Fungal infections commonly found in association with HIV/AIDS include: Cryptococcus neoformans, Pneumocystic jivoreci, Candida species, Histoplasma capsulatum and several others.
Major cause of meningitis in HIV infected persons and disseminated disease may occur. Contrary to bacterial meningitis, fever may be absent in these cases. Diagnosis depends on demonstration of positive CSF Indian Ink preparation.
The preferred regimen is Amphotericin B 0.7mg/kg/day IV + 5 Fluorocytosine 100m/kg/day orally fr 14 days, for induction phase, then Fluconazole 400mg/kg/day for 8 weeks until CSF is sterile (consolidation phase)
Maintenance therapy is Fluconazole 200mg per day (suppressive phase)
Fluconazole I.V. 400mg/day x 10 days until the patient can take orally then continue with the same dose for 10 weeks. Thereafter maintain 200 mg daily on alternate days as secondary chemoprophylaxis (is this WHO regime??)
Is the most common fungal infection in HIV/AIDS.
Clinical manifestations depend on the site of disease which include oral, pharynx, esophagus, vagina, etc.
NB. Candidiasis in the esophagus, trachea, bronchi or lungs is diagnostic of AIDS
The diagnosis is mainly based on clinical findings.
The following drugs are recommended:-
2% sodium benzoate solution
Nystatin oral suspension
Fluconazole 150mg/day or 200mg/day for 2-3 weeks (for oro-pharyngeal candidiasis and others).
NB. Treatment is continued until symptoms resolve
Pneumocystis jiroveci pneumonia (PCP)
Quite common in Tanzania especially among HIV infected children.
Typically patients with PCP present with:
Non-productive cough, fever, chest tightness and shortness of breath that has evolved over 2-4 weeks.
Chest signs may be minimal despite severe shortness of breath
CXR may show diffuse and symmetrical increased interstitial markings to diffuse alveolar pattern with infiltrations characterized by asymmetry, nodularity or cavitations. Chest radiograph may appear normal in 10-30% of patients.
In our circumstances diagnosis is based on clinical presentation and exclusion of other common causes of severe dyspnoea.
Treatment of PCP
Trimethoprim 12-15 mg/kg/day + Sulphamethoxazole 75 mg/kg/day - PO/IV for 21 days in 3 divided doses, or cotrimoxazole 1920 mg 3 times/day for 21 days
For those allergic to sulpha:
Trimethoprim 12-15mg/kg/day + Dapsone 100mg/day for 21 days
Prophylaxis therapy for PCP
Give Trimethoprim-sulphamethoxazole (TMP-SMX) as shown above.