2 management of opportunistic infections and general ... · aids-related opportunistic infections...
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2
2 management of Opportunistic Infections and General Symptoms of HIV/AIDS
ClinicalProtocolfortheWHOEuropeanRegion
2ManagementofOpportunisticInfectionsandGeneralSymptomsofHIV/AIDS
ClinicalProtocolfortheWHOEuropeanRegion
Edited by:Irina EramovaSrdan Matic Monique Munz
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Keywords
CLINICAL PROTOCOLSAIDS-RELATED OPPORTuNISTIC INfECTIONSHIV INfECTIONS – THERAPYGuIDELINESEuROPE
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Table of contents
Abbreviations .............................................................................................................................9-iv
Acknowledgements ....................................................................................................................9-vi
I. Principles .................................................................................................................................. 9-1
II. Management of opportunistic infections ............................................................................. 9-2 1. General information ............................................................................................................. 9-2 2. Initial evaluation .................................................................................................................. 9-2 3. Counselling patients on OIs and other conditions ............................................................... 9-3 4. OI prophylaxis in HIV-infected patients .............................................................................. 9-4 5. Diagnosis and treatment of OIs ........................................................................................... 9-4 5.1. Respiratory infections ................................................................................................... 9-4 5.1.1. Bacterial respiratory infections ........................................................................... 9-5 5.1.2. Atypical mycobacteriosis .................................................................................... 9-7 5.1.3. Pneumocystis pneumonia ................................................................................... 9-8 5.1.4. Other causes of pneumonia in immunosuppressed people ................................. 9-9 5.2. Gastrointestinal infections ........................................................................................... 9-9 5.3. Candidiasis ................................................................................................................. 9-10 5.4. Cryptococcal meningitis ............................................................................................. 9-13 5.5. Histoplasmosis ............................................................................................................ 9-14 5.6. Kaposi sarcoma .......................................................................................................... 9-15 5.7. Cervical cancer ........................................................................................................... 9-16 5.8. Other cancers .............................................................................................................. 9-16 5.8.1. Non-Hodgkin lymphoma .................................................................................. 9-16 5.8.2. Burkitt-type lymphoma in PLWHA .................................................................. 9-17 5.9. Neurological infections .............................................................................................. 9-18 5.9.1. Toxoplasmosis .................................................................................................. 9-18 5.9.2. Herpes simplex virus ........................................................................................ 9-19 5.9.3. Herpes zoster .................................................................................................... 9-20 5.9.4. Cytomegalovirus infection ............................................................................... 9-21 5.9.5. Epstein-Barr virus-related conditions ............................................................... 9-22
III. General symptoms .............................................................................................................. 9-24 1. Persistent generalized lymphadenopathy in adults .......................................................... 9-24 2. fever ................................................................................................................................ 9-25 3. Weight loss in adults ........................................................................................................ 9-25 4. Chronic diarrhoea in adults .............................................................................................. 9-25 5. Oral lesions ...................................................................................................................... 9-26 6. Skin and nail conditions ................................................................................................... 9-26 6.1. Dermatomycosis ....................................................................................................... 9-26 6.2. Onychomycosis ......................................................................................................... 9-27 6.3. Seborrhoeic dermatitis .............................................................................................. 9-27 6.4. Scabies ...................................................................................................................... 9-28 6.5. Staphylococcal folliculitis......................................................................................... 9-29 6.6. Molluscum contagiosum ........................................................................................... 9-29
References .................................................................................................................................. 9-30
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HIV/AIDSTREATMENTANDCARECLINICALPROTOCOLSFORTHEWHOEUROPEANREGION
AbbreviationsAfB acid-fast bacilliAIDS acquiredimmunodeficiencysyndromeART antiretroviral treatment BID twice dailyCAT computerized axial tomographyCD4 cell cluster of differentiation antigen 4 cellCHOP cyclophosphamide, hydroxydaunomycin (doxorubicin), Oncovin (vincristine) and prednisolone (a chemotherapy regimen)CIN cervical intraepithelial neoplasmaCMV cytomegalovirusCNS central nervous systemCRP C-reactive proteinCSF cerebrospinalfluidDNA deoxyribonucleic acidEBV Epstein-Barr virusEfV efavirenzEPOCH etoposide, prednisolone, Onconvin (vincristine), cyclophosphamide and hydroxorubicin (doxorubicin) (a chemotherapy regimen)GI gastrointestinalGII gastrointestinal infectionHAART highly active antiretroviral treatmentHHV6 human herpes virus 6HHV8 human herpes virus 8HIV humanimmunodeficiencyvirusHPV human papillomavirusHSV herpes simplex virusHSV 1/2 herpes simplex virus 1 and 2IDu injecting drug userIgG immunoglobulin GIM intramuscularlyINH isoniazidIu international unitIV intravenous, intravenouslyKOH potassium hydroxideKS Kaposi sarcomaKSHV Kaposi sarcoma herpesvirusLIP lymphocytic interstitial pneumonitisMAC Mycobacterium avium complexMAI Mycobacterium avium-intracellulareMRI magnetic resonance imagingNHL non-Hodgkin lymphomaNSAID non-steroidanti-inflammatorydrugOD once dailyOI opportunistic infectionOPC oropharyngeal candidiasisPCP Pneumocystis jirovecii pneumonia (formerly Pneumocystis carinii pneumonia)
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support for sexual and reproductive health in people living with hiv/aids
PCR polymerase chain reactionPGL persistent generalized lymphadenopathyPML progressive multifocal leukoencephalopathyPI protease inhibitorsPLWHA people living with HIV/AIDSPO per os (orally)PPD purifiedproteinderivative(tuberculinskintestreagent)QID four times dailyQW once weeklyRTV ritonavirSO2 oxygen saturationTB tuberculosisTID three times dailyTIW three times weeklyTMP-SMZ trimethoprim-sulfamethoxazole (cotrimoxazole)VZV varicella-zoster virusWHO World Health Organization
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HIV/AIDSTREATMENTANDCARECLINICALPROTOCOLSFORTHEWHOEUROPEANREGION
AcknowledgementsThis clinical protocol has been developed and written by Christian Traeder (Vivantes Auguste-Victoria-Klinikum, Germany). It is one of 13 clinical protocols released by the WHO Regional OfficeforEuropein2006asapartoftheHIV/AIDSTreatmentandCareClinicalProtocolsfortheWHO European Region.
The editors and the writer gratefully thank the following experts for reviewing and commenting on the information to ensure the technical accuracy of the protocol: Keikawus Arastéh (Vivantes Auguste-Victoria-Klinikum, Germany), Josip Begovac (university Hospital of Infectious Diseases, Croatia),VolodimirKurpita(WHOcountryoffice,Ukraine),AlexanderPolischukandNinaSau-tenkova(bothfromWHORegionalOfficeforEurope,Denmark).
SpecialthanksgotothefollowingpeopleattheWHORegionalOfficeforEuropewhocontributedat various stages of production: Bente Drachmann, Nico Kerski, Jeffrey V. Lazarus and Andrea Nelsen.
Irina Eramova, Srdan Matic and Monique MunzSexually transmitted infections/HIV/AIDS programme
WHO Regional Office for Europe
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management of opportunistic infections and general symptoms of hiv/aids
I. Principles
• Management of opportunistic infections (OIs) is an essential component of comprehensiveHIV/AIDStreatmentandcare.
• AllpatientswithOIs–irrespectiveofgenderorsocialclassandincludinginjectingdrugus-ers(IDUs),sexworkers,prisoners,immigrantsandothervulnerablepopulations–shouldbetreated.Thedecisionofwhomtotreatshouldbebasedexclusivelyonmedicalconsiderations.
• TreatmentforcomorbiditiesshouldnotstopwhileOIpreventionand/ortreatmentisbeingpro-vided.
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HIV/AIDS TREATMENT AND CARE CLINICAL PROTOCOLS FOR THE WHO EUROPEAN REGION
II. Management of opportunistic infections
�. General informationHIV-relatedinfectionsandillnessesincludethefollowing.
Table �. hiv-related infections and illnesses
Bacterial infections Fungal infections Viral infections Parasitic
infections Other illnesses
TuberculosisBacterialrespira-toryinfectionsBacterialentericinfectionsAtypicalmyco-bacteriosisBartonellosis
CandidaoesophagitisCryptococcosisHistoplasmosisPneumocystisjiroveciipneumonia(PCP)Coccidioidomycosis
Herpessimplexvirus(HSV)diseaseVaricella-zostervirus(VZV)diseaseCytomegalovirus(CMV)diseaseHumanherpesvirus8(HHV8)infection,alsoknownastheKaposisar-comaherpesvirus(KSHV)Humanpapillomavirus(HPV)infectionProgressivemultifocalleu-koencephalopathyHepatitisBandC(naturalcourseofinfectioniswors-enedbyHIVcoinfection)
ToxoplasmosisCryptosporidiosisMicrosporidiosisIsosporiasisLeishmaniasis
Kaposisarcoma(KS)Non-Hodgkinlym-phoma(NHL)CervicalcancerEncephalopathyVacuolarmyelopathy
ThemostcommonOIsintheWHOEuropeanRegioninclude:• tuberculosis(TB)• bacterialinfections• PCP• herpesinfections(includingherpeszoster,CMV,HSV1and2(HSV1/2)• Candida oesophagitis• Cryptococcus meningitis• toxoplasmosis.
Lessfrequentopportunisticinfectionsandcancersinclude:• Mycobacterium aviumcomplex(MACorMAI)disease• KS• NHL• CMVinfection(retina,gastrointestinal(GI)tract,encephalitis).
Theorderofinfectionsandcancersinthelistmaychange,duetofactorsthatmayormaynotberelatedtotheHIV/AIDSepidemic.
�. Initial evaluationPatientswithunknownHIVstatuswhopresentwithinfectionsorillnessesthatareassociatedwithHIVinfectionshouldbeofferedHIVtestingandcounselling.ThephysicianshouldexplaintothepatientthereasonsforofferinganHIVtestandtheimportanceofknowingtheresultsforcorrectclinicalmanagement.However,patientshavetherighttorefusetesting(optout).
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management of opportunistic infections and general symptoms of hiv/aids
TheinitialassessmentofHIVstatusshouldinclude:• HIVpretestcounselling;• serologicaltesting(typicallyELISAand/orrapidtests)forHIVantibodies,followedbyawest-
ernblotconfirmatorytest(whichindicatesHIVinfectioniftheresultispositive);and• post-test counselling–whether the result ispositiveornegative– including informationon
reducingriskybehaviour.
IfthepatientisHIV-positive, aninitialclinicalevaluationshouldbemadetodeterminetheclinicalstageoftheinfectionandidentifycomorbiditiesandconditions.(FormoreinformationpleaserefertoProtocol1,Patient evaluation and antiretroviral treatment of adults and adolescents)
�. Counselling patients on OIs and other conditions• Physiciansandnursesshouldcounselallpatientsand/orfamiliesaboutthechronicnatureof
HIVinfectionandthepossibleappearanceofOIs.• PatientsshouldbeinformedthatsomeOIscanbeprevented(seeTable2below).• Theyshouldknowthatitisessentialtodiagnoseanopportunisticinfectionearly,sothatthey
consulttheirphysicianwhentheysuspectanydiseaseprogressionmaybeoccurring.• TheyshouldbecounselledonsymptomsthatmightindicateOIsandtheneedtoinformtheir
physicianaboutthem: ° dyspnoea:Pneumocystis jirovecii pneumonia(PCP),TB,pneumonia; ° cough:PCP,TB,pneumonia; ° bloodysputum:TB,pneumonia; ° neurologicalchanges:cerebraltoxoplamosis,cerebrallymphomaormeningitis/encephalitis; ° weightloss,fever,nightsweats:TB,atypicalTB,lymphoma; ° visualimpairment:CMVretinitis; ° painfulswallowing:candidaoesophagitis;or ° diarrhoea:CMVcolitis,infectionwithcryptosporidiae,microsporidiae,salmonellosis,etc. ° visualfieldloss(readinganewspaperisagoodandsensitivetest); ° weaknessofarmsorlegs(cerebraltoxoplasmosis); ° anychangeofmentalstatusorbehaviouralsignsthatmaysignalmentalhealthproblems
(asobservedbyfriendsandfamilymembers;herpesmeningitis,toxoplasmosis,progressivemultifocalleukoencephalopathy(PML),etc.)
° changeinskinconditionsor(moreoften)oralthrush(possibleantiretroviraltreatment(ART)failure).
• Patientsshouldknowtheimportanceofmonitoringtheirchronicconditions. ° Patientswithchronichepatitisshouldhaveanabdominalultrasoundtwiceayearbecauseof
theriskofhepatocellularcarcinoma. ° PatientswithahistoryoftuberculosisshouldhaveachestX-rayonceayear. ° OlderoverweightHIVpatientswhohavehypertensionandareon anART regimen that
includesaproteaseinhibitor(PI)mustbecheckedforcardiovasculardisease,diabetesandotherconditions.
• Patientsshouldbegivenachecklistthatincludesascheduleoflaboratoryandclinicalteststobeundertakenonaregularbasis.Thecontentofthislistmayvaryduetocomorbidities.
For further informationoncounselling issuesplease refer toProtocol1,Patient evaluation and antiretroviral treatment for adults and adolescents.
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HIV/AIDS TREATMENT AND CARE CLINICAL PROTOCOLS FOR THE WHO EUROPEAN REGION
�. OI prophylaxis in HIV-infected patients• CertainOIsthatmaydevelopinpeoplelivingwithHIV/AIDS(PLWHA)canbeprevented.• ProphylaxisofOIsinPLWHAshouldbeanintegralpartofOImanagement.• After initiatingART, it ispossible todiscontinueprimaryprophylaxis if theCD4counthas
risenovertherelevantindicationlevelfor3–6months(e.g.PCP:>200cells/mm3,toxoplasmo-sis:>100cells/mm3,MAI:>50cells/mm3).SeeTable2below.Discontinuationofsecondaryprophylaxisshouldalsobepossibleinthesamesituationwithclosemonitoring.AlwaysrestartprophylaxiswhenCD4countsfallbelowtheindicationlevel.
Table2summarizesthemostrecentrecommendationsforprophylaxisstrategy.
table 2. oi prophylaxis for hiv-infected patients
Pathogen Indication First choice AlternativesPneumocystis jirovecii
CD4count<200cells/mm3
ororopharyngealcandi-diasis
TMP-SMZ(cotrimoxa-zole)double-strengthtabletPOaODb
• TMP-SMZsingle-strengthtabletPOOD(1)
• TMP-SMZdouble-strengthtabletPOTIWc(Monday,WednesdayandFriday)
• Dapsone50mgPOBIDd
• Dapsone100mgPOOD(2)• Pyrimethamine50mg
+dapsone50mg+folinicacid15mgOD
• Pentamidineinhalation300mgeverythreeweeks(3)
• Alsopossible:clindamycinoratova-quone(4, 5)
M. tuberculosis Purified protein derivative(PPD)reaction ≥5 mmorrecentcontactwithacaseofactiveTB
Isoniazid(INH)300mgPO+pyridoxine50mgPOODfor6months(6)
Furtherresearchisneededfordevelop-ingalternativeprophylaxistreatmentforTBinareaswithhighprevalenceofINHresistance.
Toxoplasma gondii, primary
CD4count<100cells/mm3
TMP-SMZdouble-strengthtabletPOOD
• TMP-SMZsingle-strengthtabletPOOD(7, 8)
• Dapsone50mgPOOD +pyrimethamine50mgPOQWe
+folinicacid25mgPOQWToxoplasma gondii, secondary
CD4count<100cells/mm3
TMP-SMZdouble-strengthtabletPOOD
Dapsone50mgPOOD+pyrimethamine50mgOD+folinicacid15–25mgOD
M. avium complex CD4count<50cells/mm3
Azithromycin1200mgPOQW
Clarithromycin500mgPOBID(9, 10)
Cryptococcus neo-formans
CD4count<50cells/mm3
Fluconazole100–200mgPOOD(11)
aPO:peros;bOD:oncedaily;cTIW:threetimesweekly;dBID:twicedaily;eQW:onceweekly
5. Diagnosis and treatment of OIs
5.�. Respiratory infections• Lower respiratory tract infectionsare themostcommonrecurrent infections inPLWHA.
Theyareusuallylife-threateningandcanbecausedbybacteria,viruses(rarely)andfungi(alsorarely).
• Patientsmaypresentearly in thecourseofHIV infectionwithbacterialpneumonias,whichrespondreadilytoantibiotics(12).
• PatientswithHIVinfectionappeartobeparticularlypronetoinfectionswithencapsulatedor-ganismssuchasStreptococcus pneumoniaeandHaemophilus influenzae (13).
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management of opportunistic infections and general symptoms of hiv/aids
• Later,andwiththeonsetofimmunesuppression,patientsmaydevelopopportunisticpulmo-naryinfections,themostimportantofwhichispulmonaryTB.
• As cell-mediated immunity deteriorates, patients may develop life-threatening opportunisticinfectionssuchasPCPandseverefungalandviralpneumonias.Table3summarizestherespira-toryillnessesassociatedwithHIVinfection.
table 3. respiratory illness in plWha
Type of infection Possible complicationsa
BacterialPneumococcalpneumonia Empyemab,pleuraleffusion,lungabscessH. influenzapneumonia Pleuraleffusionb,lungabscess,empyema,Klebsiellapneumonia Empyemab,pleuraleffusionStaphylococcalpneumonia Lungabscessb,empyema,pleuraleffusionM. tuberculosispneumonia Pericardialeffusion,lungabscess,empyema,pleuraleffusionMACpneumonia Rarecomplications:AbscessesespeciallywithIRISViralCytomegalovirus Pneumonitisb(highlylethal)Herpessimplexvirus Pneumonitisb(highlylethal)FungalPneumocystispneumonia PneumothoraxCryptococcosisHistoplasmosisAspergillosis LungabscessOther conditionsKS PleuralorpericardialeffusionLymphoma PleuralorpericardialeffusionCarcinoma(non-HIV-related) Pericardialeffusion
a Possiblecomplicationsareintheorderofthefrequencytheoccur.b Complicationsthatoccurmostfrequently.
5.�.�. Bacterial respiratory infections
• Bacteriallowerrespiratorytractinfectionsarecommoninthegeneralpopulation,buttheyaremorefrequentandmoresevereinimmunosuppressedpersonswithHIVinfection.
• S. pneumoniae isthemostcommonlowerrespiratorytractpathogen.• Patientswithbacterialpneumoniapresentwithcoughandfeverandoftenhavechestpain,dif-
ficultyinbreathingandtachypnoea.• ChestX-raysmayshowclassic lobarpneumonia,bronchopneumoniaoratypical (orabsent)
infiltrates.
DiagnosisThediagnosisofpneumoniaisusuallymadeonclinicalgroundsandbyachestX-ray,whichmayreveal:• lobarorpatchyconsolidation• diffuselunginfiltratesor• atypicalchanges,includingcavitarydisease.
Treatment• IfthepatientisnotseverelyillandnoPCPissuspected,treatmentmaybeprovidedathome
accordingtoTables4and5below.
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HIV/AIDS TREATMENT AND CARE CLINICAL PROTOCOLS FOR THE WHO EUROPEAN REGION
Table �. first-line antibiotic treatment of bacterial pneumonia
Antibiotic Dose Frequency Route DurationAmoxicillin
(Useapenicillinincombinationwithbetalactamaseinhibi-torifthereisachanceofpenicillin/ampicillinresistance.)
500–1000mg TIDa PO 7daysorlongeruntil
resolvedor:
Erythromycin 500mg QIDb PO 7daysor:
Clarithromycin 500mg BID PO 7daysor:
Azithromycin 500mg OD PO 3–4daysor:
Quinolone with pneumococcal activitiy (e.g. moxifloxacin) 400mg OD PO 7daysor:
Doxyciclin 100mg BID PO 7daysaTID:threetimesdaily;bQID:fourtimesdaily
• Ifpatientsdonotrespondtofirstlinetreatmentoveraperiodof72hours(nofever,C-reactiveprotein(CRP)elevationresolved,leukocytecountisnotreliable),thepatientshouldbereferredtothehospitalandsecondlinetreatmentprescribedasindicatedbelow.Patientsmayalsore-quireoxygen(inthiscasePCPshouldbesuspected).
• Severelyillpatientsshouldbereferredforhospitaladmissionimmediately.
Table 5. second line treatment of bacterial pneumonia
Antibiotic Dose Frequency Route DurationCeftriaxone
+erithromycin
2g
500mg
OD
QID
IV* 7days
or:Ampicillin+sulbactam
+erythromycin
1500mg
500mg
TID
QID
IV 7days
or:Quinolone with pneumococcal activitiy (e.g. moxifloxacin) 400mg OD IV/PO 7days
or:Chloramphenicol(ifotherdrugsarenotavailable) 12.5mg(base)
perkgofbodyweight
QID IV 7days
*intravenously
• Ifpatientsdonotrespondtothistreatment,considerPCPorTBasapossiblediagnosis.Thediagnosticgoldstandardislavagebybronchoscopytodefinethepathogenbeforestartinganti-biotics(14).Alsohelpfularebloodcultures,whichhaveahigherrateofpneumococcalidenti-ficationandmaybedoneuptofivetimes.
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management of opportunistic infections and general symptoms of hiv/aids
5.�.�. Atypical mycobacteriosis
Mycobacterium aviumcomplex(MACorMAI)disease is lesscommonthansomeotherOIs. Itpresentswith:• fever• weightloss• nightsweats• diarrhoea• wasting.
MACorganismsmaybefoundinthebloodandexcretaofinfectedpersons.Adefiniteinfectioncanbeshownwithacid-fastbacilli(AFB)insterilefluidsorspecimens(blood,cerebrospinalfluid,bonemarrowandliver).
Diagnosis• BloodculturesonspecialmediaarethecornerstoneofMACdiagnosis.• Inmostsymptomaticpatients,theintensityofmycobacteraemiaissuchthatmostorallblood
culturesarepositive.• BecausetheliverandbonemarrowareofteninvolvedindisseminatedMACinfection,thebac-
teriamaybevisibleinacid-fast-stainedbiopsysamplesfromthesesites.• Presumptivediagnosisbyexaminationofabiopsiedliverspecimensavestime.
Treatment
Table �. atypical mycobacteriosis treatment
Antibiotic Dose Frequency Route DurationFirst-line treatment (15, 16)
Clarithromycin+
ethambutol+
rifabutin
500mg–1000mg BID PO 6months;decideonclinicalgrounds
15mg/kg OD PO 6months;decideonclinicalgrounds
300–450mg OD PO 6months;decideonclinicalgrounds
Other drugs active against MACa
Azithromycin 500–1200mg OD PO 6monthsCiprofloxacin 500mg BID PO 6months
Amikacin 15mg/kg/dayor7.5mg/kg/day
ODBID
IVIV
Nolongerthan4weeks
aRifampicinisnoteffectiveagainstMAC.
• OnceMACtreatmenthasbeenstarted,andthereisindicationthattheconditionisimprovingandthedrugsarewelltolerated,ARTshouldbeinitiated.
• Standardprocedure is tostartonART4–6weeksafterMACtreatmenthasbegun.Aftersixmonthswithanimprovedimmuneresponse(CD4count>100 cells/mm3),reduceMACtreat-mentorstopitanduseasecondaryprophylaxis.
• Stoppingthesecondaryprophylaxisispossiblewhentheimmunesystemisstableandrespon-siveformorethan3–6months.
• MACtreatmentorsecondaryprophylaxisshouldbeadministeredforsixmonthstoensureasuccessfultreatmentandavoidrelapse.
• It isimportanttobeginwithtreatmentforMACtoavoidconfusionaboutwhetheranyside-effectscomefromMACdrugsorART.
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HIV/AIDS TREATMENT AND CARE CLINICAL PROTOCOLS FOR THE WHO EUROPEAN REGION
• Thereisthepossibilityofimmunereconstitutioninflammationsyndrome(IRIS)afterstartingART(seeProtocol1,Patient evaluation and antiretroviral treatment for adults and adolescents,sectionsClinicalfailureandImmunereconstitutioninflammatorysyndrome).
5.�.�. Pneumocystis pneumonia
• PCPisacommonHIV-associatedOI,causedbythefungusPneumocystis jirovecii(formerlyknownasPneumocystis carinii).
• Patientsusuallypresentwithcough,shortnessofbreathandfever.• OccasionallypatientswithPCPhavenochestsigns.• PatientswithPCPoftenhavefeaturesofrespiratoryfailuresuchasshortnessofbreathandcya-
nosis.• Symptomsmaybeverysevere;anattackofPCPmayleadtodeathifnottreatedearlyandef-
fectively.
Diagnosis• DiagnosisisoftenmadeonclinicalgroundswhenafebrilePLWHApresentswithrespiratory
distress,withorwithoutcyanosis.• Thepatientmayhaveanon-productivecough,butthemainfeatureoftheconditionisshortness
ofbreath,withminimalorabsentchestsignsonphysicalexamination.• ChestX-rays ° Thereisnotalwaysaground-glassopacificationinthelowerzonesofbothlungfields. ° Theremaybeevidenceofpatchyinfiltratesinbothlungfieldsthatmimicsbacterialpneu-
moniaorTB. ° AconsiderableproportionofpatientswithconfirmedPCPshownochangesatallontheX-
ray.• Bronchiallavageisthegoldstandardofdiagnosis(14).Diagnosisisconfirmeduponfinding
cystsofPneumocystisinforcedsputumorinbronchiallavageaspirate.• Ifdiagnosiscannotbeestablishedduetothelackofabronchoscope,deterioratingpulmonary
functiontestsorbloodgasanalysiscanbeusedasindicators.• Treatmentshouldbestartedimmediatelyupondiagnosis.
TreatmentPatientsshouldbeadmittedtohospitalformanagement.Supportivetherapyincludingoxygenmaybenecessary.DetailsoftreatmentaregiveninTables6and7below.
Table �. pcp first-line treatment
Antimicrobial agent Dose Frequency Route DurationTMP-SMZ 400/80mg QID PO/IV 21days
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management of opportunistic infections and general symptoms of hiv/aids
Table �. pcp second-line treatment
Antimicrobial agent Dose Frequency Route DurationClindamycin
+primaquine
600mg
15mg
QID
BID
PO/IV
PO
21days(17)
or:Pentamidine(incombinationwithabroad-spectrumantibiotictoprevent
bacterialsuperinfection,e.g.ampicillin+sulbactamfor10days)
4mg/kgIVdaily.Dosereductionto2mg/kgafter5daysoftreatment(18)
OD IV 21days
• Severelyillpatientswillrequireprednisolone,80–250mgPO/IVdailyfor1–2weeks(reducesinterstitialoedema).
• Combinationtreatmentshouldalsobeconsideredinseverecases,forexample,TMP-SMZandpentamidinemayincurahighriskoftoxicityaccordingtocasereportsonly.AseverecaseofPCPrequiresartificialventilationoranoxygensaturation(SO2)<92%.
Side-effectsshouldbemonitored,especiallythekidneys(both),pancreas(withpentamidine)andbonemarrow(withTMP-SMZ).Labanalysisshouldberequiredtwiceweekly.
AftersuccessfullytreatinganacuteepisodeofPCP:• it isnecessary tocontinuesecondaryprophylaxiswithTMP-SMZ160/800mgPOODona
long-termbasis;• prophylaxismaybediscontinuedwhenthepatient’sCD4countremainsstableat>200/mm3for
atleastthreemonths.
5.�.�. Other causes of pneumonia in immunosuppressed people
• Othercausesofpneumoniaincludefungalandviralinfections.Theyaredifficulttodiagnosewithoutsophisticatedlaboratoryfacilitiesandaredifficulttotreat.
• Viralpneumoniamaybecausedbyherpessimplexvirus, varicella-zostervirusor cytomegalo-virus.
• InadditiontoPCP,otherfungalcausesofpneumoniaincludeHistoplasma capsulatum,Crypto-coccus neoformansandAspergillus.
Diagnosis• Whenpneumoniafailstorespondtostandardtreatment,TBorpneumoniacausedbyviruses,
fungiorprotozoashouldbesuspected.• Making a specific diagnosis of fungal or other infections requires sophisticated laboratory
tests: ° pp65earlyCMVantigenfromperipheralbloodorbronchiallavage; ° polymerasechainreaction(PCR)forvirusesoftheherpesfamily(CMV,HSV1/2,VZV,
Epstein-Barrvirus(EBV),humanherpesvirus8and6(HHV8,HHV6)) ° specialculturesforslow-growingpathogens,suchasnocardia.• Closecollaborationbetweenphysicianandmicrobiologistisneeded.
TreatmentTreatmentwilldependonthecause,forexamplefoscarnetforCMVinfectionorlong-termantibiot-ics(eightweeks)fornocardia.
5.�. Gastrointestinal infections (GIIs)• GIIsinPLWHAmaybetheresultofanyofthefollowinginfections:
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HIV/AIDS TREATMENT AND CARE CLINICAL PROTOCOLS FOR THE WHO EUROPEAN REGION
° HIV(directinfectionoftheGItract) ° bacterial ° fungal ° viral ° protozoal ° parasitic.• Someoftheproblemsmayarisefromatrophyoftheintestinalvilli,whichcommonlyleadsto
malabsorption.• ThemostcommonGIproblemencounteredisdiarrhoea,whichcanbeacute,acute-on-chronic
orchronic.• DiarrhoeaispersistentorchronicinpeoplewithAIDS,andanimportantcauseofdeathamong
them.• Acutediarrhoealeadstodehydrationunlessproperlytreated.• Thepassingofbloodyorblood-stainedstoolsoccurs inpersonswithshigellosisoramoebic
dysentery.• OthercommonGIproblemsinPLWHAinclude: ° poorappetite ° nausea ° vomiting ° progressiveweightloss.
Table9summarizes theclinicalfeatures,diagnosisandtreatmentofsomeof themorecommongastrointestinalinfectionsseeninimmunosuppressedPLWHA.
Table 9. gastrointestinal infections commonly encountered in plWha
Infection Clinical features and diagnosis TreatmentNon-typhoidsalmo-nelloses
Fever,abdominalpain,diarrhoeawithorwithoutblood,weightloss,anorexia,hepatosplenomegalyDiagnosisuponbloodorstoolculture
Ciprofloxacin 500 mg PO BID for >2 weeks (19)
Shigelloses Fever,abdominalpain,bloodydiarrhoeaDiagnosisuponbloodorstoolculture
Ciprofloxacin 500 mg PO BID for 7–10 days or:Nalidixicacid500mgPOQIDfor7–10daysor:TMP-SMZ160/800mgPOBIDfor7–10days
Cryptosporidiosis Waterydiarrhoea,lossofappetite;afebrileDiagnosisuponstoolmicroscopy
Paromomycin1gPOBID+azithromycin600mgPOODfor4weeksthen:Paromycinalonefor8weeks(20, 21).Treatmentoftenfails(22).
Microsporidiosis Waterydiarrhoea,lossofappetite;afebrileDiagnosisuponstoolmicroscopy
Albendazole400mgPOBIDfor4weeks.If this does not work try:Mebendazole200mgPOTID(albendazoletendstobemoresuccessful)(23).
5.�. Candidiasis• Candida albicanscolonizesprimarilytheGItractsofbothmenandwomen.Uptoonethirdof
allnormalwomenalsocarryC. albicansinthevagina.• Womenwithvaginalcandidiasismaydevelopavaginaldischargeandvulvovaginalpruritus.• Menwithgenitalcandidiasiswilldevelopbalanitisorbalanoposthitisandwillcomplainofa
subpreputialdischargeanditchinessofthepenisandforeskin.
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• Oralcandidiasis(thrush)leadstoinflammationofthemucosalsurfacetogetherwiththeappear-anceofadherentwhiteplaques.
• C. albicanscaninfecttheskinandcausepruriticdermatitis.• Dependingonthelevelofimmunesuppression,oralinfectionmayextendtoinvolvetheoe-
sophagus.• Bronchialanddisseminatedinfectionsarerare.
Symptoms• Oralthrushcanincludeinfectionofthe: ° buccalmucosa ° tongue ° oropharynx ° gums ° hardandsoftpalates.• Patientsmayhavenosymptomsatallormaycomplainofaburningsensationinthemouth
wheneating.• Somepatientsmaycomplainofwhitepatchesinthemouth.• Ifthethrushhasextendedintotheoesophagus,patientsmaycomplainof: ° painonswallowingfood ° retrosternalpain ° excessivesalivation.
Patientsinwhomcandidiasisoccursmostfrequently:• healthypregnantwomenandhealthywomenonoralcontraceptives• healthyneonates,especiallypre-terminfants• thoseonprolongedcoursesofbroad-spectrumantibiotics• thosereceivingsteroidssystemically• thosewithdiabetesmellitus• thosewithcongenitaloracquiredimmunodeficiencies• thosesufferingfromchronicdebilitatingconditions• theseverelymalnourished• thosewithcancerandthosereceivingchemotherapyorradiotherapy.
Diagnosis• Thediagnosisoforopharyngealcandidiasisismadeonclinicalgrounds,basedondirectobser-
vationandmicroscopicexaminationofmaterialobtainedfromlesions.• Examinationof theoralcavitymayrevealrednessandinflammationof themucosa,withor
withoutpatchesofwhiteplaques.• Inflammationmaybeseenonthepalate,throat,gums,tongueand/ortheinsideofthecheeks.
Whenthetongueisaffected,itmaybesmoothandred,andthepapillaenormallyfoundonthetonguemaybeabsent.
• DiagnosishastobeconfirmedbyhistologicalexaminationoftissuebiopsiesonlyincasesofCandidaoesophagitisoraspergillosisofthelungs.
• Oropharyngealcandidiasis(OPC)isbelievedtooccuratleastonceinallPLWHA.Thesymp-tomsare:
° difficultyinswallowing ° paininthechestthatincreaseswithswallowing.• Disseminatedcandidiasiscausesfeverandsymptomsintheaffectedorgans(forexample,blind-
nesswhenitaffectstheeyes).
Treatment• Localizedcandidiasisistreatedfirstwithrelativelyinexpensivetopicaldrugssuchasnystatin,
miconazoleorclotrimazole.
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HIV/AIDS TREATMENT AND CARE CLINICAL PROTOCOLS FOR THE WHO EUROPEAN REGION
• Inpatientswithdisseminatedcandidiasisand in those inwhomtopical treatmenthas failed,systemicantifungalagentssuchasketoconazole,fluconazole,itraconazoleoramphotericinBmaybegiven.
• Fortreatmentofdrug-dependentpatientsreceivingmethadoneasopioidsubstitutiontherapy,seeTable4ofProtocol5,HIV/AIDS treatment and care for injecting drug users,fortheinterac-tionsoffluconazole,itraconazoleandketoconazolewithmethadone.
Table �0. oral candidiasis
Antifungal agent Dose Frequency Route DurationFirst-line treatment (24)
Myconazole Buccaltablets Onceaday Gumpatch 7daysor:
Fluconazole 100mg BIDfor3daysfollowedbyODfor4days
PO 7days
Second-line treatment (25)Itraconazole 200–400mg OD PO 7days
Table ��. vaginal candidiasis
Antifungal agent Dose Frequency Route DurationFirst-line treatment
Fluconazole 100mg Singledose PO OnceClotrimazole 500mg Singledose Vaginal Once
Second-line treatmentKetoconazole 200mg BID PO 3daysKetoconazole 200mg OD PO 7days
Maintenance therapyNystatin 2–4millionIU BID PO 10days
or:Fluconazole 50–200mg OD PO Everyday
Third-line treatmentKetoconazole 200mg OD PO Dependsonresponse,
usually7–10days
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Intraconazole 100mg OD PO Dependsonresponse,usually7–10days
Table ��. oesophageal and disseminated candidiasis
Antifungal agent Dose Frequency Route DurationFirst-line treatment
Ketoconazole 200–400mg BID PO 21daysor:
Fluconazole(moreeffectivethanketoconazole)
200–400mg,reduceonclinicalgroundsafter3daysto
100mg/day
OD PO/IV 14days
Second-line treatmentAmphotericinB 0.3–0.5mg/kg IV 10–14days
or:Itraconazole 200–400mg OD PO 2weeks
• Long-termmaintenancetreatmentwithfluconazole50–100mgODPO,itraconazole100mgODPOorketoconazole200mgODPOmaybenecessaryforpatientswhohavebeentreatedforcandidaloesophagitis.
• Ifthepatientfailstorespondtothistreatment,adiagnosisofCMVorHSVoesophagitisshouldbeconsidered,andthepatientshouldbereferredforanoesophagoscopy.
• Candida glabrata,C. krusei andC. tropicalis are resistant to fluconazole to someextent.Aspecimenisneededforculture;susceptibilitytestingispossibleandprescribingofamphotericinBmakesmoresense.Voriconazole,posaconazoleandcaspofunginarenewdrugsencounteringrare resistance in any fungi, includingAspergillus; all arevery expensive.Voriconazole caninteractwithARVdrugs,anditshouldnotbeprescribedtopatientstakingefavirenz(EFV)orritonavir(RTV).PatientsreceivingbothPIsandvoriconazoleshouldbecloselymonitoredforpossibleside-effects(26).
5.�. Cryptococcal meningitis• Cryptococcosismostoftenappearsasmeningitis,andoccasionallyaspulmonaryordissemi-
nateddisease.• CryptococcalmeningitisisacommonsystemicfungalinfectioninPLWHA.• Without treatment, the life expectancy of patients with cryptococcal meningitis is probably
less than a month.
DiagnosisCryptococcosisisrelativelyeasytodiagnose.Patientsusuallypresentwithheadache,fever,neckstiffnessand/orcranialnervepalsies,ortheymaybecomatose.However,signsofmeningealin-flammationsuchasfeverandneckstiffnessoftendonotoccur.Acentrifugeddepositofthecerebro-spinalfluid(CSF)shouldbeexaminedmicroscopicallyafteraddingadropofIndiaink.• Theyeastsarevisibleasorganismssurroundedbythickcapsules.• TheCSFmaybeculturedforcryptococci.
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HIV/AIDS TREATMENT AND CARE CLINICAL PROTOCOLS FOR THE WHO EUROPEAN REGION
• Thecryptococcalantigentestisusefulinassessingpatientsforcryptococcosisandcanbeper-formedonserumorcerebrospinalfluid.
Treatment
Table ��. cryptococcal meningitis treatment
Antifungal agent Dose Frequency Route Duration
First-line treatment (27)AmphotericinB
+5-flucytosine
0.7–1.0mg/kg
25mg./kg
OD
QID
IV 14days
then:fluconazole
400mg OD PO Atleast10weeks
then:fluconazole
200mg OD PO Lifelong
Second-line treatmentAmphotericinB
+5-flucytosine
0.7–1.0mg/kg
25mg/kg
OD
QID
IV 6–10weeks
or:AmphotericinB 0.7–1.0mg/kg OD IV 6–10weeksor (in mild cases):
Fluconazole 400–800mg OD PO 10–12weeksthen:
fluconazole200mg OD PO Lifelong
Secondarychemoprophylaxisormaintenancetherapy• Lifelongsecondarychemoprophylaxisisnecessary;itmaybeachievedwithfluconazole200
mgorallyoncedailyforlife.• Alternatelong-termsecondaryprophylaxismaybeachievedwithitraconazole200mgorally
oncedailyforlife.• Theneedformaintenancetherapywithpatientswhohaveanimprovedimmunesystem(CD4
count>200)ispresentlyneithersupportednorrefutedbyconcreteevidence.• Fortreatmentofdrug-dependentpatientsreceivingmethadoneasopioidsubstitutiontherapy,
seeTable4ofProtocol5,HIV/AIDS treatment and care for injecting drug users,fortheinterac-tionoffluconazolewithmethadone.
5.5. HistoplasmosisThisuncommonacuteorchronic infection iscausedby inhalingspores from the fungusHisto-plasma capsulatum.• Theoutcomeofexposuredependsontheimmunestatusofthehostaswellasthesizeofthe
inoculum.• Intactcell-mediatedimmunityisessentialforpreventingitsdissemination.Theacuteillnessis
influenza-like,with: ° fever ° anorexia ° arthralgia ° myalgia ° drycough ° chestpain.• Disseminationoccurssoonafterinitialinfectioninimmunosuppressedpatients,whodevelop: ° weightloss
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° oralandskinlesions ° chestsymptoms ° liver,spleenandlymphnodeenlargement.• Orallesionsmayappearasprotruding,necroticulcers.Theremayalsobeperforationofthepal-
ateandextensivesofttissuedestruction.
DiagnosisDiagnosisismadeonclinicalgroundsandisconfirmedbyfungalculturesorhistologicalexamina-tionofbiopsiedtissues.• AchestX-rayinacuteillnessmayshow: ° hilarlymphadenopathy ° scatteredinfiltrates ° lowerlobenodules.• Bloodandskintestshavebeendevelopedforthediagnosisofhistoplasmosis,buttheyarenot
widelyavailable.
TreatmentInnormalimmunesystems,acutehistoplasmosisisself-limitinganddoesnotrequiretreatment.InimmunosuppressedpatientsitmaybetreatedasshowninTable14.
Table ��. treatment of histoplasmosis
Antifungal agent Dose Frequency Route DurationAmphotericinB 0.7–1mg/kg OD IV 10days
Source: Johnsonetal.,2002(28).
Thisinitialtreatmentisfollowed,threemonthsafterimmunoreconstitutionwith>100CD4cells,withoneofthefollowinglong-termtreatments:• itraconazole200mgBIDPO• fluconazole200mgBIDPO• amphotericinB1mg/kgIVweekly.
Analternativeisitraconazole200mgTIDPOx3days,then200mgPOBIDx12weeks(takenwithamealandanacidicdrink).
5.�. Kaposi sarcoma (KS)• KSiscausedbythehumanherpesvirustype8(HHV8),alsoknownastheKaposisarcoma
herpesvirus(KSHV).• AnypatientsuspectedofKSshouldbeexaminedbyanoncologistandreferredtoanoncology
clinicasneeded.• InHIV-associatedimmunosuppression,KSismoreaggressive,disseminatedandrapidlypro-
gressivethantheendemicdiseasefoundinpeoplewithoutHIVinfection.
DiagnosisThediagnosisofKSismadeonclinicalsuspicionandconfirmedbyhistologicalexaminationofbiopsiedtissue.
Clinicalsignsincludethefollowing.• Lesionsmaybefoundanywhereonskinandonanymucosalsurface.Skinlesionsarehyperpig-
mented,blueorpurplishpapulesornodulesandcanbeassociatedwithlymphoedema.Systemiclesionsarecommonlyfoundonthepalate,gastrointestinaltract,lungsorlymphnodes.
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HIV/AIDS TREATMENT AND CARE CLINICAL PROTOCOLS FOR THE WHO EUROPEAN REGION
• Oral lesionsofKSmaybe foundon thehardpalateandoccasionallyon the tongue, throat,tonsilsorgums.Thelesionsarepurplepapules,usuallypainlessandsometimeslargeandpe-dunculated.
• Pulmonarylesionsareinfiltrativewithpleuraleffusionandoftenleadtorespiratoryfailure.Theconditionmaybeconfusedwithbacillaryangiomatosis(bartonellosis),aninfectiveconditionseeninPLWHA.
Treatment• KSisacancerandshouldaccordinglybetreatedbyanoncologist.• Itistreatablewithradiotherapyiflesionsarelocalizedandwithcytotoxicchemotherapyifitis
generalized.• Cytotoxicdrugcombinationsthathavebeenusedwithvaryingdegreesofsuccessinclude: ° liposomaldoxorubicinmonotherapy(bestresults)(29–31) ° bleomycin ° vincristine ° daunorubicin ° vinblastine ° etoposide.• Remissionisdifficulttoachieve,andrelapsesarecommon.• Localizedlesionsmaybesurgicallyexcisedortreatedwithliquidnitrogen(highrelapserate),
laser therapyor radiation. Intralesional injectionwithbleomycinhas alsobeen shown tobeeffective.
• KSisusuallytreatablewithARTalone;aftersuccessfulinitiationofART,KSbecomesinactiveandslowlydisappears.
5.�. Cervical cancer• Cervical cancer is one of the most common types of cancer, causing deaths among women
worldwide.Theestimatednumberofnewcasesperyearis500000(32).• Humanpapillomavirus (HPV) infection is the leadingetiologicagent in thedevelopmentof
premalignantandmalignantlowergenitaltractdisease,includingcervicalcancer.• Therelativeriskofcervicalintraepithelialneoplasma(CIN)is5–10timeshigherforwomen
withHIV/AIDS,andabnormalpathologyisobservedin20–40%oftheirPapsmears(33, 34).
DiagnosisWhenawomanisdiagnosedwithHIV,agynaecologicevaluationwithpelvicexaminationandPapsmearshouldbeperformed.TheexaminationandPapsmearshouldberepeatedatsixmonthsandthenannually.
Forfurtherinformation,pleaserefertoProtocol9,Support for sexual and reproductive health of people living with HIV/AIDS.
5.�. Other cancersLymphomas–includingnon-Hodgkin,intracranialandBurkitttypes–andsquamouscellcarcino-maaremorecommonlyfoundinimmunosuppressedPLWHAthaninpeoplewhodonothaveHIV.Anypatientsuspectedofcancershouldbeexaminedbyanoncologistandreferredtotheoncologyclinicasneeded.
5.�.�. Non-Hodgkin lymphoma (NHL)
NHL–usuallyB-cell,veryrarelyT-cell–occurscommonlyinimmunosuppressedPLWHA,butitsappearanceisindependentofCD4cellcount.ItisthoughtthatEBVorsomeothervirusplaysaroleinthepathogenesisofthisdisease.
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management of opportunistic infections and general symptoms of hiv/aids
• MalignantNHLcellsmaybedetectedinalllocations,mostofteninthelymphnodes,aswellasthemuscles;organssuchastheliver,spleen,lung,heart,brainandGItract;and(morerarely)thebones.
• Symptomsmayvary.• Swollenlymphnodesmaybepalpableindifferentlocations.• Fever,weightlossandfatiguearecommon,butnotinevitable.• Determiningthestageofthedisease(I–IV)requiresthoroughexamination–cerebral,cervical,
thoracicandabdominalcomputerizedaxialtomography(CAT)scans,bonemarrowandcere-brospinalfluidbiopsiesandgastroscopy.
• Diagnosisisperformedbybiopsyofasuspect(enlarged)lymphnode,followedbyhistologicalexamination.
5.�.�. Burkitt-type lymphoma in PLWHA
Burkitt-typelymphomas,actuallyasubgroupofNHLs,areassociatedwithHIVinfectionandmayoccurbeforeadvancedimmunosuppressionsetsin.ThistypeoftumourisassociatedwithEBV.
DiagnosisThediagnosisofBurkitt-typelymphomaismadeoncarefulexaminationoflymphnodeandtumourbiopsies,confirmedbyhistologicalexamination.
Treatmentofnon-Hodgkin,Burkitt-typeandCNSlymphomas• ForNHL,theCHOPregimeniseffectiveandshouldbeadministeredthroughsixcycles(the
numberusuallyneededforcompleteremission)ofthefollowing: ° prednisolone100mg/dayODforfivedays ° vincristine(Oncovin)1.4mg/m²(maximum2mg/day)inonedoseonDay1oftreatment ° cyclophosphamide750mg/m²/dayinonedoseonDay1 ° doxorubicin(hydroxydaunomycin)50mg/m²/dayinonedoseonDay1.
Beginanewcycleevery21days(Day22becomesDay1,etc.).• TheEPOCHregimen,whichincludesetoposide,prednisolone,vincristine,cyclophosphamide
anddaunorubicinordoxorubicin,hasbeenshowntobeeffectiveincombinationwithART.Itisbasedonaregimenofcontinuousinfusionfor96hours,asfollows:
° etoposide50mg/m²perday(viacentralvenousline) ° doxorubicin10mg/m²/day(viacentralvenousline) ° vincristine0.4mg/m²/day(max2mg/week)(viacentralvenousline) ° cyclophosphamide375mg/m²onDay5only,inabolus(viaIV) ° prednisolone100mg/dayonDays1–5ODPO.
Repeattheregimenevery21daysuntilsixcycleshavebeenperformed.• Burkitt-typelymphomaismanagedinthesamemannerasotherlymphomas,andrespondsto
CHOPorEPOCH.Treatingthisfast-growinglymphomawithmoreaggressivechemotherapy(suchastheB-ALLregimen)isunderdiscussionsotherearenospecificrecommendationsatthepresenttime(35, 36).
• InBurkitt-type lymphomas, chemotherapyshouldbe followedby radiationof the suspectedprimarylocation.
• ItispossibletotreatNHLindependentlyofCD4cellcount,butforprolongedsuccess,ARTshouldbestartedearly.EvenduringchemotherapywithCD4count>350,thereisahighrateofrelapsewithoutART(37).
• Forintracraniallymphoma(metastasis),cranialradiationinconjunctionwithcytotoxicchemo-therapyandsteroidsisadvised(38).
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• Forprimarycentralnervoussystem(CNS)lymphoma,radiationistheonlyeffectiveevidence-based therapy.MostpatientsshowCD4counts<50withdiagnosis. Inmultivariateanalysis,highlyactiveantiretroviraltreatment(HAART)istheonlyadditionalfactorinprolongedre-mission.TherearesomereportsoftheeffectivenessofHAARTalone,soitshouldbestartedimmediately(39, 40).
5.9. Neurological infectionsInvasionofthenervoussystembyHIVleadstoencephalopathy,myelopathyandperipheralneu-ropathy.NumerousneurologicalsyndromeshavebeenascribedtoHIV,including:• cerebralatrophyanddegeneration• AIDSdementiacomplex• cerebellaratrophy• vacuolarmyelopathy• facialnerveparalysis• Guillain-Barresyndrome• painfulsensoryandmotorperipheralneuropathy.
Anumberofopportunisticinfections,includingbacterial,viralandfungalinfections,alsoaffectthecentralnervoussystem.(Forcryptococcalmeningitis,pleaserefertosectionII.5.4above.)5.9.�. Toxoplasmosis
ToxoplasmosisisfrequentlyencounteredinPLWHAinindustrializedcountries.Itleadstothede-velopmentofmultipleinflammatorylesionsinthebrain.InPLWHA,itmainlyappearsasencepha-litisorasdisseminateddisease.
Diagnosis• Toxoplasmosismaybesuspectedthroughclinicalfindings,andpatientsmaypresentwith: ° alteredmentalstatus ° fever ° seizures ° headaches ° focalneurologicalfindings,includingmotordeficits,cranialnervepalsies,movementdisor-
ders,dysmetria,visual-fieldlossandaphasia.• Patientswhopresentwithevidenceofdiffusecorticaldysfunctiondevelopevidenceoffocal
neurologicaldiseaseastheinfectionprogresses.• CATorMRIbrainscansmayrevealmultiplering-enhancinglesions.• SerologicaltestsforToxoplasmaantibody(immunoglobulinG,orIgG)mayhelpinestablishing
thediagnosisintheabsenceofneuro-imagingtechniques.• Most patientswith cerebral toxoplasmosis have serological evidenceof prior infectionwith
Toxoplasma gondii(IgG-positive).
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° Iftoxoplasmosisissuspected,patientsshouldbegivenatrialoftreatment. ° Onlyif theydonotrespondtothistreatmentwithintwoweeksshouldabrainbiopsybe
considered. ° Thediagnosis canbe confirmedbyhistological examinationof tissueobtainedbybrain
biopsy.
Treatment
Table �5. treatment of toxoplasmosis
Drug Dose Frequency Route DurationPyrimethamine 200mg Once(loadingdose) PO Singledose
Then:pyrimethamine
+folinicacid
+sulfadiazine
25mgor50mg
TIDBID
PO 6–8weeks
15mg OD PO 6–8weeks
1g QID PO 6–8weeksSources: Katlamaetal.,1996;Dannemannetal.,1992;Chirgwinetal.,2002(41–43).
• Intheregimenabove,sulfadiazinemaybereplacedbyanyofthefollowing: ° clindamycin600mgQIDIV/POforsixweeks ° azithromycin1200mgODPOforsixweeks ° clarithromycin1gBIDPOforsixweeks ° atovaquone750mgQIDPOforsixweeks.• Somepatientsneedaverylongperiodofacutetreatment.Thereisnorulefortreatmentdura-
tion.ThedecisionhastobemadeonclinicalgroundsandCATscanifavailable.• Secondaryprophylaxisisgivenusinghalfthedosageoftheacutetreatmentfromtheeffective
regimen,untilCD4countisover200cells/mm3forthreemonths.
5.9.�. Herpes simplex virus (HSV)
• HSVinfectioniscommonlyencounteredinclinicalpractice.• Followinganinitialattack,therearefrequentrecurrences.• Inimmunosuppressedpeopletheinfectionmaybeextensiveandpersistentandpossiblydis-
seminated.• Disseminationmayleadtoinfectionofthelungs,oesophagusandbrain.• HSVmayalsocausemeningoencephalitisandmeningitis.
Diagnosis• ThediagnosisofHSVinfectionisusuallymadebasedonthetypicalclinicalpresentationof
vesiclesandpainfulsuperficialsoresaroundthemouth,nose,lipsand/orgenitals.• Itisoftendifficulttomakeadiagnosisofdisseminatedherpes.Speciallaboratorytests–such
asviralculture,radio-immunoblotassayandfluorescentandmonoclonalantibodytests–maybenecessary.
• TypicalchangesmaybeseenonCATscansof thebrain,whereherpessimplexencephalitisleadstomultiplelesions.
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HIV/AIDS TREATMENT AND CARE CLINICAL PROTOCOLS FOR THE WHO EUROPEAN REGION
Treatment
Table ��. treatment of herpes simplex virus: mild infection
Antiviral agent Dose Frequency Route DurationFirst-line treatment
Aciclovir 400mg TID PO 7–10daysor:
Famciclovir 250mg TID PO 7–10daysor:
Valaciclovir 1g BID PO 7–10daysSource: Conantetal.,2002;Ionnadisetal.,1998;Chang,Absar&Beall,1995;Safrin,1992(44–47).
Table ��. treatment of herpes simplex virus: recurrences
Antiviral agent Dose Frequency Route DurationFirst-line treatment
Aciclovir 800mg 5timesperday PO 7–10daysor:
Famciclovir 500mg TID PO 7–10daysor:
Valaciclovir 1g BID PO 7–10daysSource: Conantetal.,2002;Ionnadisetal.,1998;Chang,Absar&Beall,1995;Safrin,1992(44–47).
Table ��. treatment of herpes simplex virus: severe infection
Antiviral agent Dose Frequency Route DurationFirst-line treatment
Aciclovir 10mg/kg TID IV 7–10daysor:
Valaciclovir 1g BID PO 7–10daysSource: Conantetal.,2002;Ionnadisetal.,1998;Chang,Absar&Beall,1995;Safrin,1992(44–47).
Table �9. treatment of herpes virus: severe and visceral infection
Antiviral agent Dose Frequency Route DurationFirst-line treatment
Aciclovir 10mg/kg TID IV 14–21daysSecond-line treatmentFoscarnet(whenresistancetoaciclovirissuspected)
40–60mg/kg TID IV 14days
Source: Conantetal.,2002;Ionnadisetal.,1998;Chang,Absar&Beall,1995;Safrin,1992(44–47).
5.9.�. Herpes zoster (48)
• Varicella-zostervirus(VZV)oftencausesdisseminatedinfectionafterinitialexposure.• Inchildren,initialinfectionresultsinthedevelopmentofchickenpox,thoughmostwhobe-
comeinfecteddevelopnosymptomsorsignsofinfection.• Thevirusliesdormantintheparaspinalgangliaforyears.• Withimmunesuppression,regardlessofcause,thevirusreplicatesandproduceslesionsalong
thelengthofacutaneousnerveinadermatomaldistribution.
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• Disseminationcanalsooccuratthesametime,withinvolvementofskin,nervoussystem,lungsandmucousmembranes.
• Inimmunosuppressedpatients,zosterisoftenmultidermatomalindistribution,persistent,ex-tensiveandassociatedwithseverepainanddebility.
DiagnosisThediagnosisisusuallymadeonclinicalgrounds.
Treatment
Table �0. treatment of dermatomal zoster
Antiviral agent Dose Frequency Route DurationFirst-line treatment
Aciclovir 800mg 5timesaday PO 7–10daysoruntillesionscrust
or:Famciclovir 500mg TID PO 7–10days
Table ��. treatment of disseminated, visceral or ophthalmic zoster
Antiviral agent Dose Frequency Route DurationFirst-line treatment
Aciclovir 10mg/kg TID IV 7–10daysor:
Famciclovir 500mg TID PO 7–10daysSecond-line treatment
Foscarnet 60mg/kgor40mg/kg
BIDTID
IV 7–10days
• Post-herpeticneuralgiaisacommonandseriouslydebilitatingproblem.Itcausesseverepainindermatomaldistribution,usuallyatthesiteofthelesions.
• Paincontrolisoftennecessaryandmaybeachievedwithnon-steroidanti-inflammatorydrugs(NSAIDs).
• Ifpaincontrolisnotachieved,amitryptiline,carbamazepineorphenytoinmaybetried.
5.9.�. Cytomegalovirus (CMV) infection
CMVmayaffectmultiplesystemsandorgansinimmunosuppressedindividuals.Symptomsmayinclude:• feveranddiarrhoeafromCMVcolitis• dyspnoeafromCMVpneumonitis• blindnesscausedbyCMVretinitis• theappearanceofpainfululcersinthemouth,resultingindifficultyeating.
Diagnosis• Themostfrequentlocalizationistheretinaandisdiagnosedbyaspecializedophthalmologist.• Otherlocalizationsrequiresophisticatedequipmentandcostlytests,suchastissuebiopsiesand
deoxyribonucleicacid(DNA)hybridizationstudies.
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HIV/AIDS TREATMENT AND CARE CLINICAL PROTOCOLS FOR THE WHO EUROPEAN REGION
TreatmentTreatmentsforCMVGIdisease,neurologicaldiseaseandretinitisarefoundinTables22–24.
Table ��. first-line treatment of cmv gi disease, neurological disease and retinitis
Antiviral agent Dose Frequency Route DurationGanciclovir 5mg/kg BID IV 2–3weeks
Source: Whitleyetal.,1998;anon.,1997; Martinetal.,2002;Jacobsonetal.,1999;Martinetal.,1999(49–53).
Forsecondaryprophylaxis,long-termtreatmentwithganciclovir5mg/kggivenIVdailymaybenecessary.
Table ��. second-line treatment of cmv gi disease, neurological disease and retinitis
Antiviral agent Dose Frequency Route DurationFoscarnet 90mg/kg BID IV 3weeks
Source: Whitleyetal.,1998;anon.,1997; Martinetal.,2002;Jacobsonetal.,1999;Martinetal.,1999(49–53).
Forsecondaryprophylaxis, long-termtreatmentwithfoscarnet90mg/kggivenIVdailymaybenecessary.
Table ��. secondary prophylaxis of cmv retinitis
Antiviral agent Dose Frequency Route DurationGanciclovireyeimplant
+Valganciclovir
(topreventinfectionintheothereye)
900mg OD PO
UntilCD4countisover100-150cells/mm3forminimum3
months
Source: Whitleyetal.,1998;anon.,1997; Martinetal.,2002;Jacobsonetal.,1999;Martinetal.,1999(49–53).
Secondaryprophylaxiscanbestoppedaftersixmonthsandimmunereconstitutionto100–150CD4cells/mm3.
5.9.5. Epstein-Barr virus-related conditions
• InfectionwithEBV,aherpesvirus,iscommoninPLWHAandothers.• PLWHAhave increasedamountsofEBVin theiroropharyngeal secretionsandhigherEBV
antibodytitresthanHIV-negativepeople.• EBVisthoughttocauseanumberofconditionsincluding: ° oralhairyleukoplakia ° lymphocyticinterstitialpneumonitis(LIP) ° non-Hodgkinlymphoma(seesectionII.5.8.1above) ° Burkitt-typelymphoma(seesectionII.5.8.2above) ° nasopharyngealcarcinoma.
5.9.5.�. Oral hairy leukoplakia
• OralhairyleukoplakiaoccursinPLWHAaswellassomeimmunosuppressedtransplantrecipi-ents.
• Itisanon-malignantlesionofepithelialcells,presentingasraised,white,corrugatedlesionsoftheoralmucosa,especiallyonthelateralaspectofthetongue.
• Itiscommonlymistakenfororalcandidiasis,astheyarefrequentlyfoundtogether.• Nospecifictreatmentisavailableforthecondition.Patientsaregenerallyadvisedongoodoral
hygiene.
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management of opportunistic infections and general symptoms of hiv/aids
5.9.5.� Lymphocytic interstitial pneumonitis (LIP)
• LIPoccursprimarilyinchildren,butitalsooccursinadultPLWHA.• ItischaracterizedbydiffusedinterstitialpulmonaryinfiltratesthatmaybeconfusedwithTBor
PCP.However,patientswithLIPoftendonothavesignsofsevererespiratoryillness.• NospecifictreatmentisavailableforLIP.
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III. General symptoms
�. Persistent generalized lymphadenopathy (PGL) in adults• ThemostcommonclinicalmanifestationofHIVinfectionissymmetricgeneralizedlymphnode
enlargement.• Enlargedlymphnodesaregenerallypainless,firm,mobileandrubberyandaremosteasilypal-
patedintheneck,submentalarea,axillaeandthegroin.• ThepatientmayormaynothaveotherassociatedsymptomsofHIVinfection.• PGLisdefinedasthepresenceformorethanonemonthoflymphnodesmeasuringmorethan
1cmindiameterinmorethanoneareaofthebodyotherthanthegroin.• PGLisaverycommonfeatureofHIVinfection.Inmostcasesalymphnodehistologyonly
reveals“reactivehyperplasia”or“follicularhyperplasia”.Alymphnodebiopsyisnecessarytoestablishacause.
DiagnosisItisimportanttopalpatelymphnodesspecificallyinthefollowingareas:• anteriorandposteriortrianglesoftheneck• submentalarea• suboccipitalarea• anteriorandposteriorauricularareas• bothaxillae• epitrochlearareas• bothinguinalregions.
PatientswithPGLcausedbyHIVinfectionmayhaveotherfeaturesofHIVinfection,including:• oralthrush• oralhairyleukoplakia• pruriticskinrash• hyperpigmentednails• oralorgenitalherpes• involuntaryweightloss• unexplainedfever.
PGLmaybecausedbyanumberofconditionsotherthanHIVinfection,includingTB,leukaemia,lymphoma,KS,syphilis,Chlamydia trachomatis (lymphogranulomavenereum),CMV,toxoplas-mosis,EBV,cryptococcosis,histoplasmosisandsepticskinconditions,bubonicplagueandhepa-titisB.
CriteriaforperformingalymphnodebiopsyApatientwithPGLshouldbereferredforalymphnodebiopsyifpresentingwithanyofthefol-lowing:• asymmetricallymphnodeenlargement• massivelymphnodeenlargement(atleastonelymphnode>3cmindiameter)• lymphnodeenlargementoveraperiodofobservation• evidenceofTBonachestX-ray• evidenceofhilarlymphnodeenlargementonachestX-ray• evidenceofKSelsewhere• fever,nightsweatsandweightlossformorethanoneweek.
AdiagnosisofHIV-relatedlymphadenopathydoesnotruleoutotherseriousdiseaseslikelympho-mainunbiopsiedlymphnodes.Therefore,withanychangeincondition,persistentfeverorothersuspiciouscircumstance,abiopsyorlymphadenectomyshouldberepeated.
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management of opportunistic infections and general symptoms of hiv/aids
�. Fever• Fevercanoccurasaresultofinfection,inflammationormalignancy.Persistentfeverinadults
isdefinedasabodytemperatureofmorethan38°Clastingformorethantwoweeks.• InPLWHA,theonlyclinicalpresentationofHIVinfectionmaybefever.Thus,itisimportantto
keepinmindapossiblediagnosisofHIVinfectionwhenmanagingapatientwhopresentswithapersistentfeverandnoobviouscause.
• InPLWHA,persistentfevermaybeaccompaniedbyfeaturesofthepossibleunderlyingcause,forexamplepneumonia,TB,gastrointestinalinfectionorlymphoma.Inadultswithpersistentfever,thefollowingfactorsmaysuggestthepresenceofHIVinfection:
° ahistoryofunsafesexualbehaviour ° apartnerorchildknowntobeHIV-infected ° otherfeaturessuggestiveofHIVinfection,suchas: - PGL - oralorgenitalthrush - oralhairyleukoplakia - pruriticskinrash - oralorgenitalherpes - involuntaryweightloss - darkeningofthenails(melanonychia) - hypopigmentationofthelips - thinningandstraighteningofthehair.
�. Weight loss in adults• HIVinfectionisacommoncauseofweightloss.• Severeweightlossisdefinedasinvoluntarylossofmorethan10%ofone’sbodyweight.• SevereinvoluntaryweightlossinPLWHAisknownasHIV-associatedwastingsyndromeor
“slimdisease”.• Thecauseofsuchwastingisnotfullyunderstood.Possibleunsubstantiatedcausesinclude: ° chronicandrecurrentinfections ° chronicdiarrhoea ° malabsorption ° HIV-inducedmyopathy ° HIV-inducedpoorappetite.
Clinicalfeatures• Thepatientmaycomplainofinvoluntaryweightlossorlossofappetite,withorwithoutfever
anddiarrhoea.• PatientswithHIV-associatedwastingdiseaseare illandemaciatedandmaybefeverishand
dehydrated.• Oralcandidiasisiscommonlyfoundinsuchpatients.• ThepatientmayhaveotherfeaturesofAIDS,includingfeaturesofneurologicalinvolvement
suchasencephalopathyandAIDSdementiacomplex.
�. Chronic diarrhoea in adults• Adultswithchronicdiarrhoeacomplainoffrequentlypassingthreeormoreconsecutiveloose
stoolsover28days.Duringthecourseoftheillnessthepatientmayalsohaveepisodesofacutediarrhoea.
• Thestooldoesnotusuallycontainblood,exceptifthereisconcomitantdysentery.• Thepatientusuallyalsohasapoorappetiteandweightloss.• Thepatientmayalsobedehydrated,anaemicandwasted.
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HIV/AIDS TREATMENT AND CARE CLINICAL PROTOCOLS FOR THE WHO EUROPEAN REGION
• Adultswithchronicdiarrhoeaoftenhave: ° skinandhairchangestypicallyassociatedwithmalnutrition ° hypopigmentationofthelips ° darklypigmentednails ° oralthrush,hairyleukoplakiaorlymphnodeenlargement.
Detailsonthemanagementofchronicdiarrhoeaandassessmentofdehydrationinadultsarepro-videdinProtocol3,Palliative care for people living with HIV/AIDS.
5. Oral lesionsBesidescandidiadis(seesectionII.5.3above),alargenumberofotherorallesionsmaybefoundinpatientswithHIVinfection.SomeofthesearedescribedinTable25.
Table �5. description and treatment of oral lesions common in plWha
Condition Description TreatmentGingivitis Swollenandredgumsthattendtobleedeasily Metronidazole400mgPOBIDfor7days
orerythromycin500mgPOQIDfor7days
Pyorrhoea Anaccumulationofpusinthegingivalmarginaroundtheteeth
GarglingwithwarmsaltywateraftereverymealandbrushingtheteethBID
Periodontitis Apainfulconditionwithrapidlossoftheboneandsofttissuesupportingtheteeth,bleedingofthegums,toothlossandpossibleulceration
Localdebridement,chlorhexidinemouthwashesAmoxycillin500mgPOTIDormetronidazole200mgPOTIDfor5days
Aphthous ulcers
Painfulpunched-outulcersonthemucosalsur-face,usuallycoveredinapurulentexudateandtendingtobleedwhentouched
Oralhygieneandtreatmentwithtopicalsteroids
Stomatitis Inflammation of the mucosa in the oral cavity, oftenassociatedwithpoororalhygieneandinvasionofanaerobicbacteria
GarglingwithwarmsaltywateraftereverymealandbrushingtheteethBID
Cheilitis Inflammation, redness and eventual pallor of thelips,commoninpatientswithadvancedim-munosuppression
No specific treatment available; vitamins A, B andCandadviceonoralhygiene
Secondary syphilis
Lesionsonthebuccalmucosa,includingmoistpapules,“snailtrack”ulcersandcondylomatalataattheanglesofthemouthandaroundthenostrils.(Insecondarysyphilis,allserologicaltestsforsyphilisarepositive.)
Primary syphilis:Benzathinepenicillin2.4milliunitsintramuscu-larly(IM)once
Secondary syphilis:Benzathinepenicillin2.4milliunitsIMQWforthreeweeksordoxycycline100mgPOBIDfor28daysorerythromycin500mgPOQIDfor28days
�. Skin and nail conditions
�.�. Dermatomycosis• Fungalskinrashes(dermatomycoses)occurcommonlyinPLWHAandothers.• Rashesareusuallyitchyanddry,withvisiblescalesofdeadskin.• Thelesionsmaybefoundanywhereonthebody.
DiagnosisFungalelementsmaybefoundonmicroscopicexaminationofskinscrapes.
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management of opportunistic infections and general symptoms of hiv/aids
TreatmentTopicalapplicationsofantifungalointmentsandcreamswillusuallyclearthelesions.Thefollow-ingmaybeusedfortreatingdermatomycoses.
Table ��. treatment of dermatomycosis
Antifungal preparation Dose Frequency Route DurationFirst-line treatment
Topicalmiconazole TID Topical 21daysor:
Topicalclotrimazole TID Topical 21daysSecond-line treatment
Ketoconazole 200mg OD PO 1–3monthsor:
Itraconazole 100mg OD PO 1–3months
�.�. OnychomycosisNailsmayalsobecomeinfectedwithfungi(onychomycosis).Theinfectioncanresultindiscolora-tion,distortionordestructionofthenails.
Diagnosis• Diagnosisisusuallymadeonclinicalfindings.• Microscopicexaminationofpotassiumhydroxide(KOH)preparationsofsubungualmaterial
mayrevealfungalelements.
Treatment
Table ��. treatment of onychomycosis
Antifungal preparation Dose Frequency Route DurationFirst-line treatment
Terbinafine 250mg OD PO 6 weeks for fingers12weeksfortoes
or:
Itraconazole 200mg BID PO For fingers, 1 week each monthfor2months
Fortoes,1weekeachmonthfor3–4months
�.�. Seborrhoeic dermatitis• SeborrhoeicdermatitisisacommonpresentingfeatureinPLWHA.Itisprobablycausedbya
fungusknownasPityrosporum ovale(alsoknownasMalasezia furfur).• Therashiserythematousandscaly.InpersonswithHIVinfectionitmaybeextensive,persis-
tentandrecurrent.
Diagnosis• Diagnosisismadeonclinicalgrounds.Therashappearscommonlyonthe: ° face ° areaaroundnostrils ° nasolabialfolds
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HIV/AIDS TREATMENT AND CARE CLINICAL PROTOCOLS FOR THE WHO EUROPEAN REGION
° eyebrows ° scalp ° chest ° axillae ° uppertrunk ° genitalarea
Diagnosis can be confirmed by finding fungal elements on microscopic examination of skinscrapes.
Treatment• Frequentskinwashingtoremovescalesisadvised.• Shampooingwithseleniumsulfideshampooiseffective.• Topicalapplicationsof1%hydrocortisoneareprobablythemosteffective.Ketoconazole2%
creamhasalsobeenshowntobeeffective.
�.�. ScabiesScabiesiscausedbythemiteSarcoptes scabei.Thefemalemiteburrowsintotheskin,andthebur-rowsappearasraisedlinesuptoseveralcentimetreslong.• Whenapersonisinfestedwithscabiesmitesforthefirsttime,thereisusuallylittleevidenceof
infestationforthefirst2–6weeks.• Insubsequentinfestations,peopleusuallyhavebecomesensitizedtothemites,andthesymp-
tomsgenerallyoccurwithin1–4days.• Theburrowingofthemitesundertheskincausesarash,mostfrequentlyfoundonthe: ° hands(particularlythewebspacesbetweenthefingers) ° foldsofthewrist,elboworknee ° ulnarmarginsoftheforearms ° penis ° breast ° shoulderblades• Burrowsandmitesmaybefewinnumberanddifficulttofindinsomecases.• Severeitchingiscommon,especiallyatnightandfrequentlyovermuchofthebody,including
areaswherenomitesareliving.• Norwegianscabies,amoresevereformmorecommonamongimmunocompromisedpatients,
ischaracterizedbyvesiclesandtheformationofthickcrustsontheskin,accompaniedbyabun-dantmitesbutonlyslightitching.
• Complications due to infestation are usually caused by secondary bacterial infections fromscratching.
Diagnosis• Thediagnosisisusuallymadeonfindingtherashandburrows.• Skinscrapesmayrevealmitesormiteovaonmicroscopicexamination.
Treatment• Thetreatmentofchoiceisthetopicaluseofgammabenzenehexachloride1%,appliedtothe
wholebodyfromtheneckdownandwashedoffafter24hoursinadultsand8hoursinchildren.Asingleapplicationissufficient.
• Permethrin1%orlindane1%applicationsarealsouseful.Bothareappliedtoaffectedareasandwashedoffafter8hours.Theseagentsshouldnotbeusedduringpregnancyorlactationoronchildren.
• Ivermectininasingleoraldoseof200µg/kgisanalternativethatiseffectiveforcrustedscabiesinimmunocompromisedpeople.
• Allmembersofthehouseholdandsexualpartnersshouldalsobetreated.• Allclothes,beddingandtowelsshouldbewashedinhotwater,driedandironed.
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management of opportunistic infections and general symptoms of hiv/aids
�.5. Staphylococcal folliculitis• Folliculitisisaskininfectionthatislocalizedinthehairfollicles.• ApustularperifolliculitisoccurscommonlyinPLWHA.• UsuallytheconditioniscausedbyStaphylococcus aureus,thoughotherorganismsmayalsobe
responsible.
Diagnosis• Diagnosisismadeonclinicalfindings.• Lesionsaresmall(lessthan5mmindiameter),andfoundinmultipleerythematousfollicles
thatmayhaveapurulentcentre.• Lesionsareitchyandoftenfoundinclusters.
TreatmentTreatmentiswithantibiotics,suchascephalexinorcloxacillin500mgPOQIDfor7–21days.
�.�. Molluscum contagiosum• Molluscumcontagiosumisasuperficialskininfectioncausedbythemolluscumcontagiosum
virus.• The infection isspread throughclosebodycontactandmayoccur throughsharingclothing,
beddingortowelsorthroughsexualtransmission.• Theincubationperiodvariesfromseveralweekstoseveralmonths.• Shavingorscratchingmaycausetheinfectiontospread.• TheinfectionoccursmorecommonlyinimmunosuppressedPLWHA.• IncomparisontothelesionsfoundonHIV-negativepeople,thosefoundonPLWHAare: ° morewidespread ° morepersistent ° muchlarger ° moredifficulttotreat.
Diagnosis• Thediagnosisisbasedonthecharacteristicappearanceofthebumps.• Thevirusinvadestheskin,causingtheappearanceoffirm,flesh-colouredpapules2–5mmin
diameter.Thelesionscontainawhitesebaceousmaterial.• Thepapulescanoccuranywhereonthebodyandoftenremainunchangedformanymonths,
afterwhichtheydisappearandmayormaynotreappear.• Nodiagnostictestforthisvirusisavailable.
TreatmentThegoaloftreatmentistoremovethesoftcentre,afterwhichthepapuleresolves.Assuch,eachlesionneedstobetreatedindividually.Variousmethodsareavailableforthedestructionofthele-sion,including:• curettage• chemicaldestructionwithconcentratedphenol• cryotherapy• electrocautery.
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