Histoplasmosis, with AIDS

It is indicated in mucosal candidiasis, systemic candidiasis, crypttococcosis, prophylaxis of fungal infections following cytotoxic chemotherapy or radiotherapy maintenance to prevent relapse of cryptococcal meningitis in patients with AIDS sporotrichosis, histoplasmosis and vaginal candidiasis. 

Liposomal amphotericin (3 mg/kg/day) has been compared with conventional amphotericin (0.7 mg/kg/day) for induction therapy of moderate to severe disseminated histoplasmosis in a randomized, double-blind, multicenter trial in 81 patients with AIDS (119). The duration of induction was 2 weeks, to be followed by 10 weeks of itraconazole in the case of a response. Clinical success was achieved in 14 of 22 patients treated with conventional amphotericin compared with 45 of 51 patients who received liposomal amphotericin (difference, 24% 95% Cl = 1%, 52%). Culture conversion rates were similar. Three patients treated with conventional amphotericin and one treated with liposomal amphotericin died during induction. Infusion-related adverse effects were more common with conventional amphotericin (63%) than with liposomal amphotericin (25%). Nephrotoxicity occurred in 37% of patients treated with conventional amphotericin and 9% of patients treated with liposomal amphotericin. The results of this study suggest that liposomal amphotericin is less toxic than conventional amphotericin and is associated with improved survival. 

Johnson PC, Wheat LJ, Cloud GA, Goldman M, Lancaster D, Bamberger DM, Powderly WG, Hafner R, Kauffman CA, Dismnkes WE. U.S. National Institnte of Allergy and Infectious Diseases Mycoses Study Group. Safety and efficacy of hposomal amphotericin B compared with conventional amphotericin B for indnction therapy of histoplasmosis in patients with AIDS. Ann Intern Med 2002 137(2) 105-9. 

Adult patients with AIDS demonstrate an acute form of disseminated disease that resembles the syndrome seen in infants and children. Progressive disseminated histoplasmosis (PDH) can occur as the direct result of initial infection or because of the reactivation of dormant foci. In endemic areas, 50% of AIDS patients demonstrate PDH as the first manifestation of their disease. Progressive disseminated histoplasmosis is characterized by fever (75% of patients), weight loss, chills, night sweats, enlargement of the spleen, liver, or lymph nodes, and anemia. Pulmonary symptoms occur in only one-third of patients and do not always correlate with the presence of infiltrates on chest roentgenogram. A clinical syndrome resembling septicemia is seen in approximately 25% to 50% of patients. 

Butke DG, Emancipatot SN, Smith MG, et al. Histoplasmosis and kidney disease in patients with AIDS. Clin Infect Dis. 1997 25 281-284. 

Amphotericin B is the treatment of choice for mucormycosis and is used for initial treatment of cryptococcal meningitis, severe or rapidly progressing histoplasmosis, blastomycosis, coccidioidomycosis, penicilliosis mameffei, and in patients not responding to azole therapy of invasive aspergillosis, extracutaneous sporotrichosis, fusariosis, altemariosis, and trichosporonosis. Amphotericin B is given once weekly to prevent relapse in patients with AIDS who have been treated successfully for cryptococcosis or histoplasmosis. 

In the AIDS patient with progressive disseminated histoplasmosis, the diagnosis is best established by bone marrow biopsy and culture, which yield positive cultures in 90% of patients. 

As a percentage of AIDS patients presenting with histoplasmosis as the initial manifestation of their disease,... 

Asymptomatic patients with histoplasmosis are not treated, although non-AIDS patients with evident disease are treated with either oral ketoconazole or intravenous amphotericin B AIDS patients are treated with amphotericin B and then receive lifelong suppression. 

Fungal infections have emerged as a major cause of death among cancer patients and transplant recipients. In addition, patients with acquired immune-deficiency syndrome (AIDS) experience substantially more frequent and severe forms of cryptococcosis, histoplasmosis, coccidioidomycosis, and mucocutaneous (esophageal, oral, and vulvovaginal) candidiasis. 

After the initial course of therapy for histoplasmosis is complete, lifelong suppressive therapy with oral azoles or amphotericin B (1-1.5 mg/kg weekly or biweekly) is recommended because of the frequent recurrence of infection. Relapse rates in AIDS patients not receiving maintenance therapy range from 50% to 90% ... 

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