Immunocompromised patients

Cytomegalovirus (CMV) is a herpesvirus, which causes an inapparent infection in immunocompetent persons. Worldwide, approximately 40% of people are infected with CMV. In immunocompromised patients, transplant recipients and neonates, CMV can cause serious and potentially lethal disease manifestations like pneumonia, retinitis and blindness, hepatitis, infections of the digestive tract, deafness or mental retardation. 

CMV, a virus of the herpes family, isa common viral infection. Healthy individuals may beoome infected yet have no symptoms. However, immunocompromised patients (such as those with HIV or cancer) may have the infection. Symptoms include malaise, fever, pneumonia, and super infection. Infants may acquire the virus from the mother while in the uterus, resulting in learning disabilities and mental retardation. CM V can infect the eye, causing retinitis. Symptoms of CMV retinitis are blurred vision and decreased visual acuity. Visual impairment is irreversible and can lead to blindness if untreated. 

RSV infection is highly contagious and infects mostly children, causing bronchiolitis and pneumonia. Infants younger than 6 months are the most severely affected. In adults, RSV causes colds and bronchitis, with fever, cough, and nasal congestion. When RSV affects immunocompromised patients, the consequences can be severe and sometimes fatal. 

Acyclovir (Zovirax) and penciclovir (Denavir) are the only topical antiviral dragp currently available These dragp inhibit viral replication. Acyclovir is used in the treatment of initial episodes of genital herpes, as well as heqies simplex virus infections in immunocompromised patients (patients with an immune system incapable of fighting infection). Penciclovir is used for the treatment of recurrent herpes labialis (cold sores) in adults. 

Antiviral drugp interfere with viral reproduction by altering DNA synthesis. These drug are used in the treatment of herpes simplex infections of the eye, treatment in immunocompromised patients with cytomegalovirus (CMV) retinitis, and for the prevention of CMV retinitis in patients undergoing transplant. 

These dru are contraindicated in patients with hypersensitivity to the drug or any component of the drug. These drugs are used cautiously in immunocompromised patients and during pregnancy and lactation. Some of these solutions contain boric acid and may result in a precipitate that causes irritation. 

Ison MG, Gubareva LV, Atmar RL, Treanor J, Hayden EG (2006a) Recovery of drug-resistant influenza virus from immunocompromised patients a case series, J Infect Dis 193 760-764 Ison MG, Mishin VP, Braciale TJ, Hayden EG, Gubareva LV (2006b) Comparative activities of oseltamivir and A-322278 in immunocompetent and immunocompromised murine models of influenza virus infection, J Infect Dis 193 765-772... 

To translate this approach into clinical scenarios, the risk-benefit assessment of chemotherapy administration in already immunocompromised patients would favor situations in which cytotoxic drugs are indicated anyhow, such as in AIDS-related lymphomas, where alkylating agents are part of the standard regimens. 

Cytomegalovirus (CMV) Enveloped, icosahedral particles 150nm in diameter CMV is generally acquired in childhood as a subclinical infection. About 50% of adults carry the virus in a dormant state in white blood cells. The virus can cause severe disease (pneumonia, hepatitis, encephalitis) in immunocompromised patients. Primary infections during pregnancy can induce serious congenital abnormalities in the fetus... 

Patients with diarrhea should be questioned about the onset of symptoms, recent travel, diet, source of water, and medication use. Other important considerations include duration and severity of the diarrhea along with an accounting of the presence of associated abdominal pain or vomiting, blood in the stool, stool consistency, stool appearance, stool frequency, and weight loss. Although most cases of diarrhea are self-limited, infants, children, elderly persons, and immunocompromised patients are at risk for increased morbidity. 

Several studies have evaluated dietary supplements such as isoflavones, which are found in soy products and red clover. A well-controlled trial in more than 400 postmenopausal women evaluating a specific isoflavone, ipriflavone, found no benefits on bone mineral density or fracture rates after 3 years.47 Nevertheless, because these therapies are available without prescription and are not regulated by the FDA, patients may choose to self-medicate with isoflavones. Lymphocytopenia appeared in several patients treated with ipriflavone in clinical trials. Additionally, ipriflavone should be used with caution in immunocompromised patients or those with renal disease. It may inhibit CYP1A2 and CYP2C9 and may interact with drugs metabolized by those pathways, such as warfarin. 

Clinical improvement should be evident by 72 hours of therapy, as demonstrated by defervescence, reduction in nasal congestion and discharge, and improvements in facial pain or pressure and other symptoms. Patients should be monitored for common adverse events and referred to a specialist if clinical response is not obtained with first- or second-line therapy. Referral is also important for recurrent or chronic sinusitis or acute disease in immunocompromised patients. Surgery may be indicated in complicated cases. 

Once infected with M. tuberculosis, a person s lifetime risk of active TB is about 10%, with about half this risk evident during the first 2 years after infection.2,3,6 Young children, the elderly, and immunocompromised patients have greater risks. HIV-infected patients with M. tuberculosis infection are roughly 100 times more likely to develop active TB than normal hosts owing to the lack of normal cellular immunity.3,9... 

Shigella strains invade intestinal epithelial cells with subsequent multiplication, inflammation, and destruction.8 The organism infects the superficial layer of the gut, rarely penetrates beyond the mucosa, and seldom invades the bloodstream. However, bacteremia can occur in malnourished children and I immunocompromised patients. 

Follow-up is dependent on the CSF findings. If pleocytosis is present, re-examine the CSF every 6 months until the WBC count normalizes. Consider recommending a second course of treatment if the CSF white count does not decline after 6 months or completely normalize after 2 years.15 Failure to normalize may require retreatment most treatment failures occur in immunocompromised patients. 

Two to three weeks of fluconazole or itraconazole solution are highly effective and demonstrate similar clinical response rates.32 Doses of 100 to 200 mg are effective in immunocompetent patients but doses up to 400 mg are recommended for immunocompromised patients. Due to variable absorption, ketoconazole and itraconazole capsules should be considered second-line therapy. In severe cases, oral azoles may prove ineffective, warranting the use of amphotericin B for 10 days. Although echinocandins and voriconazole are effective in treatment of esophageal candidiasis, experience remains limited. 

Twenty percent of HIV-infected patients develop fluconazole-resistant Candida albicans isolates after repeated exposure to fluconazole.33 To treat fluconazole-resistant oropharyngeal candidiasis, daily itraconazole for 2 to 4 weeks may be used. Oral itraconazole solution exhibits a mycological cure rate of 88% and a clinical cure rate of 97% in immunocompromised patients.34 Fluconazole-resistant esophageal candidiasis should be treated with intravenous amphotericin B or caspofungin. 

If immunocompromised patients experience frequent or severe recurrences, particularly of esophageal candidiasis, chronic maintenance therapy with fluconazole 100 to 200 mg daily should be considered. In patients with infrequent or mild cases, secondary prophylaxis is not recommended. The rationale for not giving prophylaxis includes availability of effective treatments for acute episodes, risk of developing resistant organisms, potential for drug interactions, and the cost of therapy. 

Secondary prophylaxis or suppressive therapy is recommended for endemic mycoses in immunocompromised patients, especially in hosts with pronounced defects in T-cell-mediated immunity (i.e., AIDS). 

Immunocompromised patients on fluconazole with progressive sinus or pulmonary disease by radiography should be evaluated for possible mold infection. 

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