Clinical Manual for Management of the HIV-Infected ... - myCME.com

6–52 | Clinical Manual for Management of the HIV-Infected Adult/2006
O: Objective
Measure vital signs and document fever. Perform a
complete physical examination, with special attention to
the lymph nodes, lungs, abdomen, skin, and neurologic
system. Common findings include enlargement of
the liver, spleen, and lymph nodes. Skin lesions and
oropharyngeal ulcers may be seen.
A: Assessment
A partial differential diagnosis includes:
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Other deep-seated fungal infections, such as
cryptococcosis and coccidioidomycosis
Mycobacterial disease (Mycobacterium tuberculosis or
Mycobacterium avium complex
Pneumocystic pneumonia
Lymphoma
P: Plan
Diagnostic Evaluation
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The H capsulatum polysaccharide antigen test is
sensitive and specific. The test is most sensitive for
urine samples, but can be used on serum, bronchial
fluids, or cerebrospinal fluid specimens. Results may
be obtained in a few days. Urine antigen levels can
be used to monitor the response to therapy. The
antigen test is available from a private laboratory,
MiraVista Diagnostics (http://www.miravistalabs.
com).
Cultures of blood, bone marrow, and specimens
from other sources have reasonable sensitivity but
may take several weeks. Wright stain of buffy coat of
blood may reveal intracellular organisms.
Biopsies of lymph nodes, liver, cutaneous lesions, and
lungs may be diagnostic in up to 50% of cases; bone
marrow can be stained with methenamine silver to
show the organism within macrophages.
Lactate dehydrogenase (LDH) and ferritin,
although not specific, may be markedly elevated in
disseminated disease.
Complete blood count and chemistry panels may
show pancytopenia, elevated creatinine, or abnormal
liver function tests.
Treatment
Treatment consists of 2 phases: induction and chronic
maintenance.
Induction therapy
Mild to moderate disseminated histoplasmosis without CNS involvement
Administer itraconazole 200 mg orally 3 times daily
or 300 mg orally twice daily for 3 days, followed by
itraconazole 200 mg twice daily for 12 weeks. (See
“Treatment note” below regarding itraconazole.)
Induction therapy must be followed by maintenance
therapy (see below).
Severe disseminated histoplasmosis
Severe infection requires intravenous induction therapy
with amphotericin B 0.7-1.0 mg/kg/d (or a lipid
formulation 3-5 mg/kg/d). After 3-10 days of therapy
and stabilization of the patient’s clinical status, therapy
may be switched to itraconazole 200 mg twice daily
to complete 12 weeks of therapy. If itraconazole is
not available or is not tolerated, fluconazole 800 mg
orally once daily can be used as an alternative. (See
“Treatment note” below regarding itraconazole and
fluconazole.) CNS infection must be treated with a full
course of amphotericin B, because of poor penetration
of itraconazole into the CNS. Induction therapy must
be followed by maintenance therapy (see below).
Maintenance/suppressive therapy
Lifelong maintenance therapy must be given to prevent
relapse after the 12-week course of induction therapy
and typically includes itraconazole 200 mg orally once
daily or twice daily. Amphotericin B 50 mg once weekly
or fluconazole 400-800 mg daily are alternatives for
those who cannot tolerate or cannot obtain itraconazole.
(See “Treatment note” below regarding itraconazole and
fluconazole.)
It is not known whether maintenance therapy can be
discontinued safely in patients who achieve immune
reconstitution during antiretroviral therapy.
Treatment note
Itraconazole and fluconazole may cause fetal
abnormalities if taken during the first trimester of
pregnancy. Check pregnancy status in women of
childbearing potential before starting these medications,
and ensure that women are using appropriate birth
control. Note the possibility of drug interactions
involving itraconazole, especially with rifamycins.