Fungus Among Us
by Frank Pizzoli
With names like aspergillosis
(the name of an old girlfriend), candidiasis (a famous
French play), coccidioidomycosis (Gezzhuntite!), cryptococcal
meningitis (what killed Boris Karloff in the Mummy), and
histoplasmosis (that’s when you bomb a history test),
it’s a wonder HIV infected folks don’t die from just saying
these fungal infections.
Essentially, the body’s health
is defended by its immune system. When “germs”, such as viruses,
nasty bacteria, parasites–and fungi–arrive on the scene, our
white blood cells known as lymphocytes (B cells and T cells)
protect the body. Our protective armor is weakened and eventually
destroyed by HIV as the virus breaks down the body’s immune
system. The good news is that the threat of fungal infections,
at least for some individuals, has lessened with the advent
of newer HIV drugs.
In a set-for-publication
article on fungal infections by William G. Powderly, MD, and
Nicholas E. Haddad, MD, (The Changing Face of Mycoses in Patients
with HIV/AIDS), they point out that the “current era of effective
antiretroviral therapy has led to a marked reduction in opportunistic
infections (OIs) in those countries where such therapies are
available. Opportunistic fungal infections (FIs) are no exception,
and the incidence of such infections is now 20-25% of that
seen in the mid-1990s.”
In fact, infections associated
with very advanced HIV disease, such as azole-resistant candidiasis
and aspergillosis are also rarely seen, according to the doctors’
research. The rare occurrence of these two FIs reflects an
improved immune function. “The most common issue now is whether
patients who have had a systemic mycosis require life-long
therapy as used to be recommended. Preliminary data from small
studies suggest that, like is seen with other OIs, it may
be possible to stop suppressive therapy in patients whose
CD4 lymphocyte count rises with antiretroviral therapy,” Powderly
notes.
So what are these fungal
invaders with the awful sounding names?
Aspergillosis
Aspergillosis is formed from
a fungus found in soil and decaying plant life, and, luckily,
is somewhat rare with HIV. More commonly, cancer patients
on chemotherapy and transplant patients on immunosuppressive
therapies may contract the fungus. For the most part, aspergillosis
affects the lungs and sinus. Prominent symptoms include cough,
chest pain, shortness of breath, facial pain, fever, and night
sweat.
The danger zone is when an
individual has a CD4 count of less than 100 cells/mm, although
infections do occur in people with higher CD4+ cell counts.
Anecdotally, reports indicate that among people with AIDS
who first are treated for bacterial pneumonia or PCP, aspergillosis
may follow. Doctors think that these other infections weaken
the lungs, making it easier for the fungus to take root.
Typical treatments are amphotericin
B (AMB, IV) and itraconazole (oral).
Candidiasis
Formed from a mold called
Candida albicans, candida is the most common HIV-related fungus
infection expressing itself in the human body as “thrush”
or a yeast infection, especially in women. There are at least
four other “species” of the fungus: Candida glabrata, C. parapsilosis,
C. tropicalis, and C. krusei.
When infected, patients experience
discomfort in the mucous membranes around the mouth, vagina,
esophagus, and skin. Typical symptoms are white humps, dry
mouth, difficulty swallowing, and an altered sense of taste.
Candida in its many manifestations is an AIDS-defining illness,
according to the Centers for Disease Control (CDC), when it
appears in the mouth or when the yeast infection is found
vaginally and is persistent, frequent, or responds poorly
to therapy. An infected person with virtually any level of
CD4 count is at risk, but individuals with counts less than
CD4 200 are at greater risk.
It isn’t really clear if
preventative measures are more effective than treating thrush
after it appears. For vaginal yeast infections, yogurt containing
Lactobacillus acidophilus cultures decreases infection
rates. Drugs used to treat candida depend on where and how
in the body the fungus shows itself. For oral thrush, doctors
often prescribe fluconazole, clotrimazole, ketoconazole, and
nystatin. If the fungus appears in the esophageal area (the
swallowing tube) fluconazole, ketoconazole, and itraconazole
seem to work. Vaginal yeast infections can sometimes be treated
with over-the-counter antifungal remedies like clotrimazole
or miconazole.
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Coccidioidomycosis
Coccidioidomycosis
is a fungus found mainly in soil in the southwestern parts
of the US, in Mexico, in Central America, and in parts of
South America. During one part of this nasty germ’s life,
it is airborn—and that’s when it is most dangerous. Those
with coccidioidomycosis have inhaled the fungus, making the
lungs the most commonly affected part of the body, although
the fungus can also invade the kidneys, lymph system, brain,
and spleen. When it infects the lungs, the fungus is likely
inhaled.
Typical symptoms are cough,
weight loss, and fatigue. If left untreated, meningitis is
a commonly associated complication. The CDC also considers
this fungus an AIDS-defining illness. HIV-infected individuals
are considered to be at risk when their CD4 T-cell count is
less than 100.
There have been no studies
on preventing coccidioidomycosis. Typically, treatments include
amphotericin (IV) and fluconazole (oral).
Cryptococcal meningitis
Cryptococcal meningitis is
a yeast-like fungus infection found in soil around the world,
especially in soil contaminated by bird droppings. This disease
usually affects the brain and lungs and advance stages can
involve almost any organ. Patients are most at risk when their
CD4 T-cell count is less than 50.
Because the disease is so
deadly, the CDC recommends patients consider using fluconazole
for those with CD4 T-cell counts less than 50. Be advised
that sometimes this preventative treatment isn’t indicated
because this type of meningitis is rare and the treatment
is expensive. Infected individuals who accept preventive treatment
may end up with fungi that are resistant to treatments for
cryptococcal meningitis. Another factor may influence whether
or not individuals take preventive steps: the preventive drugs
may interact with other important treatments.
Typically, this infection
is treated with amphotericin B, flucytosine, and fluconazole.
Once infected with this fungal invader, long-term treatment
(maintenance therapy) is almost always needed to prevent a
relapse.
Histoplasmosis
Histoplasmosis is a yeast-like
fungus infection found in the southern parts of the US and
South America in soil contaminated by bird dung. Infection
occurs by inhaling the fungus, which means the lungs are almost
always infected, although histoplasmosis can affect other
internal organs. This is an AIDS-defining illness, according
to the CDC.
Symptoms include fever, skin
lesions, breathing problems, weight loss, and liver enlargement.
Patients are most at risk when their CD4 T-cell count is less
than 100. Itraconazole is sometimes used as a prophylaxis
preventive for those with very low CD4 T-cell counts who live
in southern parts of the US.
Treatments include amphotericin
B (IV), and itraconazole (orally). Once infected with the
fungus, long-term maintenance therapy is usually needed.
Although sticks and stones
can break one’s bones, and normally words won’t hurt someone,
HIV-infected individuals should consult their physicians on
how best to combat fungal infections.
Freelance
writer Frank Pizzoli is founder and executive director of
Positive Opportunities in Harrisburg, Pennsylvania, an HIV-employment
service and wellness and prevention program. E-mail fpizzoli@aol.com.
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