==Special Considerations During Pregnancy==
Image: HIV_opportunistic01.jpeg| '''Chlamydia psittaci'''. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Physiologic changes during pregnancy can complicate the recognition of OIs and complicate pharmacokinetics. Factors to consider include the following:


* Increased cardiac output by 30%--50% with concomitant increase in glomerular filtration rate and renal clearance.
Image: HIV_opportunistic02.jpeg| '''Candidemia (Bloodstream infection with Candida)'''. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
* Increased plasma volume by 45%--50% while red cell mass increases only by 20%--30%, leading to dilutional anemia.
* Tidal volume and pulmonary blood flow increase, possibly leading to increased absorption of aerosolized medications. The tidal volume increase of 30%--40% should be considered if ventilatory assistance is required.
* Placental transfer of drugs, increased renal clearance, altered gastrointestinal absorption, and metabolism by the fetus might affect maternal drug levels.
* Limited pharmacokinetic data are available; use usual adult doses based on current weight, monitor levels if available, and consider the need to increase doses if the patient is not responding as expected.


Also in regards with risk in '''Fetus''', pregnancy should not preclude usual diagnostic evaluation when an OI is suspected.<ref name="pmid15339791">{{cite journal |author= |title=ACOG Committee Opinion. Number 299, September 2004 (replaces No. 158, September 1995). Guidelines for diagnostic imaging during pregnancy |journal=Obstet Gynecol |volume=104 |issue=3 |pages=647–51 |year=2004 |month=September |pmid=15339791 |doi= |url= |accessdate=2012-04-06}}</ref><ref name="pmid10208701">{{cite journal |author=Toppenberg KS, Hill DA, Miller DP |title=Safety of radiographic imaging during pregnancy |journal=Am Fam Physician |volume=59 |issue=7 |pages=1813–8, 1820 |year=1999 |month=April |pmid=10208701 |doi= |url=http://www.aafp.org/link_out?pmid=10208701 |accessdate=2012-04-06}}</ref><ref name="pmid10331526">{{cite journal |author=Adelstein SJ |title=Administered radionuclides in pregnancy |journal=Teratology |volume=59 |issue=4 |pages=236–9 |year=1999 |month=April |pmid=10331526 |doi=10.1002/(SICI)1096-9926(199904)59:4<236::AID-TERA9>3.0.CO;2-6 |url=http://dx.doi.org/10.1002/(SICI)1096-9926(199904)59:4<236::AID-TERA9>3.0.CO;2-6 |accessdate=2012-04-06}}</ref> Experience with use of magnetic resonance imaging (MRI) in pregnancy is limited, but no adverse fetal effects have been noted.<ref name="pmid15339791">{{cite journal |author= |title=ACOG Committee Opinion. Number 299, September 2004 (replaces No. 158, September 1995). Guidelines for diagnostic imaging during pregnancy |journal=Obstet Gynecol |volume=104 |issue=3 |pages=647–51 |year=2004 |month=September |pmid=15339791 |doi= |url= |accessdate=2012-04-06}}</ref>
Image: HIV_opportunistic04.jpeg| '''Candidiasis in kidney tissue'''. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>


==Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents==
Image: HIV_opportunistic05.jpeg| '''Candidiasis in kidney tissue'''. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Outline of the Guideline:


'''I:  [[HIV opportunistic infections#Pneumocystis Pneumonia|Pneumocystis Pneumonia ]]'''
Image: HIV_opportunistic06.jpeg| '''Kaposi’s sarcoma due to human herpesvirus 8 (HHV8)'''. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
*[[HIV opportunistic infections#Preventing Exposure|Preventing Exposure]]
*[[HIV opportunistic infections#Preventing Disease|Preventing Disease]]
**[[HIV opportunistic infections#Initiating Primary Prophylaxis|Initiating Primary Prophylaxis]]
**[[HIV opportunistic infections#Discontinuing Primary Prophylaxis|Discontinuing Primary Prophylaxis]]
*[[HIV opportunistic infections#Treatment of Disease|Treatment of Disease]]
*[[HIV opportunistic infections#Monitoring and Adverse Events, Including Immune Reconstitution Inflammatory Syndrome (IRIS)|Monitoring and Adverse Events, Including Immune Reconstitution Inflammatory Syndrome (IRIS)]]
*[[HIV opportunistic infections#Management of Treatment Failure|Management of Treatment Failure]]
*[[HIV opportunistic infections#Preventing Recurrence|Preventing Recurrence]]
*[[HIV opportunistic infections#Discontinuing Secondary Prophylaxis (Chronic Maintenance Therapy)|Discontinuing Secondary Prophylaxis (Chronic Maintenance Therapy)]]
*[[HIV opportunistic infections#Pneumocystis Pneumonia: Special considerations during pregnancy|Special Considerations During Pregnancy]]


'''II: [[HIV opportunistic infections#Toxoplasma gondii Encephalitis|Toxoplasma gondii Encephalitis]]'''
Image: HIV_opportunistic07.jpeg| '''Penicillium marneffei yeast cells in human spleen'''. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
*[[HIV opportunistic infections#Toxoplasma gondii: Preventing Exposure|Preventing Exposure]]


*[[HIV opportunistic infections#Toxoplasma gondii: Preventing Disease|Preventing Disease]]
Image: HIV_opportunistic08.jpeg| '''Gram-positive Mycobacterium tuberculosis bacteria'''. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
**[[HIV opportunistic infections#Toxoplasma gondii: Initiating Primary Prophylaxis|Initiating Primary Prophylaxis]]
**[[HIV opportunistic infections#Toxoplasma gondii: Discontinuing Primary Prophylaxis|Discontinuing Primary Prophylaxis]]
*[[HIV opportunistic infections#Toxoplasma gondii: Treatment of Disease|Treatment of Disease]]


Image: HIV_opportunistic09.jpeg| '''Gram-positive Mycobacterium tuberculosis bacteria'''. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>


Image: HIV_opportunistic10.jpeg| '''Streptococcus anginosus bacteria'''. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>


===Disease Specific Recommendations===
Image: HIV_opportunistic11.jpeg| '''Intraoral Kaposi’s sarcoma with candidiasis infection'''. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
====Pneumocystis Pneumonia====


=====Preventing Exposure=====
Image: HIV_opportunistic12.jpeg| '''Oral pseudomembraneous candidiasis infection'''. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Certain authorities might recommend that persons who are at risk for PCP not share a hospital room with a patient who has PCP, a recommendations based on animal studies and anecdotal human experience. Data are insufficient to support this recommendation as standard practice ('''CIII''').
</gallery>


=====Preventing Disease=====
==References==
======Initiating Primary Prophylaxis======
{{reflist|2}}
*HIV-infected adults and adolescents, including pregnant women and those on ART, should receive chemoprophylaxis against PCP if they have a CD4+ count of <200 cells/µL ('''AI''') or a history of oropharyngeal candidiasis ('''AII''').<ref name="pmid1967190">{{cite journal |author=Phair J, Muñoz A, Detels R, Kaslow R, Rinaldo C, Saah A |title=The risk of Pneumocystis carinii pneumonia among men infected with human immunodeficiency virus type 1. Multicenter AIDS Cohort Study Group |journal=N. Engl. J. Med. |volume=322 |issue=3 |pages=161–5 |year=1990 |month=January |pmid=1967190 |doi=10.1056/NEJM199001183220304 |url=http://dx.doi.org/10.1056/NEJM199001183220304 |accessdate=2012-04-06}}</ref><ref name="pmid9806044">{{cite journal |author=Kaplan JE, Hanson DL, Navin TR, Jones JL |title=Risk factors for primary Pneumocystis carinii pneumonia in human immunodeficiency virus-infected adolescents and adults in the United States: reassessment of indications for chemoprophylaxis |journal=J. Infect. Dis. |volume=178 |issue=4 |pages=1126–32 |year=1998 |month=October |pmid=9806044 |doi= |url=http://www.jid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=9806044 |accessdate=2012-04-06}}</ref>
*Persons who have a CD4+ cell percentage of <14% or a history of an AIDS-defining illness, but do not otherwise qualify, should be considered for prophylaxis ('''BII'''). <ref name="pmid1967190">{{cite journal |author=Phair J, Muñoz A, Detels R, Kaslow R, Rinaldo C, Saah A|title=The risk of Pneumocystis carinii pneumonia among men infected with human immunodeficiency virus type 1. Multicenter AIDS Cohort Study Group |journal=N. Engl. J. Med. |volume=322 |issue=3 |pages=161–5 |year=1990|month=January |pmid=1967190 |doi=10.1056/NEJM199001183220304 |url=http://dx.doi.org/10.1056/NEJM199001183220304|accessdate=2012-04-06}}</ref><ref name="pmid9806044">{{cite journal |author=Kaplan JE, Hanson DL, Navin TR, Jones JL|title=Risk factors for primary Pneumocystis carinii pneumonia in human immunodeficiency virus-infected adolescents and adults in the United States: reassessment of indications for chemoprophylaxis |journal=J. Infect. Dis.|volume=178 |issue=4 |pages=1126–32 |year=1998 |month=October |pmid=9806044 |doi=|url=http://www.jid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=9806044 |accessdate=2012-04-06}}</ref>
*When monitoring CD4+ counts frequently (e.g., every 1--3 months) is not possible, initiating chemoprophylaxis at a CD4+ count of >200, but <250 cells/µL, also should be considered ('''BII'''). <ref name="pmid9806044">{{cite journal |author=Kaplan JE, Hanson DL, Navin TR, Jones JL |title=Risk factors for primary Pneumocystis carinii pneumonia in human immunodeficiency virus-infected adolescents and adults in the United States: reassessment of indications for chemoprophylaxis |journal=J. Infect. Dis. |volume=178 |issue=4 |pages=1126–32 |year=1998 |month=October |pmid=9806044 |doi=|url=http://www.jid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=9806044 |accessdate=2012-04-06}}</ref>
*[[TMP-SMX]] is the recommended prophylactic agent ('''AI''').<ref name="pmid7854375">{{cite journal |author=Bozzette SA, Finkelstein DM, Spector SA, Frame P, Powderly WG, He W, Phillips L, Craven D, van der Horst C, Feinberg J |title=A randomized trial of three antipneumocystis agents in patients with advanced human immunodeficiency virus infection. NIAID AIDS Clinical Trials Group |journal=N. Engl. J. Med. |volume=332 |issue=11 |pages=693–9 |year=1995 |month=March |pmid=7854375 |doi=10.1056/NEJM199503163321101 |url=http://dx.doi.org/10.1056/NEJM199503163321101 |accessdate=2012-04-06}}</ref><ref name="pmid1360145">{{cite journal |author=Schneider MM, Hoepelman AI, Eeftinck Schattenkerk JK, Nielsen TL, van der Graaf Y, Frissen JP, van der Ende IM, Kolsters AF, Borleffs JC |title=A controlled trial of aerosolized pentamidine or trimethoprim-sulfamethoxazole as primary prophylaxis against Pneumocystis carinii pneumonia in patients with human immunodeficiency virus infection. The Dutch AIDS Treatment Group |journal=N. Engl. J. Med. |volume=327 |issue=26 |pages=1836–41 |year=1992 |month=December |pmid=1360145 |doi=10.1056/NEJM199212243272603 |url=http://dx.doi.org/10.1056/NEJM199212243272603 |accessdate=2012-04-06}}</ref><ref name="pmid7769306">{{cite journal |author=Schneider MM, Nielsen TL, Nelsing S, Hoepelman AI, Eeftinck Schattenkerk JK, van der Graaf Y, Kolsters AF, Borleffs JC |title=Efficacy and toxicity of two doses of trimethoprim-sulfamethoxazole as primary prophylaxis against Pneumocystis carinii pneumonia in patients with human immunodeficiency virus. Dutch AIDS Treatment Group |journal=J. Infect. Dis. |volume=171 |issue=6 |pages=1632–6 |year=1995 |month=June |pmid=7769306 |doi= |url=http://www.jid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=7769306 |accessdate=2012-04-06}}</ref> One double-strength tablet daily is the preferred regimen ('''AI'''). However, one single-strength tablet daily also is effective and might be better tolerated than one double-strength tablet daily ('''AI''').<ref name="pmid7769306">{{cite journal |author=Schneider MM, Nielsen TL, Nelsing S, Hoepelman AI, Eeftinck Schattenkerk JK, van der Graaf Y, Kolsters AF, Borleffs JC |title=Efficacy and toxicity of two doses of trimethoprim-sulfamethoxazole as primary prophylaxis against Pneumocystis carinii pneumonia in patients with human immunodeficiency virus. Dutch AIDS Treatment Group |journal=J. Infect. Dis. |volume=171 |issue=6 |pages=1632–6 |year=1995 |month=June |pmid=7769306 |doi= |url=http://www.jid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=7769306 |accessdate=2012-04-06}}</ref> One double-strength tablet three times weekly also is effective ('''BI''')<ref name="pmid10589887">{{cite journal |author=El-Sadr WM, Luskin-Hawk R, Yurik TM, Walker J, Abrams D, John SL, Sherer R, Crane L, Labriola A, Caras S, Pulling C, Hafner R |title=A randomized trial of daily and thrice-weekly trimethoprim-sulfamethoxazole for the prevention of Pneumocystis carinii pneumonia in human immunodeficiency virus-infected persons. Terry Beirn Community Programs for Clinical Research on AIDS (CPCRA) |journal=Clin. Infect. Dis. |volume=29 |issue=4 |pages=775–83 |year=1999 |month=October |pmid=10589887 |doi=10.1086/520433 |url=http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=10589887 |accessdate=2012-04-06}}</ref>.  TMP-SMX at a dose of one double-strength tablet daily confers cross-protection against toxoplasmosis<ref name="pmid1351371">{{cite journal |author=Carr A, Tindall B, Brew BJ, Marriott DJ, Harkness JL, Penny R, Cooper DA |title=Low-dose trimethoprim-sulfamethoxazole prophylaxis for toxoplasmic encephalitis in patients with AIDS |journal=Ann. Intern. Med. |volume=117 |issue=2 |pages=106–11 |year=1992 |month=July |pmid=1351371 |doi= |url= |accessdate=2012-04-06}}</ref> and selected common respiratory bacterial infections.<ref name="pmid7854375">{{cite journal|author=Bozzette SA, Finkelstein DM, Spector SA, Frame P, Powderly WG, He W, Phillips L, Craven D, van der Horst C, Feinberg J |title=A randomized trial of three antipneumocystis agents in patients with advanced human immunodeficiency virus infection. NIAID AIDS Clinical Trials Group |journal=N. Engl. J. Med. |volume=332 |issue=11|pages=693–9 |year=1995 |month=March |pmid=7854375 |doi=10.1056/NEJM199503163321101|url=http://dx.doi.org/10.1056/NEJM199503163321101 |accessdate=2012-04-06}}</ref><ref name="pmid1448121">{{cite journal |author=Hardy WD, Feinberg J, Finkelstein DM, Power ME, He W, Kaczka C, Frame PT, Holmes M, Waskin H, Fass RJ |title=A controlled trial of trimethoprim-sulfamethoxazole or aerosolized pentamidine for secondary prophylaxis of Pneumocystis carinii pneumonia in patients with the acquired immunodeficiency syndrome. AIDS Clinical Trials Group Protocol 021 |journal=N. Engl. J. Med. |volume=327 |issue=26 |pages=1842–8 |year=1992 |month=December |pmid=1448121 |doi=10.1056/NEJM199212243272604 |url=http://dx.doi.org/10.1056/NEJM199212243272604 |accessdate=2012-04-06}}</ref> Lower doses of TMP-SMX also likely confer such protection. For patients who have an adverse reaction that is not life threatening, chemoprophylaxis with TMP-SMX should be continued if clinically feasible; for those who have discontinued such therapy because of an adverse reaction, reinstituting TMP-SMX should be strongly considered after the adverse event has resolved ('''AII'''). Patients who have experienced adverse events, including fever and rash, might better tolerate reintroduction of the drug with a gradual increase in dose (i.e., [[desensitization]]), according to published regimens ('''BI''') <ref name="pmid11015150">{{cite journal |author=Para MF, Finkelstein D, Becker S, Dohn M, Walawander A, Black JR |title=Reduced toxicity with gradual initiation of trimethoprim-sulfamethoxazole as primary prophylaxis for Pneumocystis carinii pneumonia: AIDS Clinical Trials Group 268 |journal=J. Acquir. Immune Defic. Syndr. |volume=24 |issue=4 |pages=337–43 |year=2000 |month=August |pmid=11015150 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=1525-4135&volume=24&issue=4&spage=337 |accessdate=2012-04-06}}</ref><ref name="pmid11574913">{{cite journal |author=Leoung GS, Stanford JF, Giordano MF, Stein A, Torres RA, Giffen CA, Wesley M, Sarracco T, Cooper EC, Dratter V, Smith JJ, Frost KR |title=Trimethoprim-sulfamethoxazole (TMP-SMZ) dose escalation versus direct rechallenge for Pneumocystis Carinii pneumonia prophylaxis in human immunodeficiency virus-infected patients with previous adverse reaction to TMP-SMZ |journal=J. Infect. Dis. |volume=184 |issue=8 |pages=992–7 |year=2001 |month=October |pmid=11574913 |doi=10.1086/323353 |url=http://www.jid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=11574913 |accessdate=2012-04-06}}</ref> or reintroduction of TMP-SMX at a reduced dose or frequency ('''CIII'''); as many as 70% of patients can tolerate such reinstitution of therapy.<ref name="pmid1448121">{{cite journal |author=Hardy WD, Feinberg J, Finkelstein DM, Power ME, He W, Kaczka C, Frame PT, Holmes M, Waskin H, Fass RJ |title=A controlled trial of trimethoprim-sulfamethoxazole or aerosolized pentamidine for secondary prophylaxis of Pneumocystis carinii pneumonia in patients with the acquired immunodeficiency syndrome. AIDS Clinical Trials Group Protocol 021|journal=N. Engl. J. Med. |volume=327 |issue=26 |pages=1842–8 |year=1992 |month=December |pmid=1448121|doi=10.1056/NEJM199212243272604 |url=http://dx.doi.org/10.1056/NEJM199212243272604 |accessdate=2012-04-06}}</ref>
*If TMP-SMX cannot be tolerated, alternative prophylactic regimens include [[dapsone]] ('''BI''')<ref name="pmid7854375">{{cite journal |author=Bozzette SA, Finkelstein DM, Spector SA, Frame P, Powderly WG, He W, Phillips L, Craven D, van der Horst C, Feinberg J |title=A randomized trial of three antipneumocystis agents in patients with advanced human immunodeficiency virus infection. NIAID AIDS Clinical Trials Group |journal=N. Engl. J. Med. |volume=332 |issue=11 |pages=693–9 |year=1995 |month=March |pmid=7854375 |doi=10.1056/NEJM199503163321101 |url=http://dx.doi.org/10.1056/NEJM199503163321101 |accessdate=2012-04-06}}</ref>, dapsone plus [[pyrimethamine]] plus [[leucovorin]] ('''BI''')<ref name="pmid7717598">{{cite journal |author=Podzamczer D, Salazar A, Jiménez J, Consiglio E, Santín M, Casanova A, Rufí G, Gudiol F |title=Intermittent trimethoprim-sulfamethoxazole compared with dapsone-pyrimethamine for the simultaneous primary prophylaxis of Pneumocystis pneumonia and toxoplasmosis in patients infected with HIV |journal=Ann. Intern. Med. |volume=122 |issue=10 |pages=755–61 |year=1995 |month=May |pmid=7717598 |doi= |url= |accessdate=2012-04-06}}</ref><ref name="pmid7756472">{{cite journal |author=Opravil M, Hirschel B, Lazzarin A, Heald A, Pechère M, Rüttimann S, Iten A, von Overbeck J, Oertle D, Praz G |title=Once-weekly administration of dapsone/pyrimethamine vs. aerosolized pentamidine as combined prophylaxis for Pneumocystis carinii pneumonia and toxoplasmic encephalitis in human immunodeficiency virus-infected patients |journal=Clin. Infect. Dis. |volume=20 |issue=3 |pages=531–41 |year=1995 |month=March |pmid=7756472 |doi= |url=http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=7756472 |accessdate=2012-04-06}}</ref><ref name="pmid8479488">{{cite journal |author=Girard PM, Landman R, Gaudebout C, Olivares R, Saimot AG, Jelazko P, Gaudebout C, Certain A, Boué F, Bouvet E |title=Dapsone-pyrimethamine compared with aerosolized pentamidine as primary prophylaxis against Pneumocystis carinii pneumonia and toxoplasmosis in HIV infection. The PRIO Study Group |journal=N. Engl. J. Med. |volume=328 |issue=21 |pages=1514–20 |year=1993 |month=May |pmid=8479488 |doi=10.1056/NEJM199305273282102 |url=http://dx.doi.org/10.1056/NEJM199305273282102 |accessdate=2012-04-06}}</ref>, [[erosolized]] [[pentamidine]] administered by the Respirgard II nebulizer (manufactured by Marquest, Englewood, Colorado) ('''BI''')<ref name="pmid1360145">{{cite journal |author=Schneider MM, Hoepelman AI, Eeftinck Schattenkerk JK, Nielsen TL, van der Graaf Y, Frissen JP, van der Ende IM, Kolsters AF, Borleffs JC |title=A controlled trial of aerosolized pentamidine or trimethoprim-sulfamethoxazole as primary prophylaxis against Pneumocystis carinii pneumonia in patients with human immunodeficiency virus infection. The Dutch AIDS Treatment Group |journal=N. Engl. J. Med. |volume=327 |issue=26 |pages=1836–41 |year=1992 |month=December |pmid=1360145 |doi=10.1056/NEJM199212243272603 |url=http://dx.doi.org/10.1056/NEJM199212243272603 |accessdate=2012-04-06}}</ref>, and atovaquone ('''BI''')<ref name="pmid10395851">{{cite journal |author=Chan C, Montaner J, Lefebvre EA, Morey G, Dohn M, McIvor RA, Scott J, Marina R, Caldwell P |title=Atovaquone suspension compared with aerosolized pentamidine for prevention of Pneumocystis carinii pneumonia in human immunodeficiency virus-infected subjects intolerant of trimethoprim or sulfonamides |journal=J. Infect. Dis. |volume=180 |issue=2 |pages=369–76 |year=1999 |month=August |pmid=10395851 |doi=10.1086/314893 |url=http://www.jid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=10395851 |accessdate=2012-04-06}}</ref><ref name="pmid9862944">{{cite journal |author=El-Sadr WM, Murphy RL, Yurik TM, Luskin-Hawk R, Cheung TW, Balfour HH, Eng R, Hooton TM, Kerkering TM, Schutz M, van der Horst C, Hafner R |title=Atovaquone compared with dapsone for the prevention of Pneumocystis carinii pneumonia in patients with HIV infection who cannot tolerate trimethoprim, sulfonamides, or both. Community Program for Clinical Research on AIDS and the AIDS Clinical Trials Group |journal=N. Engl. J. Med. |volume=339 |issue=26 |pages=1889–95 |year=1998 |month=December |pmid=9862944 |doi=10.1056/NEJM199812243392604 |url=http://dx.doi.org/10.1056/NEJM199812243392604 |accessdate=2012-04-06}}</ref> Atovaquone is as effective as aerosolized pentamidine<ref name="pmid10395851">{{cite journal |author=Chan C, Montaner J, Lefebvre EA, Morey G, Dohn M, McIvor RA, Scott J, Marina R, Caldwell P |title=Atovaquone suspension compared with aerosolized pentamidine for prevention of Pneumocystis carinii pneumonia in human immunodeficiency virus-infected subjects intolerant of trimethoprim or sulfonamides |journal=J. Infect. Dis. |volume=180 |issue=2 |pages=369–76 |year=1999 |month=August |pmid=10395851 |doi=10.1086/314893 |url=http://www.jid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=10395851 |accessdate=2012-04-06}}</ref> or dapsone (BI) <ref name="pmid9862944">{{cite journal |author=El-Sadr WM, Murphy RL, Yurik TM, Luskin-Hawk R, Cheung TW, Balfour HH, Eng R, Hooton TM, Kerkering TM, Schutz M, van der Horst C, Hafner R|title=Atovaquone compared with dapsone for the prevention of Pneumocystis carinii pneumonia in patients with HIV infection who cannot tolerate trimethoprim, sulfonamides, or both. Community Program for Clinical Research on AIDS and the AIDS Clinical Trials Group |journal=N. Engl. J. Med. |volume=339 |issue=26 |pages=1889–95 |year=1998|month=December |pmid=9862944 |doi=10.1056/NEJM199812243392604 |url=http://dx.doi.org/10.1056/NEJM199812243392604|accessdate=2012-04-06}}</ref> but is substantially more expensive than the other regimens. For patients seropositive for Toxoplasma gondii who cannot tolerate TMP-SMX, recommended alternatives to TMP-SMX for prophylaxis against both PCP and toxoplasmosis include dapsone plus pyrimethamine plus leucovorin ('''BI''')<ref name="pmid7717598">{{cite journal |author=Podzamczer D, Salazar A, Jiménez J, Consiglio E, Santín M, Casanova A, Rufí G, Gudiol F |title=Intermittent trimethoprim-sulfamethoxazole compared with dapsone-pyrimethamine for the simultaneous primary prophylaxis of Pneumocystis pneumonia and toxoplasmosis in patients infected with HIV |journal=Ann. Intern. Med. |volume=122 |issue=10 |pages=755–61 |year=1995 |month=May |pmid=7717598 |doi= |url= |accessdate=2012-04-06}}</ref><ref name="pmid7756472">{{cite journal |author=Opravil M, Hirschel B, Lazzarin A, Heald A, Pechère M, Rüttimann S, Iten A, von Overbeck J, Oertle D, Praz G |title=Once-weekly administration of dapsone/pyrimethamine vs. aerosolized pentamidine as combined prophylaxis for Pneumocystis carinii pneumonia and toxoplasmic encephalitis in human immunodeficiency virus-infected patients |journal=Clin. Infect. Dis. |volume=20 |issue=3 |pages=531–41 |year=1995 |month=March |pmid=7756472 |doi= |url=http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=7756472 |accessdate=2012-04-06}}</ref><ref name="pmid8479488">{{cite journal |author=Girard PM, Landman R, Gaudebout C, Olivares R, Saimot AG, Jelazko P, Gaudebout C, Certain A, Boué F, Bouvet E |title=Dapsone-pyrimethamine compared with aerosolized pentamidine as primary prophylaxis against Pneumocystis carinii pneumonia and toxoplasmosis in HIV infection. The PRIO Study Group |journal=N. Engl. J. Med. |volume=328 |issue=21 |pages=1514–20 |year=1993 |month=May |pmid=8479488 |doi=10.1056/NEJM199305273282102 |url=http://dx.doi.org/10.1056/NEJM199305273282102 |accessdate=2012-04-06}}</ref>, [[erosolized]] [[pentamidine]] administered by the Respirgard II nebulizer (manufactured by Marquest, Englewood, Colorado) ('''BI''')<ref name="pmid1360145">{{cite journal |author=Schneider MM, Hoepelman AI, Eeftinck Schattenkerk JK, Nielsen TL, van der Graaf Y, Frissen JP, van der Ende IM, Kolsters AF, Borleffs JC |title=A controlled trial of aerosolized pentamidine or trimethoprim-sulfamethoxazole as primary prophylaxis against Pneumocystis carinii pneumonia in patients with human immunodeficiency virus infection. The Dutch AIDS Treatment Group |journal=N. Engl. J. Med. |volume=327 |issue=26 |pages=1836–41 |year=1992 |month=December |pmid=1360145 |doi=10.1056/NEJM199212243272603 |url=http://dx.doi.org/10.1056/NEJM199212243272603 |accessdate=2012-04-06}}</ref>, and atovaquone ('''BI''')<ref name="pmid10395851">{{cite journal |author=Chan C, Montaner J, Lefebvre EA, Morey G, Dohn M, McIvor RA, Scott J, Marina R, Caldwell P |title=Atovaquone suspension compared with aerosolized pentamidine for prevention of Pneumocystis carinii pneumonia in human immunodeficiency virus-infected subjects intolerant of trimethoprim or sulfonamides |journal=J. Infect. Dis. |volume=180 |issue=2 |pages=369–76 |year=1999 |month=August |pmid=10395851 |doi=10.1086/314893 |url=http://www.jid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=10395851 |accessdate=2012-04-06}}</ref><ref name="pmid9862944">{{cite journal |author=El-Sadr WM, Murphy RL, Yurik TM, Luskin-Hawk R, Cheung TW, Balfour HH, Eng R, Hooton TM, Kerkering TM, Schutz M, van der Horst C, Hafner R |title=Atovaquone compared with dapsone for the prevention of Pneumocystis carinii pneumonia in patients with HIV infection who cannot tolerate trimethoprim, sulfonamides, or both. Community Program for Clinical Research on AIDS and the AIDS Clinical Trials Group |journal=N. Engl. J. Med. |volume=339 |issue=26 |pages=1889–95 |year=1998 |month=December |pmid=9862944 |doi=10.1056/NEJM199812243392604 |url=http://dx.doi.org/10.1056/NEJM199812243392604 |accessdate=2012-04-06}}</ref> or atovaquone with or without pyrimethamine plus leucovorin ('''CIII''').
*Oral pyrimethamine plus sulfadoxine also has activity in preventing PCP ('''CIII''')<ref name="pmid12072919">{{cite journal |author=Schürmann D, Bergmann F, Albrecht H, Padberg J, Wünsche T, Grünewald T, Schürmann M, Grobusch M, Vallée M, Ruf B, Suttorp N |title=Effectiveness of twice-weekly pyrimethamine-sulfadoxine as primary prophylaxis of Pneumocystis carinii pneumonia and toxoplasmic encephalitis in patients with advanced HIV infection |journal=Eur. J. Clin. Microbiol. Infect. Dis. |volume=21 |issue=5 |pages=353–61 |year=2002 |month=May |pmid=12072919 |doi=10.1007/s10096-002-0723-3 |url=http://dx.doi.org/10.1007/s10096-002-0723-3 |accessdate=2012-04-06}}</ref><ref name="pmid9863502">{{cite journal |author=Payen MC, De Wit S, Sommereijns B, Clumeck N |title=A controlled trial of dapsone versus pyrimethamine-sulfadoxine for primary prophylaxis of Pneumocystis carinii pneumonia and toxoplasmosis in patients with AIDS |journal=Biomed. Pharmacother. |volume=51 |issue=10 |pages=439–45 |year=1997 |pmid=9863502 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0753332297823220 |accessdate=2012-04-06}}</ref><ref name="pmid11243747">{{cite journal |author=Schürmann D, Bergmann F, Albrecht H, Padberg J, Grünewald T, Behnsch M, Grobusch M, Vallée M, Wünsche T, Ruf B, Suttorp N |title=Twice-weekly pyrimethamine-sulfadoxine effectively prevents Pneumocystis carinii pneumonia relapse and toxoplasmic encephalitis in patients with AIDS |journal=J. Infect. |volume=42 |issue=1 |pages=8–15 |year=2001 |month=January |pmid=11243747 |doi=10.1053/jinf.2000.0772 |url=http://linkinghub.elsevier.com/retrieve/pii/S0163-4453(00)90772-2 |accessdate=2012-04-06}}</ref> This combination should not be used in patients with hypersensitivity to sulfonamides. Pyrimethamine plus sulfadoxine has an increased risk for severe cutaneous reactions, including [[Stevens-Johnson syndrome]]<ref name="pmid2860516">{{cite journal |author=Navin TR, Miller KD, Satriale RF, Lobel HO |title=Adverse reactions associated with pyrimethamine-sulfadoxine prophylaxis for Pneumocystis carinii infections in AIDS |journal=Lancet |volume=1 |issue=8441 |pages=1332 |year=1985 |month=June |pmid=2860516 |doi= |url= |accessdate=2012-04-06}}</ref>, and the long half-life of both pyrimethamine and sulfadoxine will result in a delayed clearance when the drug is stopped. Largely because TMP-SMX has superior safety, widespread availability, and is low cost, oral pyrimethamine plus sulfadoxine should be used rarely in the United States ('''CIII''').
*The following regimens cannot be recommended as alternatives because data regarding their efficacy for PCP prophylaxis are insufficient:
** Aerosolized pentamidine administered by other nebulization devices.
** Intermittently administered parenteral pentamidine.
** Oral clindamycin plus primaquine.
However, clinicians might consider using these agents in unusual situations in which the recommended agents cannot be administered ('''CIII''').
======Discontinuing Primary Prophylaxis======
*Primary pneumocystis prophylaxis should be discontinued for adult and adolescent patients who have responded to ART with an increase in CD4+ counts to >200 cells/µL for >3 months ('''AI'''). In observational and randomized studies supporting this recommendation, the majority of patients were taking antiretroviral regimens that included a protease inhibitor (PI), and the majority had a CD4+ count of >200 cells/µL for >3 months before discontinuing PCP prophylaxis.<ref name="pmid10915098">{{cite journal |author=Dworkin MS, Hanson DL, Kaplan JE, Jones JL, Ward JW |title=Risk for preventable opportunistic infections in persons with AIDS after antiretroviral therapy increases CD4+ T lymphocyte counts above prophylaxis thresholds |journal=J. Infect. Dis. |volume=182 |issue=2 |pages=611–5 |year=2000 |month=August |pmid=10915098 |doi=10.1086/315734 |url=http://www.jid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=10915098 |accessdate=2012-04-06}}</ref><ref name="pmid10823763">{{cite journal |author=Mussini C, Pezzotti P, Govoni A, Borghi V, Antinori A, d'Arminio Monforte A, De Luca A, Mongiardo N, Cerri MC, Chiodo F, Concia E, Bonazzi L, Moroni M, Ortona L, Esposito R, Cossarizza A, De Rienzo B |title=Discontinuation of primary prophylaxis for Pneumocystis carinii pneumonia and toxoplasmic encephalitis in human immunodeficiency virus type I-infected patients: the changes in opportunistic prophylaxis study |journal=J. Infect. Dis. |volume=181 |issue=5 |pages=1635–42 |year=2000 |month=May |pmid=10823763 |doi=10.1086/315471 |url=http://www.jid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=10823763 |accessdate=2012-04-06}}</ref>  The median CD4+ count at the time prophylaxis was discontinued was >300 cells/µL, most had a CD4+ cell percentage of >14 %, and many patients had a sustained suppression of HIV plasma RNA levels below detection limits of the assay employed. Median follow-up was 6 - 19 months.
 
*Discontinuing primary prophylaxis among these patients is recommended because prophylaxis adds limited disease prevention (i.e., for PCP, toxoplasmosis, or bacterial infections).<ref name="pmid10823763">{{cite journal |author=Mussini C, Pezzotti P, Govoni A, Borghi V, Antinori A, d'Arminio Monforte A, De Luca A, Mongiardo N, Cerri MC, Chiodo F, Concia E, Bonazzi L, Moroni M, Ortona L, Esposito R, Cossarizza A, De Rienzo B |title=Discontinuation of primary prophylaxis for Pneumocystis carinii pneumonia and toxoplasmic encephalitis in human immunodeficiency virus type I-infected patients: the changes in opportunistic prophylaxis study |journal=J. Infect. Dis. |volume=181 |issue=5 |pages=1635–42|year=2000 |month=May |pmid=10823763 |doi=10.1086/315471 |url=http://www.jid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=10823763 |accessdate=2012-04-06}}</ref><ref name="pmid11172138">{{cite journal |author=Lopez Bernaldo de Quiros JC, Miro JM, Peña JM, Podzamczer D, Alberdi JC, Martínez E, Cosin J, Claramonte X, Gonzalez J, Domingo P, Casado JL, Ribera E |title=A randomized trial of the discontinuation of primary and secondary prophylaxis against Pneumocystis carinii pneumonia after highly active antiretroviral therapy in patients with HIV infection. Grupo de Estudio del SIDA 04/98 |journal=N. Engl. J. Med. |volume=344 |issue=3 |pages=159–67 |year=2001 |month=January |pmid=11172138 |doi=10.1056/NEJM200101183440301 |url=http://dx.doi.org/10.1056/NEJM200101183440301 |accessdate=2012-04-06}}</ref>
 
*Prophylaxis should be reintroduced if the CD4+ count decreases to <200 cells/µL ('''AIII''').
=====Treatment of Disease=====
*TMP-SMX is the treatment of choice ('''AI''').<ref name="pmid8479489">{{cite journal |author=Hughes W, Leoung G, Kramer F, Bozzette SA, Safrin S, Frame P, Clumeck N, Masur H, Lancaster D, Chan C |title=Comparison of atovaquone (566C80) with trimethoprim-sulfamethoxazole to treat Pneumocystis carinii pneumonia in patients with AIDS |journal=N. Engl. J. Med. |volume=328 |issue=21 |pages=1521–7 |year=1993 |month=May |pmid=8479489 |doi=10.1056/NEJM199305273282103 |url=http://dx.doi.org/10.1056/NEJM199305273282103 |accessdate=2012-04-06}}</ref> The dose must be adjusted for abnormal renal function. Multiple randomized clinical trials indicate that TMP-SMX is as effective as parenteral pentamidine and more effective than other regimens. Adding leucovorin to prevent myelosuppression during acute treatment is not recommended because of questionable efficacy and some evidence for a higher failure rate ('''DII'''). Oral outpatient therapy of TMP-SMX is highly effective among patients with mild-to-moderate disease ('''AI''').
 
*Mutations associated with resistance to sulfa drugs have been documented, but their effect on clinical outcome is uncertain. Patients who have PCP despite TMP-SMX prophylaxis are usually effectively treated with standard doses of TMP-SMX ('''BIII''').
 
*Patients with documented or suspected PCP and moderate-to-severe disease, as defined by room air pO2 <70 mm Hg or arterial-alveolar O2 gradient >35 mm Hg, should receive adjunctive corticosteroids as early as possible, and certainly within 72 hours after starting specific PCP therapy ('''AI''').<ref name="pmid1613673">{{cite journal |author=Nielsen TL, Eeftinck Schattenkerk JK, Jensen BN, Lundgren JD, Gerstoft J, van Steenwijk RP, Bentsen K, Frissen PH, Gaub J, Orholm M |title=Adjunctive corticosteroid therapy for Pneumocystis carinii pneumonia in AIDS: a randomized European multicenter open label study |journal=J. Acquir. Immune Defic. Syndr. |volume=5 |issue=7 |pages=726–31 |year=1992 |pmid=1613673 |doi= |url= |accessdate=2012-04-07}}</ref><ref name="pmid2233917">{{cite journal |author=Bozzette SA, Sattler FR, Chiu J, Wu AW, Gluckstein D, Kemper C, Bartok A, Niosi J, Abramson I, Coffman J |title=A controlled trial of early adjunctive treatment with corticosteroids for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome. California Collaborative Treatment Group |journal=N. Engl. J. Med. |volume=323 |issue=21 |pages=1451–7 |year=1990 |month=November |pmid=2233917 |doi=10.1056/NEJM199011223232104 |url=http://dx.doi.org/10.1056/NEJM199011223232104 |accessdate=2012-04-07}}</ref><ref name="pmid2190515">{{cite journal |author=Montaner JS, Lawson LM, Levitt N, Belzberg A, Schechter MT, Ruedy J |title=Corticosteroids prevent early deterioration in patients with moderately severe Pneumocystis carinii pneumonia and the acquired immunodeficiency syndrome (AIDS) |journal=Ann. Intern. Med. |volume=113 |issue=1 |pages=14–20 |year=1990 |month=July |pmid=2190515 |doi= |url= |accessdate=2012-04-07}}</ref><ref name="pmid9823998">{{cite journal |author=Gallant JE, Chaisson RE, Moore RD |title=The effect of adjunctive corticosteroids for the treatment of Pneumocystis carinii pneumonia on mortality and subsequent complications |journal=Chest |volume=114 |issue=5 |pages=1258–63 |year=1998 |month=November |pmid=9823998 |doi= |url=http://www.chestjournal.org/cgi/pmidlookup?view=long&pmid=9823998 |accessdate=2012-04-07}}</ref><ref name="pmid16271157">{{cite journal |author=Briel M, Boscacci R, Furrer H, Bucher HC |title=Adjunctive corticosteroids for Pneumocystis jiroveci pneumonia in patients with HIV infection: a meta-analysis of randomised controlled trials |journal=BMC Infect. Dis. |volume=5 |issue= |pages=101 |year=2005 |pmid=16271157 |pmc=1309617 |doi=10.1186/1471-2334-5-101 |url=http://www.biomedcentral.com/1471-2334/5/101 |accessdate=2012-04-07}}</ref>  If steroids are started at a later time, their benefits are unclear, although the majority of clinicians would use them in such circumstances for patients with moderate-to-severe disease ('''BIII'''). [[Methylprednisolone]] at 75% of the respective [[prednisone]] dose can be used if parenteral administration is necessary.
 
*Alternative therapeutic regimens for mild-to-moderate disease include :
**[[Dapsone]] and [[TMP]] ('''BI''') (this regimen might have similar efficacy and fewer side effects than TMP-SMX but is less convenient because of the number of pills).<ref name="pmid8610948">{{cite journal |author=Safrin S, Finkelstein DM, Feinberg J, Frame P, Simpson G, Wu A, Cheung T, Soeiro R, Hojczyk P, Black JR |title=Comparison of three regimens for treatment of mild to moderate Pneumocystis carinii pneumonia in patients with AIDS. A double-blind, randomized, trial of oral trimethoprim-sulfamethoxazole, dapsone-trimethoprim, and clindamycin-primaquine. ACTG 108 Study Group |journal=Ann. Intern. Med. |volume=124 |issue=9 |pages=792–802 |year=1996 |month=May |pmid=8610948 |doi= |url= |accessdate=2012-04-07}}</ref><ref name="pmid2392131">{{cite journal |author=Medina I, Mills J, Leoung G, Hopewell PC, Lee B, Modin G, Benowitz N, Wofsy CB |title=Oral therapy for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome. A controlled trial of trimethoprim-sulfamethoxazole versus trimethoprim-dapsone |journal=N. Engl. J. Med. |volume=323 |issue=12 |pages=776–82 |year=1990 |month=September |pmid=2392131 |doi=10.1056/NEJM199009203231202 |url=http://dx.doi.org/10.1056/NEJM199009203231202 |accessdate=2012-04-07}}</ref>
**[[Primaquine]] plus [[clindamycin]] ('''BI''') (the clindamycin component can be administered intravenously for more severe cases.<ref name="pmid8086551">{{cite journal |author=Black JR, Feinberg J, Murphy RL, Fass RJ, Finkelstein D, Akil B, Safrin S, Carey JT, Stansell J, Plouffe JF |title=Clindamycin and primaquine therapy for mild-to-moderate episodes of Pneumocystis carinii pneumonia in patients with AIDS: AIDS Clinical Trials Group 044 |journal=Clin. Infect. Dis. |volume=18 |issue=6 |pages=905–13 |year=1994 |month=June |pmid=8086551 |doi= |url=http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=8086551 |accessdate=2012-04-07}}</ref>
**Atovaquone suspension ('''BI''')  (this is less effective than TMP-SMX for mild-to-moderate disease but has fewer side effects).
*Patients should be tested for [[G6PD]] deficiency whenever possible before administration of primaquine.
*Alternative therapeutic regimens for patients with moderate-to-severe disease include clindamycin-primaquine or intravenous (IV) [[pentamidine]] ('''AI''')  ('''usually the drug of second choice for severe disease'''). Certain clinicians prefer IV pentamidine because of convincing data regarding its high degree of efficacy. Other clinicians prefer clindamycin-primaquine because this combination is better tolerated than pentamidine, although data regarding efficacy are not as robust as the data supporting pentamidine. Aerosolized pentamidine should not be used for the treatment of PCP because of limited efficacy and more frequent relapse ('''DI'''). Trimetrexate is no longer available commercially.
*The recommended '''duration''' of therapy for PCP is 21 days ('''AII''').<ref name="pmid6231873">{{cite journal |author=Kovacs JA, Hiemenz JW, Macher AM, Stover D, Murray HW, Shelhamer J, Lane HC, Urmacher C, Honig C, Longo DL |title=Pneumocystis carinii pneumonia: a comparison between patients with the acquired immunodeficiency syndrome and patients with other immunodeficiencies |journal=Ann. Intern. Med. |volume=100 |issue=5 |pages=663–71 |year=1984 |month=May |pmid=6231873 |doi= |url= |accessdate=2012-04-07}}</ref> The probability and rate of response to therapy depend on:
**The agent used.
**Number of previous PCP episodes.
**Severity of illness.
**Degree of immunodeficiency.
**Timing of initiation of therapy.
*Although the overall prognosis of patients whose degree of [[hypoxemia]] requires [[intensive care unit]] (ICU) admission or [[mechanical ventilation]] remains poor, survival in up to 50% of patients requiring ventilatory support has been reported in recent years.<ref name="pmid10934059">{{cite journal |author=Curtis JR, Yarnold PR, Schwartz DN, Weinstein RA, Bennett CL |title=Improvements in outcomes of acute respiratory failure for patients with human immunodeficiency virus-related Pneumocystis carinii pneumonia |journal=Am. J. Respir. Crit. Care Med. |volume=162 |issue=2 Pt 1 |pages=393–8 |year=2000 |month=August |pmid=10934059 |doi= |url=http://ajrccm.atsjournals.org/cgi/pmidlookup?view=long&pmid=10934059 |accessdate=2012-04-07}}</ref><ref name="pmid11294675">{{cite journal |author=Dworkin MS, Hanson DL, Navin TR |title=Survival of patients with AIDS, after diagnosis of Pneumocystis carinii pneumonia, in the United States |journal=J. Infect. Dis. |volume=183 |issue=9 |pages=1409–12 |year=2001 |month=May |pmid=11294675 |doi=10.1086/319866 |url=http://www.jid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=11294675 |accessdate=2012-04-07}}</ref> Because long-term survival is possible for patients in whom ART is effective, certain patients with AIDS and severe PCP should be offered intensive care unit (ICU) admission or mechanical ventilation when appropriate (e.g., when they have reasonable functional status) ('''AII''').
*Because of the potential for additive or synergistic toxicities associated with anti-PCP and antiretroviral therapies, certain health-care providers delay initiation of ART until after the completion of anti-PCP therapy, or until at least 2 weeks after initiating anti-PCP therapy, despite some suggestion of potential benefit of early ART in the treatment of PCP ('''CIII'''). <ref name="pmid11294675">{{cite journal |author=Dworkin MS, Hanson DL, Navin TR |title=Survival of patients with AIDS, after diagnosis of Pneumocystis carinii pneumonia, in the United States |journal=J. Infect. Dis. |volume=183 |issue=9 |pages=1409–12 |year=2001|month=May |pmid=11294675 |doi=10.1086/319866 |url=http://www.jid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=11294675|accessdate=2012-04-07}}</ref><ref name="pmid16837681">{{cite journal |author=Huang L, Quartin A, Jones D, Havlir DV |title=Intensive care of patients with HIV infection |journal=N. Engl. J. Med. |volume=355 |issue=2 |pages=173–81 |year=2006 |month=July |pmid=16837681 |doi=10.1056/NEJMra050836 |url=http://dx.doi.org/10.1056/NEJMra050836 |accessdate=2012-04-07}}</ref>
=====Monitoring and Adverse Events, Including Immune Reconstitution Inflammatory Syndrome (IRIS)=====
Careful monitoring during therapy is important to evaluate response to treatment and to detect toxicity as soon as possible. Follow-up after therapy includes assessment for early relapse, especially when therapy has been with an agent other than TMP-SMX or was shortened for toxicity.  PCP prophylaxis should be initiated immediately upon completion of therapy and maintained until the CD4+ count is >200 cells/µL.
 
Adverse reaction rates among patients with AIDS are high for TMP-SMX (20%--85%).<ref name="pmid8479489">{{cite journal |author=Hughes W, Leoung G, Kramer F, Bozzette SA, Safrin S, Frame P, Clumeck N, Masur H, Lancaster D, Chan C |title=Comparison of atovaquone (566C80) with trimethoprim-sulfamethoxazole to treat Pneumocystis carinii pneumonia in patients with AIDS |journal=N. Engl. J. Med. |volume=328|issue=21 |pages=1521–7 |year=1993 |month=May |pmid=8479489 |doi=10.1056/NEJM199305273282103|url=http://dx.doi.org/10.1056/NEJM199305273282103 |accessdate=2012-04-06}}</ref><ref name="pmid1613673">{{cite journal |author=Nielsen TL, Eeftinck Schattenkerk JK, Jensen BN, Lundgren JD, Gerstoft J, van Steenwijk RP, Bentsen K, Frissen PH, Gaub J, Orholm M |title=Adjunctive corticosteroid therapy for Pneumocystis carinii pneumonia in AIDS: a randomized European multicenter open label study |journal=J. Acquir. Immune Defic. Syndr.|volume=5 |issue=7 |pages=726–31 |year=1992 |pmid=1613673 |doi= |url= |accessdate=2012-04-07}}</ref><ref name="pmid2392131">{{cite journal |author=Medina I, Mills J, Leoung G, Hopewell PC, Lee B, Modin G, Benowitz N, Wofsy CB |title=Oral therapy for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome. A controlled trial of trimethoprim-sulfamethoxazole versus trimethoprim-dapsone |journal=N. Engl. J. Med. |volume=323 |issue=12 |pages=776–82 |year=1990|month=September |pmid=2392131 |doi=10.1056/NEJM199009203231202 |url=http://dx.doi.org/10.1056/NEJM199009203231202|accessdate=2012-04-07}}</ref> Common adverse effects are [[rash]] (30%--55%) (including [[Stevens-Johnson syndrome]]), [[fever]] (30%--40%),[[ leukopenia]] (30%--40%), [[thrombocytopenia]] (15%), [[azotemia]] (1%--5%), [[hepatitis]] (20%), and [[hyperkalemia]]. Supportive care for common adverse effects should be attempted before discontinuing TMP-SMX ('''AIII'''). Rashes can often be "treated through" with [[antihistamines]], [[nausea]] can be controlled with [[antiemetics]], and fever can be managed with [[antipyretics]].
 
The most common adverse effects of alternative therapies include [[methemoglobinemia]] and [[hemolysis]] with [[dapsone]] or [[primaquine]] (especially in those with [[G6PD]] deficiency); rash and fever with [[dapsone]]; [[azotemia]], [[pancreatitis]], hypo- or [[hyperglycemia]], [[leukopenia]], [[electrolyte]] abnormalities, and [[cardiac]] [[dysrhythmia]] with pentamidine; [[anemia]], rash, fever, and [[diarrhea]] with primaquine and clindamycin; and [[headache]], nausea, diarrhea, rash, and transaminase elevations with atovaquone.
 
IRIS has been reported following PCP. Most cases have occurred within weeks of the episode of PCP. Reported cases are not sufficient to provide guidance on the optimal time to start ART following a mild or severe case of PCP.<ref name="pmid11549544">{{cite journal |author=Wislez M, Bergot E, Antoine M, Parrot A, Carette MF, Mayaud C, Cadranel J |title=Acute respiratory failure following HAART introduction in patients treated for Pneumocystis carinii pneumonia |journal=Am. J. Respir. Crit. Care Med. |volume=164 |issue=5 |pages=847–51 |year=2001 |month=September |pmid=11549544 |doi= |url=http://ajrccm.atsjournals.org/cgi/pmidlookup?view=long&pmid=11549544 |accessdate=2012-04-07}}</ref><ref name="pmid12145736">{{cite journal |author=Koval CE, Gigliotti F, Nevins D, Demeter LM |title=Immune reconstitution syndrome after successful treatment of Pneumocystis carinii pneumonia in a man with human immunodeficiency virus type 1 infection |journal=Clin. Infect. Dis. |volume=35 |issue=4 |pages=491–3 |year=2002 |month=August |pmid=12145736 |doi=10.1086/341974 |url=http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=12145736 |accessdate=2012-04-07}}</ref>
=====Management of Treatment Failure=====
Switching to another regimen is the appropriate management for treatment-related toxicity ('''BII'''). Failure attributed to lack of drug efficacy occurs in approximately 10% of those with mild-to-moderate disease. No convincing clinical trials exist on which to base recommendations for the management of treatment failure attributed to lack of drug efficacy. Clinicians should wait at least 4--8 days before switching therapy for lack of clinical improvement ('''BIII''') In the absence of corticosteroid therapy, early and reversible deterioration within the first 3--5 days of therapy is typical, probably because of the inflammatory response caused by antibiotic-induced lysis of organisms in the lung. Other concomitant infections must be excluded as a cause for clinical failure ;<ref name="pmid7985710">{{cite journal |author=Baughman RP, Dohn MN, Frame PT |title=The continuing utility of bronchoalveolar lavage to diagnose opportunistic infection in AIDS patients |journal=Am. J. Med. |volume=97 |issue=6 |pages=515–22 |year=1994 |month=December |pmid=7985710 |doi= |url= |accessdate=2012-04-08}}</ref><ref name="pmid6375497">{{cite journal |author=Stover DE, Zaman MB, Hajdu SI, Lange M, Gold J, Armstrong D |title=Bronchoalveolar lavage in the diagnosis of diffuse pulmonary infiltrates in the immunosuppressed host |journal=Ann. Intern. Med. |volume=101 |issue=1 |pages=1–7 |year=1984 |month=July |pmid=6375497 |doi= |url= |accessdate=2012-04-08}}</ref> bronchoscopy with bronchoalveolar lavage should be strongly considered to evaluate for this possibility, even if it was conducted before initiating therapy.
 
If TMP-SMX has failed or must be avoided for toxicity in moderate-to-severe disease, the common practice is to use parenteral pentamidine or primaquine combined with clindamycin ('''BII''').<ref name="pmid9770152">{{cite journal |author=Toma E, Thorne A, Singer J, Raboud J, Lemieux C, Trottier S, Bergeron MG, Tsoukas C, Falutz J, Lalonde R, Gaudreau C, Therrien R |title=Clindamycin with primaquine vs. Trimethoprim-sulfamethoxazole therapy for mild and moderately severe Pneumocystis carinii pneumonia in patients with AIDS: a multicenter, double-blind, randomized trial (CTN 004). CTN-PCP Study Group |journal=Clin. Infect. Dis. |volume=27 |issue=3 |pages=524–30 |year=1998 |month=September |pmid=9770152 |doi= |url=http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=9770152 |accessdate=2012-04-08}}</ref><ref name="pmid3521428">{{cite journal |author=Wharton JM, Coleman DL, Wofsy CB, Luce JM, Blumenfeld W, Hadley WK, Ingram-Drake L, Volberding PA, Hopewell PC |title=Trimethoprim-sulfamethoxazole or pentamidine for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome. A prospective randomized trial |journal=Ann. Intern. Med. |volume=105 |issue=1 |pages=37–44 |year=1986 |month=July |pmid=3521428 |doi= |url= |accessdate=2012-04-08}}</ref><ref name="pmid8014493">{{cite journal |author=Sattler FR, Frame P, Davis R, Nichols L, Shelton B, Akil B, Baughman R, Hughlett C, Weiss W, Boylen CT |title=Trimetrexate with leucovorin versus trimethoprim-sulfamethoxazole for moderate to severe episodes of Pneumocystis carinii pneumonia in patients with AIDS: a prospective, controlled multicenter investigation of the AIDS Clinical Trials Group Protocol 029/031 |journal=J. Infect. Dis. |volume=170 |issue=1 |pages=165–72 |year=1994 |month=July |pmid=8014493 |doi= |url=http://www.jid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=8014493 |accessdate=2012-04-08}}</ref> For mild disease, [[atovaquone]] is a reasonable alternative ('''BII'''). Although one meta-analysis concluded that the combination of clindamycin and primaquine might be the most effective regimen for salvage therapy, no prospective clinical trials have evaluated the optimal approach to patients who experience a therapy failure with TMP-SMX.<ref name="pmid11427101">{{cite journal |author=Smego RA, Nagar S, Maloba B, Popara M |title=A meta-analysis of salvage therapy for Pneumocystis carinii pneumonia |journal=Arch. Intern. Med. |volume=161 |issue=12 |pages=1529–33 |year=2001 |month=June |pmid=11427101 |doi= |url=http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=11427101 |accessdate=2012-04-08}}</ref>
=====Preventing Recurrence=====
Patients who have a history of PCP should be administered [[chemoprophylaxis]] for life (i.e., [[Prophylaxis|secondary prophylaxis]] or chronic maintenance therapy) with TMP-SMX unless immune reconstitution occurs as a result of ART ('''AI''').<ref name="pmid12617574">{{cite journal |author=Masur H, Kaplan JE, Holmes KK |title=Guidelines for preventing opportunistic infections among HIV-infected persons--2002. Recommendations of the U.S. Public Health Service and the Infectious Diseases Society of America |journal=Ann. Intern. Med. |volume=137 |issue=5 Pt 2 |pages=435–78 |year=2002 |month=September |pmid=12617574 |doi= |url=http://www.annals.org/cgi/pmidlookup?view=long&pmid=12617574 |accessdate=2012-04-08}}</ref> For patients who are intolerant of TMP-SMX, alternatives are dapsone, dapsone combined with pyrimethamine, atovaquone, or aerosolized pentamidine.
=====Discontinuing Secondary Prophylaxis (Chronic Maintenance Therapy)=====
Secondary prophylaxis should be discontinued for adult and adolescent patients whose CD4+ count has increased from <200 cells/µL to >200 cells/µL for >3 months as a result of ART ('''BII'''). Reports from observational studies<ref name="pmid10915098">{{cite journal |author=Dworkin MS, Hanson DL, Kaplan JE, Jones JL, Ward JW |title=Risk for preventable opportunistic infections in persons with AIDS after antiretroviral therapy increases CD4+ T lymphocyte counts above prophylaxis thresholds |journal=J. Infect. Dis. |volume=182 |issue=2 |pages=611–5 |year=2000 |month=August |pmid=10915098 |doi=10.1086/315734 |url=http://www.jid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=10915098 |accessdate=2012-04-08}}</ref><ref name="pmid10509565">{{cite journal |author=Kirk O, Lundgren JD, Pedersen C, Nielsen H, Gerstoft J |title=Can chemoprophylaxis against opportunistic infections be discontinued after an increase in CD4 cells induced by highly active antiretroviral therapy? |journal=AIDS |volume=13 |issue=13 |pages=1647–51 |year=1999 |month=September |pmid=10509565 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0269-9370&volume=13&issue=13&spage=1647 |accessdate=2012-04-08}}</ref><ref name="pmid10770540">{{cite journal |author=Soriano V, Dona C, Rodríguez-Rosado R, Barreiro P, González-Lahoz J |title=Discontinuation of secondary prophylaxis for opportunistic infections in HIV-infected patients receiving highly active antiretroviral therapy |journal=AIDS |volume=14 |issue=4 |pages=383–6 |year=2000 |month=March |pmid=10770540 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0269-9370&volume=14&issue=4&spage=383 |accessdate=2012-04-08}}</ref><ref name="pmid15577626">{{cite journal |author=Zellweger C, Opravil M, Bernasconi E, Cavassini M, Bucher HC, Schiffer V, Wagels T, Flepp M, Rickenbach M, Furrer H |title=Long-term safety of discontinuation of secondary prophylaxis against Pneumocystis pneumonia: prospective multicentre study |journal=AIDS |volume=18 |issue=15 |pages=2047–53 |year=2004 |month=October |pmid=15577626 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0269-9370&volume=18&issue=15&spage=2047 |accessdate=2012-04-08}}</ref> and from two randomized trials <ref name="pmid12594647">{{cite journal |author=Mussini C, Pezzotti P, Antinori A, Borghi V, Monforte A, Govoni A, De Luca A, Ammassari A, Mongiardo N, Cerri MC, Bedini A, Beltrami C, Ursitti MA, Bini T, Cossarizza A, Esposito R |title=Discontinuation of secondary prophylaxis for Pneumocystis carinii pneumonia in human immunodeficiency virus-infected patients: a randomized trial by the CIOP Study Group |journal=Clin. Infect. Dis. |volume=36 |issue=5 |pages=645–51 |year=2003 |month=March |pmid=12594647 |doi=10.1086/367659 |url=http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=12594647 |accessdate=2012-04-08}}</ref><ref name="pmid11172138">{{cite journal |author=Lopez Bernaldo de Quiros JC, Miro JM, Peña JM, Podzamczer D, Alberdi JC, Martínez E, Cosin J, Claramonte X, Gonzalez J, Domingo P, Casado JL, Ribera E |title=A randomized trial of the discontinuation of primary and secondary prophylaxis against Pneumocystis carinii pneumonia after highly active antiretroviral therapy in patients with HIV infection. Grupo de Estudio del SIDA 04/98 |journal=N. Engl. J. Med. |volume=344 |issue=3 |pages=159–67 |year=2001 |month=January |pmid=11172138 |doi=10.1056/NEJM200101183440301 |url=http://dx.doi.org/10.1056/NEJM200101183440301 |accessdate=2012-04-08}}</ref>and a combined analysis of eight European cohorts being followed prospectively<ref name="pmid11188837">{{cite journal |author=Ledergerber B, Mocroft A, Reiss P, Furrer H, Kirk O, Bickel M, Uberti-Foppa C, Pradier C, D'Arminio Monforte A, Schneider MM, Lundgren JD |title=Discontinuation of secondary prophylaxis against Pneumocystis carinii pneumonia in patients with HIV infection who have a response to antiretroviral therapy. Eight European Study Groups |journal=N. Engl. J. Med. |volume=344 |issue=3 |pages=168–74 |year=2001 |month=January |pmid=11188837 |doi=10.1056/NEJM200101183440302 |url=http://dx.doi.org/10.1056/NEJM200101183440302 |accessdate=2012-04-08}}</ref> support this recommendation.
 
In these studies, patients had responded to ART with an increase in CD4+ counts to >200 cells/µL for >3 months. The majority of patients were taking PI-containing regimens. The median CD4+ count at the time prophylaxis was discontinued was >300 cells/µL and most had a CD4+ cell percentage of >14%. The majority of patients had sustained suppression of plasma HIV RNA levels below the detection limits of the assay employed; the longest follow-up was 40 months. If the episode of PCP occurred at a CD4+ count of >200 cells/µL, continuing PCP prophylaxis for life, regardless of how high the CD4+ count rises as a consequence of ART, would be prudent ('''CIII'''); however, data regarding the most appropriate approach in this setting are limited.
 
Discontinuing secondary prophylaxis for patients is recommended because prophylaxis adds limited disease prevention (i.e., for PCP, [[toxoplasmosis]], or bacterial infections) and because discontinuing drugs reduces pill burden, potential for drug toxicity, drug interactions, selection of drug-resistant pathogens, and cost.
 
Prophylaxis should be reintroduced if the CD4+ count decreases to <200 cells/µL ('''AIII'''). If PCP recurs at a CD4+ count of >200 cells/µL, lifelong prophylaxis should be administered ('''CIII''').
 
===== Pneumocystis Pneumonia: Special considerations during pregnancy=====
PCP diagnostic considerations for pregnant women are the same as for nonpregnant women. Indications for therapy are the same as for nonpregnant women. The preferred initial therapy during pregnancy is TMP-SMX, although alternate therapies can be used if patients are unable to tolerate or are unresponsive to TMP-SMX ('''AI''').<ref name="pmid7937279">{{cite journal |author=Connelly RT, Lourwood DL |title=Pneumocystis carinii pneumonia prophylaxis during pregnancy |journal=Pharmacotherapy |volume=14 |issue=4|pages=424–9 |year=1994 |pmid=7937279 |doi= |url= |accessdate=2012-04-08}}</ref> In case-control studies, trimethoprim has been associated with an increased risk for neural tube defects and cardiovascular, urinary tract, and multiple anomalies after first-trimester exposure.<ref name="pmid11738517">{{cite journal |author=Czeizel AE, Rockenbauer M, Sørensen HT, Olsen J |title=The teratogenic risk of trimethoprim-sulfonamides: a population based case-control study |journal=Reprod. Toxicol. |volume=15 |issue=6 |pages=637–46 |year=2001 |pmid=11738517 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0890623801001782 |accessdate=2012-04-09}}</ref><ref name="pmid11096168">{{cite journal |author=Hernández-Díaz S, Werler MM, Walker AM, Mitchell AA |title=Folic acid antagonists during pregnancy and the risk of birth defects |journal=N. Engl. J. Med. |volume=343 |issue=22 |pages=1608–14 |year=2000 |month=November |pmid=11096168 |doi=10.1056/NEJM200011303432204 |url=http://dx.doi.org/10.1056/NEJM200011303432204 |accessdate=2012-04-09}}</ref><ref name="pmid11384952">{{cite journal |author=Hernández-Díaz S, Werler MM, Walker AM, Mitchell AA |title=Neural tube defects in relation to use of folic acid antagonists during pregnancy |journal=Am. J. Epidemiol. |volume=153 |issue=10 |pages=961–8 |year=2001 |month=May |pmid=11384952 |doi= |url=http://aje.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=11384952 |accessdate=2012-04-09}}</ref>  Epidemiologic data suggest that folic acid supplementation might reduce this risk,<ref name="pmid11096168">{{cite journal |author=Hernández-Díaz S, Werler MM, Walker AM, Mitchell AA |title=Folic acid antagonists during pregnancy and the risk of birth defects |journal=N. Engl. J. Med. |volume=343 |issue=22 |pages=1608–14 |year=2000 |month=November |pmid=11096168 |doi=10.1056/NEJM200011303432204 |url=http://dx.doi.org/10.1056/NEJM200011303432204 |accessdate=2012-04-09}}</ref><ref name="pmid11384952">{{cite journal |author=Hernández-Díaz S, Werler MM, Walker AM, Mitchell AA |title=Neural tube defects in relation to use of folic acid antagonists during pregnancy |journal=Am. J. Epidemiol. |volume=153 |issue=10 |pages=961–8 |year=2001 |month=May |pmid=11384952 |doi= |url=http://aje.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=11384952 |accessdate=2012-04-09}}</ref> but no controlled studies have been done. In a small study, an increased risk for birth defects among infants born to women receiving antiretrovirals and folate antagonists, primarily trimethoprim, was reported, whereas no increase was observed among those with either antiretroviral or folate antagonist exposure alone.<ref name="pmid11714944">{{cite journal |author=Jungmann EM, Mercey D, DeRuiter A, Edwards S, Donoghue S, Booth T, Mohan D, Lyall H, Taylor GP |title=Is first trimester exposure to the combination of antiretroviral therapy and folate antagonists a risk factor for congenital abnormalities? |journal=Sex Transm Infect |volume=77 |issue=6 |pages=441–3 |year=2001 |month=December |pmid=11714944 |pmc=1744398 |doi= |url=http://sti.bmj.com/cgi/pmidlookup?view=long&pmid=11714944 |accessdate=2012-04-09}}</ref> Although first-trimester exposure to trimethoprim might be related to a small increased risk for birth defects, pregnant women in their first trimester with PCP should be treated with TMP-SMX ('''AIII'''). Although folic acid supplementation of 0.4 mg/day is routinely recommended for all pregnant women, data do not indicate if higher levels of supplementation, such as the 4 mg/day recommended for pregnant women with a previous infant with a neural tube defect, would provide added benefit in this situation. Follow-up ultrasound to assess fetal anatomy at 18--20 weeks is recommended ('''BIII''').
 
Neonatal-care providers should be informed of maternal sulfa or dapsone therapy if used near the delivery date because of the theoretical increased risk for [[hyperbilirubinemia]] and [[kernicterus]].
 
Pentamidine is [[embryotoxic]] but not [[teratogenic]] among rats and rabbits.<ref name="pmid2403167">{{cite journal |author=Harstad TW, Little BB, Bawdon RE, Knoll K, Roe D, Gilstrap LC |title=Embryofetal effects of pentamidine isethionate administered to pregnant Sprague-Dawley rats |journal=Am. J. Obstet. Gynecol. |volume=163 |issue=3 |pages=912–6 |year=1990 |month=September |pmid=2403167 |doi= |url= |accessdate=2012-04-09}}</ref> Adjunctive [[corticosteroid]] [[therapy]] should be used as indicated in nonpregnant adults ('''AIII''').<ref name="pmid8159362">{{cite journal |author=Albino JA, Shapiro JM |title=Respiratory failure in pregnancy due to Pneumocystis carinii: report of a successful outcome |journal=Obstet Gynecol |volume=83 |issue=5 Pt 2 |pages=823–4 |year=1994 |month=May |pmid=8159362 |doi= |url= |accessdate=2012-04-09}}</ref><ref name="pmid2782348">{{cite journal |author=Madinger NE, Greenspoon JS, Ellrodt AG |title=Pneumonia during pregnancy: has modern technology improved maternal and fetal outcome? |journal=Am. J. Obstet. Gynecol. |volume=161 |issue=3 |pages=657–62 |year=1989 |month=September |pmid=2782348 |doi= |url= |accessdate=2012-04-09}}</ref><ref name="pmid2783746">{{cite journal |author=Koonin LM, Ellerbrock TV, Atrash HK, Rogers MF, Smith JC, Hogue CJ, Harris MA, Chavkin W, Parker AL, Halpin GJ |title=Pregnancy-associated deaths due to AIDS in the United States |journal=JAMA |volume=261 |issue=9 |pages=1306–9 |year=1989 |month=March |pmid=2783746 |doi= |url= |accessdate=2012-04-09}}</ref><ref name="pmid7124859">{{cite journal |author=Benedetti TJ, Valle R, Ledger WJ |title=Antepartum pneumonia in pregnancy |journal=Am. J. Obstet. Gynecol. |volume=144 |issue=4 |pages=413–7 |year=1982 |month=October |pmid=7124859 |doi= |url= |accessdate=2012-04-09}}</ref> Maternal fasting and [[postprandial]] [[glucose]] levels should be monitored closely when corticosteroids are used in the third [[trimester]] because the risk for [[glucose intolerance]] is increased.
 
Rates of preterm labor and preterm delivery are increased with pneumonia during pregnancy. Pregnant women with pneumonia after 20 weeks of gestation should be monitored for evidence of contractions('''BII''').
 
Chemoprophylaxis for PCP should be administered to pregnant women the same as for other adults and adolescents ('''AIII'''). TMP-SMX is the recommended prophylactic agent; dapsone is an alternative. Because of theoretical concerns regarding possible teratogenicity associated with drug exposures during the first trimester, health-care providers might withhold prophylaxis during the first trimester. In such cases, aerosolized pentamidine can be considered because of its lack of systemic absorption and the resultant lack of exposure of the developing embryo to the drug ('''CIII''').
 
==Toxoplasma gondii Encephalitis==
Toxoplasmic [[encephalitis]] (TE) is caused by the protozoan [[Toxoplasma gondii]]. Disease appears to occur almost exclusively because of [[reactivation]] of latent tissue [[cysts]].
 
===Toxoplasma gondii: Preventing Exposure===
HIV-infected persons should be tested for IgG antibody to Toxoplasma soon after the diagnosis of HIV infection to detect latent infection with T. gondii ('''BIII''').
 
HIV-infected persons, including those who lack IgG antibody to Toxoplasma, should be counseled regarding sources of Toxoplasma infection. To minimize risk for acquiring toxoplasmosis, HIV-infected persons should be advised not to eat raw or undercooked meat, including undercooked lamb, beef, pork, or venison ('''BIII'''). Specifically, lamb, beef, venison, and pork should be cooked to an internal temperature of 165ºF--170ºF; meat cooked until it is no longer pink inside usually has an internal temperature of 165ºF--170ºF and therefore, from a more practical perspective, satisfies this requirement. To minimize the risk for acquiring toxoplasmosis, HIV-infected persons should wash their hands after contact with raw meat and after gardening or other contact with soil; in addition, they should wash fruits and vegetables well before eating them raw ('''BIII''').  If the patient owns a cat, the litter box should be changed daily, preferably by an HIV-negative, nonpregnant person; alternatively, patients should wash their hands thoroughly after changing the litter box ('''BIII'''). Patients should be encouraged to keep their cats inside and not to adopt or handle stray cats ('''BIII'''). Cats should be fed only canned or dried commercial food or well-cooked table food, not raw or undercooked meats ('''BIII'''). Patients need not be advised to part with their cats or to have their cats tested for toxoplasmosis ('''EII''')
 
===Toxoplasma gondii: Preventing Disease===
====Toxoplasma gondii: Initiating Primary Prophylaxis====
Toxoplasma-seropositive patients who have a CD4+ count of <100 cells/µL should be administered prophylaxis against TE ('''AII''').<ref name="pmid1351371">{{cite journal |author=Carr A, Tindall B, Brew BJ, Marriott DJ, Harkness JL, Penny R, Cooper DA |title=Low-dose trimethoprim-sulfamethoxazole prophylaxis for toxoplasmic encephalitis in patients with AIDS |journal=Ann. Intern. Med. |volume=117 |issue=2 |pages=106–11 |year=1992 |month=July |pmid=1351371 |doi= |url= |accessdate=2012-04-09}}</ref> The double-strength tablet daily dose of TMP-SMX recommended as the preferred regimen for PCP prophylaxis also is effective against TE and is therefore recommended ('''AII'''). TMP-SMX, one double-strength tablet three times weekly, is an alternative ('''BIII''').  If patients cannot tolerate TMP-SMX, the recommended alternative is dapsone-pyrimethamine plus leucovorin, which is also effective against PCP ('''BI''').<ref name="pmid7717598">{{cite journal |author=Podzamczer D, Salazar A, Jiménez J, Consiglio E, Santín M, Casanova A, Rufí G, Gudiol F |title=Intermittent trimethoprim-sulfamethoxazole compared with dapsone-pyrimethamine for the simultaneous primary prophylaxis of Pneumocystis pneumonia and toxoplasmosis in patients infected with HIV |journal=Ann. Intern. Med. |volume=122 |issue=10 |pages=755–61 |year=1995 |month=May |pmid=7717598 |doi= |url= |accessdate=2012-04-09}}</ref><ref name="pmid7756472">{{cite journal |author=Opravil M, Hirschel B, Lazzarin A, Heald A, Pechère M, Rüttimann S, Iten A, von Overbeck J, Oertle D, Praz G |title=Once-weekly administration of dapsone/pyrimethamine vs. aerosolized pentamidine as combined prophylaxis for Pneumocystis carinii pneumonia and toxoplasmic encephalitis in human immunodeficiency virus-infected patients |journal=Clin. Infect. Dis. |volume=20 |issue=3 |pages=531–41 |year=1995 |month=March |pmid=7756472 |doi= |url=http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=7756472 |accessdate=2012-04-09}}</ref><ref name="pmid8479488">{{cite journal |author=Girard PM, Landman R, Gaudebout C, Olivares R, Saimot AG, Jelazko P, Gaudebout C, Certain A, Boué F, Bouvet E |title=Dapsone-pyrimethamine compared with aerosolized pentamidine as primary prophylaxis against Pneumocystis carinii pneumonia and toxoplasmosis in HIV infection. The PRIO Study Group |journal=N. Engl. J. Med. |volume=328 |issue=21 |pages=1514–20 |year=1993 |month=May |pmid=8479488 |doi=10.1056/NEJM199305273282102 |url=http://dx.doi.org/10.1056/NEJM199305273282102 |accessdate=2012-04-09}}</ref> Atovaquone with or without pyrimethamine/leucovorin also can be considered ('''CIII'''). Prophylactic monotherapy with dapsone, pyrimethamine, azithromycin, or clarithromycin cannot be recommended on the basis of available data ('''DII'''). Aerosolized pentamidine does not protect against TE and is not recommended ('''EI''').<ref name="pmid7854375">{{cite journal |author=Bozzette SA, Finkelstein DM, Spector SA, Frame P, Powderly WG, He W, Phillips L, Craven D, van der Horst C, Feinberg J |title=A randomized trial of three antipneumocystis agents in patients with advanced human immunodeficiency virus infection. NIAID AIDS Clinical Trials Group |journal=N. Engl. J. Med. |volume=332 |issue=11 |pages=693–9 |year=1995 |month=March |pmid=7854375 |doi=10.1056/NEJM199503163321101 |url=http://dx.doi.org/10.1056/NEJM199503163321101 |accessdate=2012-04-09}}</ref><ref name="pmid1351371">{{cite journal |author=Carr A, Tindall B, Brew BJ, Marriott DJ, Harkness JL, Penny R, Cooper DA |title=Low-dose trimethoprim-sulfamethoxazole prophylaxis for toxoplasmic encephalitis in patients with AIDS |journal=Ann. Intern. Med. |volume=117 |issue=2 |pages=106–11 |year=1992 |month=July |pmid=1351371 |doi= |url= |accessdate=2012-04-09}}</ref>
 
Toxoplasma-seronegative persons who are not taking a PCP prophylactic regimen known to be active against TE (e.g., aerosolized pentamidine) should be retested for IgG antibody to Toxoplasma when their CD4+ counts decline to <100 cells/µL to determine whether they have seroconverted and are therefore at risk for TE ('''CIII'''). Patients who have seroconverted should be administered prophylaxis for TE as described previously ('''AII''').


====Toxoplasma gondii: Discontinuing Primary Prophylaxis====
[[Category:HIV/AIDS]]
Prophylaxis against TE should be discontinued among adult and adolescent patients who have responded to ART with an increase in CD4+ counts to >200 cells/µL for >3 months ('''AI'''). Multiple observational studies<ref name="pmid10915098">{{cite journal |author=Dworkin MS, Hanson DL, Kaplan JE, Jones JL, Ward JW |title=Risk for preventable opportunistic infections in persons with AIDS after antiretroviral therapy increases CD4+ T lymphocyte counts above prophylaxis thresholds |journal=J. Infect. Dis. |volume=182 |issue=2 |pages=611–5 |year=2000 |month=August |pmid=10915098 |doi=10.1086/315734 |url=http://www.jid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=10915098 |accessdate=2012-04-09}}</ref><ref name="pmid10509565">{{cite journal |author=Kirk O, Lundgren JD, Pedersen C, Nielsen H, Gerstoft J |title=Can chemoprophylaxis against opportunistic infections be discontinued after an increase in CD4 cells induced by highly active antiretroviral therapy? |journal=AIDS |volume=13 |issue=13 |pages=1647–51 |year=1999 |month=September |pmid=10509565 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0269-9370&volume=13&issue=13&spage=1647 |accessdate=2012-04-09}}</ref><ref name="pmid10881897">{{cite journal |author=Furrer H, Opravil M, Bernasconi E, Telenti A, Egger M |title=Stopping primary prophylaxis in HIV-1-infected patients at high risk of toxoplasma encephalitis. Swiss HIV Cohort Study |journal=Lancet |volume=355 |issue=9222 |pages=2217–8 |year=2000 |month=June |pmid=10881897 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0140673600024077 |accessdate=2012-04-09}}</ref> and two randomized trials<ref name="pmid16758422">{{cite journal |author=Miro JM, Lopez JC, Podzamczer D, Peña JM, Alberdi JC, Martínez E, Domingo P, Cosin J, Claramonte X, Arribas JR, Santín M, Ribera E |title=Discontinuation of primary and secondary Toxoplasma gondii prophylaxis is safe in HIV-infected patients after immunological restoration with highly active antiretroviral therapy: results of an open, randomized, multicenter clinical trial |journal=Clin. Infect. Dis. |volume=43 |issue=1 |pages=79–89 |year=2006 |month=July |pmid=16758422 |doi=10.1086/504872 |url=http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=16758422 |accessdate=2012-04-09}}</ref><ref name="pmid10823763">{{cite journal |author=Mussini C, Pezzotti P, Govoni A, Borghi V, Antinori A, d'Arminio Monforte A, De Luca A, Mongiardo N, Cerri MC, Chiodo F, Concia E, Bonazzi L, Moroni M, Ortona L, Esposito R, Cossarizza A, De Rienzo B |title=Discontinuation of primary prophylaxis for Pneumocystis carinii pneumonia and toxoplasmic encephalitis in human immunodeficiency virus type I-infected patients: the changes in opportunistic prophylaxis study |journal=J. Infect. Dis. |volume=181 |issue=5 |pages=1635–42 |year=2000 |month=May |pmid=10823763 |doi=10.1086/315471 |url=http://www.jid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=10823763 |accessdate=2012-04-09}}</ref>  have reported that primary prophylaxis can be discontinued with minimal risk for developing TE among patients who have responded to ART with an increase in CD4+ count from <200 cells/µL to >200 cells/µL for >3 months. In these studies, the majority of patients were taking PI-containing regimens and the median CD4+ count at the time prophylaxis was discontinued was >300 cells/µL. At the time prophylaxis was discontinued, the majority of patients had sustained suppression of plasma HIV RNA levels below the detection limits of available assays; the median follow-up was 7--22 months. Although patients with CD4+ counts of <100 cells/µL are at greatest risk for having TE, the risk for TE occurring when the CD4+ count has increased to 100--200 cells/µL has not been studied as rigorously as an increase to >200 cells/µL. Thus, the recommendation specifies discontinuing prophylaxis after an increase to >200 cells/µL. Discontinuing primary TE prophylaxis is recommended because prophylaxis at CD4+ count >200 cells/ µL adds limited disease prevention for toxoplasmosis and because discontinuing drugs reduces pill burden, potential for drug toxicity, drug interaction, selection of drug-resistant pathogens, and cost. Prophylaxis for TE should be reintroduced if the CD4+ count decreases to <100--200 cells/µL ('''AIII''').
[[Category:Disease]]
 
[[Category:Immune system disorders]]
===Toxoplasma gondii: Treatment of Disease===
[[Category:Viral diseases]]
The initial therapy of choice for TE consists of the combination of pyrimethamine plus sulfadiazine plus leucovorin ('''AI''').<ref name="pmid8838183">{{cite journal |author=Katlama C, De Wit S, O'Doherty E, Van Glabeke M, Clumeck N |title=Pyrimethamine-clindamycin vs. pyrimethamine-sulfadiazine as acute and long-term therapy for toxoplasmic encephalitis in patients with AIDS |journal=Clin. Infect. Dis. |volume=22 |issue=2 |pages=268–75 |year=1996 |month=February |pmid=8838183 |doi= |url=http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=8838183 |accessdate=2012-04-09}}</ref><ref name="pmid1727093">{{cite journal |author=Dannemann B, McCutchan JA, Israelski D, Antoniskis D, Leport C, Luft B, Nussbaum J, Clumeck N, Morlat P, Chiu J |title=Treatment of toxoplasmic encephalitis in patients with AIDS. A randomized trial comparing pyrimethamine plus clindamycin to pyrimethamine plus sulfadiazine. The California Collaborative Treatment Group |journal=Ann. Intern. Med. |volume=116 |issue=1 |pages=33–43 |year=1992 |month=January |pmid=1727093 |doi= |url= |accessdate=2012-04-09}}</ref><ref name="pmid3337134">{{cite journal |author=Leport C, Raffi F, Matheron S, Katlama C, Regnier B, Saimot AG, Marche C, Vedrenne C, Vilde JL |title=Treatment of central nervous system toxoplasmosis with pyrimethamine/sulfadiazine combination in 35 patients with the acquired immunodeficiency syndrome. Efficacy of long-term continuous therapy |journal=Am. J. Med. |volume=84 |issue=1 |pages=94–100 |year=1988 |month=January |pmid=3337134 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/0002-9343(88)90014-9 |accessdate=2012-04-09}}</ref><ref name="pmid8366923">{{cite journal |author=Luft BJ, Hafner R, Korzun AH, Leport C, Antoniskis D, Bosler EM, Bourland DD, Uttamchandani R, Fuhrer J, Jacobson J |title=Toxoplasmic encephalitis in patients with the acquired immunodeficiency syndrome. Members of the ACTG 077p/ANRS 009 Study Team |journal=N. Engl. J. Med. |volume=329 |issue=14 |pages=995–1000 |year=1993 |month=September |pmid=8366923 |doi=10.1056/NEJM199309303291403 |url=http://dx.doi.org/10.1056/NEJM199309303291403 |accessdate=2012-04-09}}</ref> Pyrimethamine penetrates the brain parenchyma efficiently even in the absence of inflammation.<ref name="pmid1388895">{{cite journal |author=Leport C, Meulemans A, Robine D, Dameron G, Vildé JL |title=Levels of pyrimethamine in serum and penetration into brain tissue in humans |journal=AIDS |volume=6 |issue=9 |pages=1040–1 |year=1992 |month=September |pmid=1388895 |doi= |url= |accessdate=2012-04-09}}</ref> Use of leucovorin reduces the likelihood of the hematologic toxicities associated with pyrimethamine therapy. The preferred alternative regimen for patients with TE who are unable to tolerate or who fail to respond to first-line therapy is pyrimethamine plus clindamycin plus leucovorin ('''AI'''). <ref name="pmid8838183">{{cite journal |author=Katlama C, De Wit S, O'Doherty E, Van Glabeke M, Clumeck N |title=Pyrimethamine-clindamycin vs. pyrimethamine-sulfadiazine as acute and long-term therapy for toxoplasmic encephalitis in patients with AIDS |journal=Clin. Infect. Dis. |volume=22 |issue=2 |pages=268–75 |year=1996|month=February |pmid=8838183 |doi= |url=http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=8838183|accessdate=2012-04-09}}</ref><ref name="pmid1727093">{{cite journal |author=Dannemann B, McCutchan JA, Israelski D, Antoniskis D, Leport C, Luft B, Nussbaum J, Clumeck N, Morlat P, Chiu J |title=Treatment of toxoplasmic encephalitis in patients with AIDS. A randomized trial comparing pyrimethamine plus clindamycin to pyrimethamine plus sulfadiazine. The California Collaborative Treatment Group |journal=Ann. Intern. Med. |volume=116 |issue=1|pages=33–43 |year=1992 |month=January |pmid=1727093 |doi= |url= |accessdate=2012-04-09}}</ref>
[[Category:Pandemics]]
 
[[Category:Sexually transmitted infections]]
==Related Chapters==
[[Category:Virology]]
*[[Opportunistic infections]]
[[Category:Immunodeficiency]]
 
[[Category:Microbiology]]
==Reference==
[[Category:Emergency mdicine]]
{{reflist|2}}
[[Category:Up-To-Date]]
[[Category:Infectious disease]]

Latest revision as of 22:12, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [18]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [19]; Jesus Rosario Hernandez, M.D. [20]

Overview

It is important to recognize that the relationship between opportunistic infections (OIs) and HIV infection is bi-directional. HIV causes the immunosuppression that allows opportunistic pathogens to cause disease in HIV-infected persons. OIs, as well as other co-infections that may be common in HIV-infected persons, such as sexually transmitted infections (STIs), can adversely affect the natural history of HIV infection by causing reversible increases in circulating viral load that could accelerate HIV progression and increase transmission of HIV. The widespread use of ART starting in the mid-1990s has had the most profound influence on reducing OI-related mortality in HIV-infected persons in those countries in which these therapies are accessible and affordable. Major OIs characteristic of AIDS include viral infections such as CMV retinitis, mucosal HSV, and varicella zoster, bacterial infections such as bacillary angiomatosis, tuberculosis, mycobacterium avium complex, and syphilis, and fungal infections such as cryptococcosis, mucocutaneous candidiasis, coccidiomycosis, and pneumocystis jirovecii pneumonia.

Opportunistic Infections

Bacteria

Disease Description Clinical Findings Diagnosis Prevention / Prophylaxis Treatment
Mycobacterium avium complex (MAC)
  • M. avium is the etiologic agent in 95% of patients with MAC disease
  • The greatest risk of disease occurs among patients with a CD4+ <50 cells/µL
Fever, night sweats, weight loss, fatigue, diarrhea, and abdominal pain. Isolation of MAC from cultures of blood, lymph node or bone marrow. Prophylaxis is indicated when CD4 < 50 cells/µL
(Testing of susceptibility to clarithromycin or azithromycin is recommended)
Respiratory Disease Fever, chills, rigors, chest pain or pleurisy, productive cough, and dyspnea Diagnosis is the same as in HIV-negative patients (chest X-ray, sputum analysis) Pneumococcal and influenza vaccination is recommended for all HIV patients.
Note: Live attenuated influenza vaccine is contraindicated in HIV-infected persons
  • Treatment should be pathogen specific.
  • Empiric therapy:
Enteric Infections Severe and prolonged diarrheal disease, potentially associated with fever, bloody diarrhea, and weight loss.
  • The diagnosis of Gram-negative bacterial enteric infection is established through cultures of stool and blood.
  • Stool sample for C. difficile toxin or polymerase chain reaction assay (if recent antibiotic use)
Antimicrobial prophylaxis to prevent bacterial enteric illness usually is not recommended.
  • Treatment should be pathogen specific.
  • Empiric therapy: Ciprofloxacin 500–750 mg PO q12h
  • Oral or IV hydration therapy as appropriate.
Bacillary Angiomatosis
  • B. henselae and B. quintana infections have been identified in HIV- infected patients
  • The greatest risk of disease occurs among patients with a CD4+ <50 cells/µL
Cutaneous lesions (red, globular and non-blanching, with a vascular appearance), sub-cutaneous nodules. Histopathologic examination of biopsied tissue Primary chemoprophylaxis for Bartonella-associated disease is not recommended
  • Doxycycline 100 mg PO or IV q12h, OR
  • Erythromycin 500 mg PO or IV q6h
Syphilis
  • Treponema pallidum is the causative pathogen.
  • Early syphilis in HIV-infected patients may cause a transient decrease in CD4 count and increase in HIV viral load.
  • Primary: Single painless nodule that ulcerates (chancre) or multiple atypical chancres may be seen.
  • Secondary: More rapid progression or severity in HIV patients. Manifestations include maculopapular skin lesions, condyloma lata, lymphadenopathy, fever, malaise, anorexia, arthralgias, and headache.
  • Terciary: Manifestations of neurosyphilis, such as concomitant uveitis and meningitis, may be more common in HIV-infected persons. Other manifestations include cardiovascular syphilis and gummatous syphilis.
  • Serologic tests: VDRL, RPR, FTA-ABS, TP-PA
  • Darkfield microscopy and tests to detect T. pallidum in lesion exudates or tissue (biopsy with silver stain) are definitive for diagnosing early syphilis
  • Routine serologic screening for syphilis is recommended at least annually for all HIV- infected patients who are sexually active.
  • Prophylaxis is indicated in patients who were exposed sexually within 90 days preceding the diagnosis of primary, secondary, or early-latent syphilis in a sex partner or exposed >90 days before syphilis diagnosis in a sex partner, if serologic test results are not available immediately and the opportunity for follow-up is uncertain.
  • Primary: Benzathine penicillin G 2.4 million units IM for 1 dose
  • Secondary and terciary: Benzathine penicillin G 2.4 million units IM weekly for 3 doses
Table adapted from Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents[1]

Virus

Disease Description Clinical Findings Diagnosis Prevention / Prophylaxis Treatment
Cytomegalovirus Infection
  • The greatest risk of disease occurs among patients with a CD4+ <50 cells/µL
  • Retinitis is the most common clinical manifestation of CMV end-organ disease
  • Colitis occurs in 5% to 10% of patients with AIDS and CMV end-organ disease, clinical manifestations include weight loss, anorexia, abdominal pain, diarrhea, and malaise.
  • Esophagitis occurs in a small percentage of patients
CMV viremia can be detected by PCR, antigen assays, or culture
  • CMV end-organ disease is best prevented by using ART to maintain CD4 count >100 cells/uL
  • Ganciclovir or valganciclovir primary prophylaxis is not recommended.
  • Some specialists recommend yearly funduscopic examination in patients with CD4 < 50 cells/uL
  • Preferred Regimen: Valganciclovir 900 mg PO daily
  • For sight threatening lesions: Add intravitreal injections of ganciclovir or foscarnet to normal regimen.
Herpes Simplex Virus Infection
  • Approximately 70% of HIV-infected persons are HSV-2 seropositive and 95% are seropositive for either HSV-1 or HSV-2.
  • The greatest risk of disease occurs among patients with a CD4+ <100 cells/µL
  • HSV-1: Orolabial herpes (cold sores, fever blisters).
  • HSV-2: Genital herpes (papules, vesicles or ulcers).
  • Non-mucosal HSV infections, such as HSV keratitis, HSV encephalitis, HSV hepatitis, and herpetic whitlow, are similar in presentation to manifestations observed in HIV-seronegative individuals
Viral culture, HSV DNA PCR, and HSV antigen detection are available methods for diagnosis of mucocutaneous lesions. Prophylaxis with antiviral drugs to prevent primary HSV infection is not recommended.

Genital lesions (for 5-14 days):

  • Valacyclovir 1 g PO BID, or
  • Famciclovir 500 mg PO BID, or
  • Acyclovir 400 mg PO TID

Oral lesions (for 5-10 days):

  • Valacyclovir 1 g PO BID, or
  • Famciclovir 500 mg PO BID, or
  • Acyclovir 400 mg PO TID
Varicella-Zoster Virus (VZV) Infection
  • The greatest risk of herpes zoster occurs among patients with a CD4+ <200 cells/µL
  • Because most HIV-infected adults in the United States are VZV seropositive, primary varicella is an uncommon.
  • Varicella rash tends to have a central distribution with lesions first appearing on the head, then trunk, and finally the extremities, evolving through stages of macules, papules, vesicles, pustules, and crusts
  • Herpes zoster manifests as a painful cutaneous eruption in a dermatomal distribution, often preceded by prodromal pain.
  • Diagnosis is made clinically.
  • History of varicella or VZV exposure, a rash that began with a dermatomal pattern, and VZV serologic testing to assess prior VZV infection may be helpful.
  • Avoid exposure to individuals with varicella or herpes zoster.
  • Prophylaxis with antiviral drugs to prevent varicella is not recommended.
  • Varicella vaccination is recommended for patients with CD4 > 200 cells/µL.
  • Post-exposure prophylaxis: VariZIG 125 IU/10 kg IM
  • Valacyclovir 1000 mg PO TID, OR
  • Famciclovir 500 mg PO TID
Human Herpesvirus-8 Infection
  • The greatest risk of herpes zoster occurs among patients with a CD4+ <200 cells/µL
  • Most patients are asymptomatic
  • Kaposi Sarcoma: nontender, purplish, indurated skin lesions.
  • Multicentric Castleman’s disease: generalized adenopathy and fever and can progress to multi-organ failure.
  • Primary effusion lymphoma characteristically presents with effusions of the pleural, pericardial, or abdominal spaces
Diagnosis is made with cytologic and immunologic cell markers Screening is not recommended
  • Kaposi Sarcoma: Start or adjust ART
  • Multicentric Castleman’s disease: Valganciclovir 900 mg PO BID for 3 weeks, or Ganciclovir 5 mg/kg IV q12h for 3 weeks, or Valganciclovir 900 mg PO BID + zidovudine 600 mg PO q6h for 7–21 days.
Human Papillomavirus Infection
  • HPV 16 and 18 are associated with cervical malignancy.
  • HPV 6 and 11 cause 90% of genital warts.
  • Oral, genital, and anal warts (condyloma acuminata) are usually flat, papular, or pedunculated growths on the mucosa or epithelium.
  • Cervical cancer can be asymptomatic or may manifest with bleeding, pain, or a palpable mass.
  • Diagnosis of genital and oral warts is made by visual inspection and can be confirmed by biopsy.
  • Cytology (Pap test) and colposcopic techniques with biopsy are used to detect CIN.
  • HPV vaccination is recommended in HIV infected patients
  • Podophyllotoxin or Imiquimod self-application to warts.
  • Cryotherapy, surgical excision, laser surgery.
Table adapted from Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents [1]

Fungus

Disease Description Clinical Findings Diagnosis Prevention / Prophylaxis Treatment
Pneumocystis Pneumonia

(Click here for more information)
  • Caused by the fungus Pneumocystis jirovecii.
  • 90% of cases occurred among patients with CD4+ <200
  • Incidence among HIV patients: 2-3 cases per 100 person-year
Subacute onset of progressive dyspnea, fever, nonproductive cough, and chest discomfort that worsens within days to weeks. Tachypnea, tachycardia, and diffuse dry rales are found in the physical examination.
  • Clinical presentation, blood tests, or chest x-rays are not pathognomonic for PCP.
    BAL or induced sputum samples are required for a definite diagnosis.
Start TMP-SMX prophylaxis when CD4+ <200 cells/µL or history of oropharyngeal candidiasis.
Discontinue prophylaxis when CD4+ is >200 cells/µL for >3 month.
  • TMP-SMX
  • Administer adjunctive corticosteroids in patients with pO2 <70 mm Hg or arterial-alveolar O2 gradient >35 mm Hg
  • In patients not on ART, ART should be initiated, when possible, within 2 weeks of diagnosis of PCP
Mucocutaneous Candidiasis
  • Candida albicans is the causative agent.
  • Oropharyngeal and esophageal candidiasis are common in HIV-infected patients
  • The greatest risk of disease occurs among patients with a CD4+ <200 cells/µL
  • Oropharyngeal: Painless, creamy white, plaque-like lesions that can occur on the buccal surface, hard or soft palate, oropharyngeal mucosa, or tongue surface.
  • Esophageal: retrosternal burning pain or discomfort along with odynophagia.
  • Usually diagnosed clinically based on the characteristic appearance of lesions (can be scraped off)
  • Definitive diagnosis of esophageal candidiasis requires direct endoscopic visualization of lesions with histopathologic demonstration of characteristic Candida yeast
Routine primary prophylaxis is not recommended

Oropharyngeal:

Esophageal:

Cryptococcosis
  • Cryptococcus neoformans is the causative pathogen.
  • The greatest risk of disease occurs among patients with a CD4+ <100 cells/µL
  • Subacute meningitis or meningoencephalitis with fever, malaise, and headache.
  • Other symptoms such as lethargy, altered mental status, personality changes, and memory loss may be present.
  • CSF analysis shows mildly elevated levels of protein, low-to-normal glucose, and pleocytosis consisting mostly of lymphocytes
  • Opening pressure in the CSF may be elevated
  • Diagnosed through culture of blood or CSF, CSF microscopy with India ink staining, or cryptococcal antigen (CrAg) detection
  • Primary prophylaxis or screening for serum CrAg in asymptomatic patients is not recommended in the US
  • Prophylactic fluconazole or itraconazole can reduce the frequency of primary cryptococcal disease in patients who have CD4 cell counts <100 cells/mm according to prospective RCT.

Induction Therapy:

  • Liposomal amphotericin B 3–4 mg/kg IV daily + flucytosine 25 mg/kg PO QID

Consolidation Therapy:

  • Fluconazole 400 mg PO or IV once daily
Histoplasmosis
  • Histoplasma capsulatum is the causative pathogen.
  • The greatest risk of disease occurs among patients with a CD4+ <150 cells/µL

Fever, fatigue, weight loss, hepatosplenomegaly, cough, chest pain, and dyspnea.

  • Detection of Histoplasma antigen in blood, urine or BAL is a sensitive method for rapid diagnosis of disseminated histoplasmosis and acute pulmonary histoplasmosis.
  • Avoid activities known to be associated with increased risk (areas contaminated of bird or bat droppings)
  • Start prophylaxis with Itraconazole 200 mg PO once daily when CD4+ <150 cells/µL and the patients is at high risk of exposure.

Induction Therapy:

  • Liposomal amphotericin B 3 mg/kg IV daily (for 2 weeks)

Consolidation Therapy:

  • Itraconazole 200 mg PO TID for 3 days, then BID for > 12 months
Coccidioidomycosis
  • Caused by a soil-dwelling fungus that consists of two species, Coccidioides immitis and Coccidioides posadasii.
  • The greatest risk of disease occurs among patients with a CD4+ <250 cells/µL

Focal pneumonia (most common in patients with CD4 >250 cells/µL), diffuse pneumonia, cutaneous disease, meningitis, liver or lymph node involvement.

  • Diagnosis is confirmed by culture.
  • Serology (IgM and IgG) is useful
  • Avoid activities involving exposure to infection while living in or visiting areas in which Coccidioides spp. are endemic.
  • Chemoprophylaxis is not recommended.

Mild infections:

  • Fluconazole 400 mg PO once daily (BII), OR
  • Itraconazole 200 mg PO twice daily

Severe infection

  • Amphotericin B deoxycholate 0.7–1.0 mg/kg IV daily, OR
  • Lipid formulation amphotericin B 4–6 mg/kg IV daily
Aspergillosis
  • Aspergillus fumigatus is the most common causative agent.
  • The greatest risk of disease occurs among patients with a CD4+ <100 cells/µL
Symptoms of pneumonia include fever, cough, dyspnea, chest pain, hemoptysis, and hypoxemia
  • Lung CT: Halo of low attenuation surrounding a pulmonary nodule or a cavity.
  • Bronchoscopic examination demonstrates ulcerative or plaque-like lesions adherent to the tracheal wall
  • Isolation of Aspergillus spp. from respiratory secretions or the finding of septate hyphae consistent with Aspergillus spp. in respiratory samples in association with typical CT findings
Antifungal therapy is not recommended for prevention. Voriconazole 6 mg/kg IV q12h for 1 day, then 4 mg/kg IV q12h , followed by voriconazole PO 200 mg q12h after clinical improvement.
Table adapted from Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents [1]

Parasite

Disease Description Clinical Findings Diagnosis Prevention / Prophylaxis Treatment
Toxoplasma gondii Encephalitis

(Click here for more information)
  • Caused by the protozoan Toxoplasma gondii
  • The greatest risk of disease occurs among patients with a CD4+ <50 cells/µL
  • Primary infection occurs after eating undercooked meat containing tissue cysts or ingesting oocysts that have been shed in cat feces and have sporulated in the environment
Focal encephalitis with headache, confusion, or motor weakness and fever
  • Diagnosis is done with IgG antibodies.
  • CT scan or MRI of the brain will typically show multiple contrast-enhancing lesions, often with associated edema.
  • Definite diagnosis requires a brain biopsy.
  • PET is helpful to distinguish between toxoplasmosis and primary CNS lymphoma.
  • Start TMP-SMX prophylaxis when CD4+ <100 cells/µL
    Discontinue prophylaxis when CD4+ is >200 cells/µL for >3 month.
Administer:
Cryptosporidiosis

(Click here for more information)
  • Caused by the protozoan Cryptosporidium (C. hominis, C. parvum, and C. meleagridis)
  • The greatest risk of disease occurs among patients with a CD4+ <100 cells/µL
Acute or subacute onset of watery diarrhea, nausea, vomiting, lower abdominal pain. Fever is seen in 1/3 of patients. Microscopic examination of oocysts in stool with direct immunofluorescence.
  • Initiate ART
  • Education of possibles ways of transmission (infected patients, diapers, animals)
  • Avoid direct contact of pet stool
  • Scrupulous handwashing is recommended.
  • Initiate or optimize ART for immune restoration to CD4 count >100 cells/mm3
  • Aggressive oral and/or IV rehydration and replacement of electrolyte loss, and symptomatic treatment of diarrhea with anti- motility agent.
Microsporidiosis
  • The microsporidia reported as pathogens in humans include Encephalitozoon cuniculi, Encephalitozoon hellem, Encephalitozoon intestinalis, Enterocytozoon bieneusi, Trachipleistophora hominis, Trachipleistophora anthropophthera, Pleistophora species, P. ronneafiei, Vittaforma corneae, Microsporidium sp, Nosema ocularum, Anncaliia connori, Anncaliia vesicularum, and Anncaliia algerae.
  • The greatest risk of disease occurs among patients with a CD4+ <100 cells/µL

Clinical syndromes can vary by infecting species. The most common manifestation is diarrhea.

  • E. bieneusi is associated with malabsorption, diarrhea, and cholangitis.
  • E. cuniculi is associated with hepatitis, encephalitis, and disseminated disease.
  • E. intestinalis is associated with diarrhea, disseminated infection, and superficial keratoconjunctivitis.
  • E. hellem is associated with superficial keratoconjunctivitis, sinusitis, respiratory disease, prostatic abscesses, and disseminated infection.
  • Anncaliia and Trachipleistophora are associated with keratoconjunctivitis.
  • Nosema, Vittaforma, and Microsporidium are associated with stromal keratitis following trauma in immunocompetent hosts.
  • Pleistophora, Anncaliia, and Trachipleistophora are associated with myositis.
  • Trachipleistophora is associated with encephalitis and disseminated disease.
Examination of 3 stool samples with chromotrope and chemofluorescent stains
  • Patients who have CD4 counts <200 cells/µL should avoid untreated water sources.
  • No specific chemoprophylactic regimens are known to be effective in preventing microsporidiosis.
  • Initiate or optimize ART with immune restoration to CD4 count >100 cells/mm3
  • Severe dehydration, malnutrition, and wasting should be managed by fluid support and nutritional supplements
Table adapted from Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents [1]

Gallery

References

  1. 1.0 1.1 1.2 1.3 "Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Accessed Oct 2014" (PDF). line feed character in |title= at position 93 (help)
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 "Public Health Image Library (PHIL)".