Fungus Among Us
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 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).
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.
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 airborne -- 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 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 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 firstname.lastname@example.org.
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