9 basic Inronmarion DEFINITION ‘Acquted immunodetcency syndrome (NDS) is a disorder caused by infection wit the human immunodeficiency virus (HV) and marked by progressive deterioration ofthe cellular immune sjstom, leading to secondary (opportunistic) infections and/or malignancies. ‘SYNONYM ADs eD-10cm CODE B20 Human immunodeficiency ius [HV] disease EPIDEMIOLOGY & DEMOGRAPHICS INCIDENCE (IN U.S): ‘The estimated number of persons dlag- nosed wth AIDS in the US. i approximately 18,0004. There Is a dsproportonate number of new [ADS cases among blacW/Atcan Americans and Latinoispanic Americans. compared with white Ameren. The majority ofall new ADS dlagnoses are among gay, bisexual, or athe men wh have sex with men OSM) PREVALENCE (IN U.S): The cumulative rum- ber of ADS dlagnoses inthe US. exceeds 1.2 milo. PREDOMINANT SEX: Men constitute approx- ‘mately 75% of incident AIDS diagnoses in the US; more than hall of ADS diagnoses occur in MSM. PREDOMINANT AGE: The predominant age ‘group ciagnosed with ADS is 25 to $8 yr of age. PEAK INCIDENCE: Ages 25 to $8 yr SSENETICS: + Familial ispositon: Altiough there is no proven genetic predisposition, individuals With deletions in the CRS gene are less -susceptle to HIV infection wih macrophage ‘topic virus (the predominant virus in sexual transmission) and may progress to AIDS more slowly + Congenital infection 1. -HIV is transmiable from an infected motier tothe fetus In utero in as many 2 30% of pregnancies if untreated 2. No. specitic congenital. malformations ascociated with infection; low bith Weight and spontaneous abortion are posse PHYSICAL FINDINGS & CLINICAL PRESENTATION, + Nonspecific findings: Fover, weight los, + Specie syndromes: 1. Seem in association with spectc opport- nisi infections and malignancies. These include: Opportunistic infections: (1) Disseminated strongyloidas's (Disseminated toxoplasmosis, cryptococcosis, histoplasmosis, cytomegalovirus (CMV), herpes simplex vius (HSV, or mycobac- teal disease (most common is rmyeooacterium avium complex) (8) Candida esophagitis or broncho- pulmonary disease (4) Chronic erytosporidass diarrhea (6) Pneumocystis jrovec! pneumonia Par) (@ Extensive pulmonary and extra- pulmonary tuserclosis (78) (Recurrent pneumonia or other bacteria infections (8) Progressive multifocal leukoen- cephalopathy (PML) b. AIDS-tlated nooplasms: (1) Kaposi sarcoma (2) Primary brain rmphoma (3) Invasive cervical carcinoma (@)Hgh-grade B-coll_ non-Hodgkin Iymphoma, Burkitt ymphoma, Undifferentiated non-Hodgkin lymphoma, orimmunoblasti m= phoma 2, Most comman: 2, Respiratory infections (Pneumocystis jroveci [formetly known as Preumocyts carinil pneumonia, TB, bacterial preumonia, fungal infection} CNS infections (toxoplasmosis, TB) €. Gl. (crypiosporiioss, isosporiasis, CMV; Sections lI and I describe organisms associated with diarrhea in patients with AIDS 4. Eye infections (CMY, toxoplasmosis) Kepos sarcome (cutaneous o viscer- al) or ymohoma (nodal or extranodal) + Possibly asymptomatic + Diagnosis of ADS if the CD4 cell count is <200 oF <14% of total lymphocyte in the presence of proven HW Infection, even inthe absence of ater infections ‘+ The various manifestations of HIV infection are described in Section I ETIoLocy ‘Caused by infection with HIV-1 or HV-2 (les common ‘+ HIV is transmitted by sexual contact, nee- fle-sharing (during IV drug use, transtu- sion of contaminated blood or blood prod- Uusts, and fram infected mother to fetus of neonate, Dx) DIAGNOSIS DIFFERENTIAL DIAGNOSIS “Other wasting esses mimicking the non- spect features of AIDS: LB 2, Neoplasms 4. Disseminated fungal inection 44 Malabsorption syncromes 5. Depression Ag P1@ Acquired Immunodeficiency Syndrome + other disorders associated with dementia ‘oF demyalntion rodicing encephalopathy, myelopathy, or neuropathy WORKUP Prompt evaluation of respiratory, CNS, and GI complaints LABORATORY TESTS + HIV antibody testing, See "Human Immunodeficiency Virus" topic for the updated surveillance case definition for HN inecton (DS cell count: Performed to determine the ogres of immunodeficiency. Viral load assay: To plan long-term antiviral therapy and to folow progression and suc- cess of testment (ie. HIV RNA PCR) ‘CSF examination: For menings or neuro logic disease i incicated. Serologic tests for syphilis, hepatts A, hepa Its B, hepattsC, and toxoplasmosis Testing for other sexually transmited infoc- tions (STs) such as syphis, gonortea, and colar Genatypic resistance testing: Used to assess for primary resistance in naive patients and secondary resistance in patients faling a regimen, ‘+ ye exam: To ovalate for CMW rains in patients with CD4 counts <$0 cells/mm + Cryptococcal antigen: Part of the evaluation im AIDS patients with CD4 counts <100 cells! mmm? wha have fovr, cifuse pneumonia, or evidence of meningitis Evaluation for inection with mycobacterium (1B or MA) including a tuberculin skin test (TS1 or interteron-gamma release assay AGRA), sputum cultures, chest radograph, and blood cures for acid-ast bactria, depending on ciical presentation. IMAGING STUDIES ‘+ MRI or CT of hea for encephalopathy or focal CAS complications (e.g, toxoplasmosis [Fi E'], lymohoma) + Chest radiography or CT to aid in the iagno- sis of Pnoumocysts rove! pneumonia (PP, TB, or bacterial pneumonia, (Q rReaTment The most important aspect in management of [NDS cue to HI infection isthe timely intation of antiretroviral therapy. NONPHARMACOLOGIC THERAPY «+ Maintain adequate caloric intake * Encourage good oral hygiene and regular dontal eae. + Avoid high-risk behaviors that increase the risk of ether potential pathogens—use con- doms, avoid sharing needles. et. Update vaccines—particulay Téap (tetanus, diphtheria and pertussis), pneumococcal meningococcal, and hepattis AB vaccines ‘along with annul inuenza vacines. 19 siopiosig pur sass20 Acquired Immunodeficiency Syndrome @ @ ‘+ Avoid administration of any lve attenuated vaccines that may be @ sk to these immuno- compromised patients (eg. MMR, varcoi). {See Section V for immunizaton ‘schedules ‘or HN-infected children) When feasiole, avoid actives that might Increase risk of exposure to opportunistic infectons (e.., leaning out a cat Iter box [toxoplasmosis getting scratched by a eat [Bartoneta infections), exposure to pet rep- ‘los [salnonelass, traveling to developing counties [cryptospridioss. tuberculosis). testing undercooked foods and drinking fom unsafe water supolies, etc). description of fnteropathogens causing infections in HIV- infected patients i provided in Table 1 ACUTE GENERAL Rx ‘Acute management of opportunistic infections is ‘summarized in Tobe 2 and reviewed elsewhere in this text under spectic AIDS-related dsor- ders. For management of AIDS-related maig- nancies, pease refer to the specific malignancy elsewhere inthis text CHRONIC Rx For al Hinected patients, patcualy those meeting the case definition of ADS: + Preventwe therapy for Preumocystjrovect Pneumonia and Mycobactorum avium (see specific chapters elsewhere in tis tex. With appropiate antretovirl therapy, many patents experience substantial restoration of calla immune function. Preventive thera- Py for Pheumocystisjroveci can be safely stopped ifthe CD4 call count rises above 200 foratleast 3 mo. Based on the Department of Health and Human Senices (DHHS) Guidenes, active antietroral therapy (ART) sul be started regardless of CD4 call count. naviduals with (4 call counts <350 and especially C04 call counts <200 should be stongy encouraged to start ART inatimaly fashion ART svally includes thre-drug combina tions of 1, Nucleoside reverse transcriptase inhib- tors (NATH: Teotoveaisopoxl tumarate (TDF), tenofovir aletenamide fumarate (TAR), lamivudine. (870), emtriitabine (FIC), and abacavir (ABC), Older drugs such’ as zidovudine (AZT, didanosine (dd), and stavudine (G47) are generally hot recommended, Protease inhibitors (P): Atazanavir or darunavir 3, Nonmucleoside reverse transcriptase innibitors (NRT: Nevrapine, efavirenz (EFD, etravrne, and ipivene 4, Integra inhibitors: Rltegravir elvitegra- vir bitegravi, and dolutegravir 5. Others: Maravirc, entuitide, and ibal- zuma TABLE 1 Organisms That Cause Gastrointestinal Tract Infection: Patients with HIV/AIDS Organisms Candide abieane ytomepilovius® eres spec vs ‘ytomegalovius psp Hepattopic uses ‘yeobaeterim avim campler’ Camppabacter snes ytomegatovis ypesporiu Gia tambe leosora bee ‘ycobatenum avium camper’ Mesasporidl®(Etercytazoon bienesiandEncephltezoon ines ‘Saimana species! Entoagoregathe Ecol ‘Stongyiesstercras Campylobacter species stu ace nomegslovtus histories simplex virus? ‘Salmana species! Entoaggregate ca ‘Shiela speces soe eh gaara vara alte ns ‘Sin Coal ng Ponto sulin ee et rian eas, From her Da: Fon and Chan’ pei nus esse 048 Pain, 209, ee, Esophagus Hepa ‘ml esne Large intestine The medications ritonavir oF cobcistat are usualy used in combination with other prote- ase inhibitors of integrase inhibitors to obtain ‘more sustained drug levels. Usval inal dosing regimens include two NRTIs and an NNRTI or PI-or integrase inhibtr. Curent, integrase inhibitors are recommended as frsine drugs because of tolerability. Examples o inal rege mens recommended by the guidelines: 1. Blctegravirtenofovicomtctabine 2, Dolutegraviabacavirlamivudin (in patents Who are HLA-BY5701 NEGATWE) 3. Dolutegravir plus tenofovifemtictabine™ 4. Raltoorair plus tenofoviromtictabine" 5. EWitegravicobicistattenofovifemticitabine 6. Darunavirrtonavr or darunavilobiistat plus tenofvivemtiitabine “Tenatoicbasd formulate can ialudelentone 4sopros| fumarate (TOF) © tenoourltenamide cc Previous frst line drugs, nclucng efavirenz! tenofoviremtctabine and ripivirinetenofovet femtictabina, are now considered altemative regimens. Al these drugs have unique and class spectc side effects and requre careful and expert folow-yp to achieve optimal antiviral effects, ensute compliance, and maintain eff- cacy. Antiviral response should be monitored by baseline HW vial load and CO4 count and repeat measurement at 2 wk and 4 wi into ‘reatment and then periodically (3 to 6 mo) to ensure viral suppression. ‘The approach toa patient with CNS sign and symptoms is described in Fg. 2, and Fg. 3 describes the management of CNS mass lesions, + Genotypic resistance testing is strongly encouraged for al ations inating treat- ‘ment and for any patent faling antretovirel ‘therapy. Poor adherence to therapy, however, often unceriesvolegic flue. DISPOSITION The outlook for KV has changed radlaly since ‘the advent of ART trom an essentially fatal Aisease to a chronic medical illness compatible with longterm survival and remarkably good ‘qualty of fe, Patents should be aggressively ‘teated fr sever lnesses a outcomes fllow- ing OU admissions remain good. This is accom- plished through expert and continuous follow Up, use of ART, and careful detail to compliance to medications and lfestyle modification. REFERRAL A patists with HIV should be referred to 2 Physician knowiodgeable and experienced in the management of the disease and is com- Dliations. RELATED CONTENT Acquired. Immunodeficiency Syndrome (NDS) (Patent Information) Candidiasis, Cutaneous Related Key Topic) Candis, Invasive (Related Key Topic) Cryptosporisium Infection (Related Key Topic) Cytomegalovirus Infection Rated Key Tope) Herpes Simplex (Related Key Tope) Histoplasmosis (Related Key Topic) HW-Assocated Cognitive Dysfunction (Releted Key Tope) Human Immunodeficiency Vius Related Key Tope) Kaos Sarcoma (Related Key Tope) Pneumonia, preumocysts jrovee! (carini) (Related Key Tope) Progressive Multifocal Leukoencephalopathy (Related Key Tape) Toxoplasmosis (Related Key Topic) Tuberculosis, Pulmonary (Related Key Topic) AUTHOR: Pili A. Chan, MD, MS,@® @ Acquired Immunodeficiency Syndrome = ‘TABLE 2 Treatment of AIDS-Associated Opportunistic Infections oops SE net mar Aura Tecan te Comments ee as 5 Te a ey se TEE a sree 1 Sat mee Saar opfetT® «Re crtina 8 fora oF leotonai or 7 mo. APB i aes potent C¥PB84 ince than RF ané is rotors in aes recog Pl ontnuedz Acquired Immunodeficiency Syndrome @ @® TABLE 2 Treatment of AIDS-Associated Opportunistic Infections—cont'd Opportunistic Infection Preferred Therapy ‘Alternative Therapy Other Comments Bacterial resi ratory i= ses (th focus on pneumonia) onary 1 and autre poste war 2 mo of T teatmen: Exrapulmanary TB wh CS ict: si2me, Extapuarary 18 wih neo int imvobement6 09 ma Exrapumanay Tin ote tes: 6 ma Total dation of therapy shoul be based on numberof donee recies naton calendar tne ‘At ast 2 Orgs as itl Therapy with Crtromycin $00 mg PO bi + t= ‘ambutol 18 mg PO daly, or ‘atom 800-600 mg + eam {ah 18 mg PO ay era inerac thn or ileranceprechces reuse of cate Durations Atleast 12 mo of therapy, can iscon- tue no sgn ad symptoms of WAC disease and sustained 8 mo} CDA count >10 cell n response t ART. ‘Resistant to Rfamyens = Or Digs: Rogiran and duration ef weatment shoul be nddualed ase on re sistance patter, diel ae micobo= logic esprses, ad in cee const tan vith expeenced specasts ation o thir our rug shouldbe conieea for patents wth advanced inmunosuppession (D4 founts<80 casa righ myeobate- Fallon (22g Cm ahead), or Incheabsoneofefectve ANT Tid or Four Drag Opens ay nude: eB 200 mg PO daly (oeage aut rent maybe necessary bated on dug Interaction) or Amikacin 10-18 maf W daly, oF Steplomycn 1 gW of M daly or onifxacn 400 mg PO daly orev ‘rain 5009 PO aly Epi anioe trap sou be insted romp for pn presenting wit cial {td radayapicevcece consistent wit azeri neumona. The recommendations liste are suggested emo therany. The regimen shoulé be meted as needed once ricobologie results ae aval Empire Outpatient Therapr ‘APO lactam + PO maroe (axoromyein clarion Prtered lactams High-caseamox- can ariinelevlrae, ‘AleatveBactams:elpacxime or Caluroxime. or Fro penclnalergc patie: evox ‘in 750 m9 PO once dy, or moxtox ‘in 400 9 PO oace dah Duration: 7-10 dys (a minirun of S ay), Patents shoud be ater for {48:72 noire ane cially stable before stopping abitis. “EmptieTheroy fr Non 1CU Hoste ‘aed Patt: Fn Wfsnctam + 2 marae (tro rnin o dato DProtered lactams: Cetaxone t= ‘acre, or argiesin-subactar, Ferpencilnalergc patients Levefoacn, 750 mg once daly, or rmasnogen, 400 mg W once daly, “Empie Teraoy fr cy Patets: An facta + W azthvomyen, ar Emp Otpetont Teray: 1APO Buta + O aoxeytne Prtered(-actams ign-soe amok ican or amoxctovelverat. ‘Aternate pacts Cefpsorie or telurae Empire Therapy fr Non AC Hospital 120d Patt: AnIV Baca + doxgeyeine. + Epic Merny for eu Patents For peneiln-alerge patents: Aten ram V+ featoaia 750 mV ence fal er moixacin 409 mg once aly Epi Therapy fr Patent at ik of PesudomonasPreumeni: AnlVantpraumecocaanteseude- rnorallactam + an aminapycos de st auktronyee ar ‘nce-woehyapantine can osu hdevlp- mont of famyein resistance In H-acid pax tents and rot reammendea Therapie dug montorag shuld be consieed ington receiving ifamyes and interacing ART Parson! RS thts not severe canbe tested with NSADs witost a change in TB o HV ther oy For severe IRIS reacton, consider preisone ana taper over 4 wk asec on lial symptoms, For rama: Irecsiving RI Predrizone 1.8 mpd for 2 when 0.75 malay fr? neaks, I recing RFB: Prensone 1.0 malay fe 2 we ten OS mgfgiy for 2 wk ‘Amor gradual apering Schedule over afew mo ray be necessary fr some pains Testing of suscepti to artronyein ard szomyein i recommended NSAIDs canbe used fr patets wno experince ‘oterae to severe symptoms atte t IS TTR symptoms persist, shart (8 W595 tee coteosteals(equvalent 20-40 mg presse) ca be used. Fuorocunolones should be wed wit auton in Patents in whom Ts suspected but rt beng trates Emp therapy wih amacoiealone is nota: tnely commented because of easing pev- Imococealressare Pallets ecevig a macro for WAC prop: lois shouldnt rcave macro anoterapy tor emote weatment ot bacterial preurai. For patents begun on Vanity, sohing to PO stout be considera wien ty ‘89 cincaly improved and able to torate oa mredeatons heropropiyins an be considered for oetiens with requentrecurences of sos bacterial prauraria@® @ Acquired Immunodeficiency Syndrome 2s TABLE 2 Treatment of AIDS-Associated Opportunistic Infections—cont’d Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments ~ An flacam + (evafarach 760mg > Above acim + anaminghyeasice > Clclane shoul be eautaur abo ug abi once daly or maxitoain 400mg (evoonac 750 mgIV ance daly ies a grovnt ecarencesSecauze of te pon ance da, ‘ormoxiosacn 400 mgIV once cxih, tal or developing cup resstance and og txe- + Prteredfactams:Cetacne cet. or ies lakine, or ampir-sbacam, + For panic alergic patents Replace + EmpicTharapy fr Petts a Rsk of th lactam wih szveena, Pseudomonas Preumons ‘An artpnemoeozcalaipseuto- ronal lactam = eprolxacn 400 mp I gb-12n or levatnsin 750 m9 0 once day Proto etams: Pipers a2 acta, cefepime, imipenem, oe ‘open Emp Therapy fr Patents at ik for Metin Resistant Slapocoecus tureue Provan 2d vancomyelnW or tneral (Vor 0) oe baseline regimen, ‘adn of dari Vancomycin (but na to nel) can be carsicred {or severe necrotng pnearona to Imig acter tox produce, sated siopiosig pur Baca ente- + Diagnostic teal specimens shouldbe Empie Perpy + Hossain wih W anit shou be eon lenfecions _eblaned eto talon ot erp an- + Catratone 1g V a2, ar dered in paterts wih marked nausea, yotg. mpi therapy ‘iti therapy. 2 caine 1 gIV aan data. decays abromaltes, css, nd ending + Emp artbate therapy is ineates Blood ress stb. fenve {or pas with advaness HW (604 + Oral orl rehyéationfineate. slagesis fount <200 cele or concomitant + Antimottyagets shoul be avided i tee [DS-defningllnesee ity clic ‘ance about infirmary date, inuting severe care (28 stole), aioe Cstum aee-assacited cas accompanying feo ils, + on cna response ater 5-7 days, conser fo + Enpine Marapy low-up tol ele uth antbit ueepty * bftoxsen 500-780 m PO (or 400 testing or trative saprate sis (ota mpi at2n sen, molecu testng, sterativedagoss, + Therapy stould be adusted based on or abit reetance, the rests of dagostie workup. + For patents with chonis dares 214 days} wibout severe crea ans, = rc atbits terapy snot neces far, can witha Veatment url a gnosis made. Ssinonelosie _AHN-infcted patti salmaeloes shoul be sled because of high rk of act + Oral WY ehyeatin i nda rami, + Animotyagenis soul be evaded, + Ofpotorscin 500-750°mg PO (or 400+ Levitin 750 mq (PO or azeh, + The lof ong-eem secondary papas n img aT 2h suscepti o patents wih ecrantSaonet bacteria is + Duraton of Meapy + Meitoracn 400 0 or 2, nat wel estabsbe. Must weigh bane against + Far gatontrt witos bacteremia o "sof long-term anboitexposu 4 WOH court 200 cel 7-14 days,» TNP.160.mg-SMK 800mg POorM + Eee ART may reduce the fequncy.sevety, * WDA cout <200 cal: 2.6 wk aieh or and recurence of Salman infestans. For gasoanans with batoremi: + Cotane 1 9 W gd, or +H COM caunt 700/118 days; longer + etotnme 1g IV ab uration bacteremia pests othe infecton is compat 9, meta tae fol ot ifn ar presen}. + WO4 cour <20 cel 2-8 9 Secondary Prope Soul Be Cosi. rd fr + Pars with rcurertSaimonla gas- ‘wombs « bacteremia + Pater wih 64 <200 east wth vere cathe, Continuedz+ Acquired Immunodeficiency Syndrome @ @ TABLE 2 Treatment of AIDS-Associated Opportunistic Infections — cont'd Opportunistic Infection Preferred Therapy ‘Alternative Therapy Other Comments iMicoctaeous For Grapharyngeal Cacia ar Oropharyngeal Candis ia ~ Girne 6 prelenged us of aos may proms tanddass Episodes for 7-14 6x3: Episodes or 7-14 cay) ovelopment of esstarce + oral teapy + Ova therapy + ghar lapse rte fr asoghageal cancdlais * Fluconazole 100 mg PO daly or * traconazt orl soutien en wit ectingcardns han wth Nuconazoe + Topical therapy 200 mg PO daly oF te * clvmazcle Woche, 10mg PO times» Posaronaroe eral saluon + Suppressive therapy is usualy nt recommandes daly or 400 mg PO tid for dy ten Uns patents ave quant or severe + Micontak mucoadhesve buceal 00g dai, recurences 50-mg lablet—appy to mucosal + Topeal ray InDeesson to Use Suppressive Tharany: Oropha- #rface over the carne foes ance + Nystatin suspension 4-8 mi it ‘yngeal Candas Ahly ont sow, cheno erst, 71-2 favorea pass 4-5 times + Flieanazle 100mg PO daly oti Far Esophageal Candas flr 14.21 tay * teacnazle fl slien 20 mg PO day. da For Esophageal Caniiasis + Esophageal Cariiass: + Fluconazole 100 mg to 400 mg) tor 14-21 aay + Flicaraale 100-200 mg Po cay, Poort daly or ‘+ Nononazle 200 mq PO rv bis or + Pasaconezle 400mg PO bi + Hacanaol or soluten 200 mg PO + Paratonaoe 400 mg 20d uvovaginl Candas dai * fniulstngin 100 mg tra ten + Flucaazle 130 mg PO once wees, Fer Uncomplicated Vuoraginal 50mg W daly or Canadas + Caspar 80 mg W daly or + Ora Puconazle 180°mp fort dos, or + Miatung 150 mg Si + Tonia azles(otimazl, + Amphatarcin 8 dealt 0.8 mg bafosonaol meanazae econo, kg W daly, or or tercaazoe for 3:7 da. + Ubi formation of amphoterin 8 Fer Sere or Reuter uivvaginal EA mpg daly. candi, For Uncamplcated Vuboraginal + Flucanzole 100-200 mp PO daly for Canadas: BT dys. oF + Teaconazl rl soliton 200 mg PO Topi antungal 27 cys. aly for 3-7 dys. Cypocsecess ——Cyptcoceal Menigts cryptococcal Meningie + Adsiion of ueytain o amphoterin & hasbeen = inucton Therapy rat set 2 wk,» Induction Therapy for at et 2 wk assocaad with more api sterlizaton of CSF faowed by conslston therapy foloaed by cosaieton nd deceared sk or subsequent lapse + Uposomalamphoterien B34 maikg NW thrapy + Patents receing vyiosn soul ave eter day « cosine 25 mika PO (sr: Flussing dase shoul beat use in patents with el dstnc- te Cansldaton Therapy at est 8 wk flowed by maintenance tarapy Fluconazole 400 mg 0 or dal + Maintenance tera. Fluconazole 200 mg P daly frat least 12 mo. For Non-ONS, Exeapumonary Cryptocoe- cost and Die Pulmonary eae + Weatrat same a or erptacaecal rmanngs. NCHS Grptcoecsi with Ms 0 ‘Moderate Symptoms ad Focal Pulno- ay inate: + Fluconazole, 400 mg PO daly tor 1m + Amphotericin 8 deonetolate 07 mag daly = fuerasne 25, mgt ?0 qe, or + Amphotericin 8 oid compen Simghg daly + fueyasne 25mgikg PO ad ar Lposomal amphoterin B54 mghg W daly + fuconazcle 800 mg PO ar W daly, or + Aphatrcn 8 deoxycholate 17 mag daly + fuconaae 800.9 PO or daly. or Fucanzsle 400-800 "mg PO oc daly + fasine 25 maha PO i, Fuconazse 1200 mg PO day * conan Therapy frat ast 8 ih tolled by maintenance tterapy Tacorazle 200 ng PO bi for Saket efecte tan ‘henna, + Maitonance tery. No arate terpy recommends, oo eels mentored (ak evel 2 hous afer fase soul be 80-80 ugh or close monting 1 tond cous or development of eters Dosage stuld ve agsted in patents wh ral inet, + Opening recur sould ays be measure wren an Lis peared Repested LPs or CSF hut ne exenta to etestey manage trenzed nero presue, + Coricosteris and anni aeinefcv in dtc intacranl pressure an 2 notecon= mended Some spacial rcommand abit course of Certeotri for management of severe IS syrotons.@® @ Acquired Immunodeficiency Syndrome TABLE 2 Treatment of AIDS-Associated Opportunistic Infections—cont’d Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments iisopasnoss Madea Severe to Severe Disomipated Moderato Sve t Soveve ~ Wazinale, poracoazoks, and vrcoazale may ‘Disease induction Thorapy for atleast —-‘Disamnaad Disease induction nave sinfeantimracts with cen ARV 2 kor nt clncaly mproved: Therapy fora east 2 wo nt Agents. Tess interaction are complex and can + Uposomal amphoterin 83 mpg clay improve Be ldecton sai + Arghotein pi comple 3myfkg + Therapeutic dug manring and dosage ast- + Manteance Therap, Waxy or iment maybe necessary to ensue tzleai- Coctiddmycois Aspro * Hraconazole 200 mg PO td for 98, then 200 my Pi. Lees Seer Disoinated Disease + nducton and Maintenance Therapy * Hraconazole 200 mq PO a fo 3 a, then 200 mg P + Duration of Therapy. + Atleast 12 mo, Menogtis ‘Inctn Therapy (1-6 8 + LUpesomlamprotrin 85 mgalay. + Manenance Trap. * Iraonazole 200mg PO bid for ‘Bly and unl resoliton of abeorral SF findings. + Long-Term SoporessionTery + Far patents wit severe clsseminat (or CHS infection ater completion of t leas 12 mo of therany and thse wo ‘alpse cesta aproprate therapy + Trazonszole 200 mg PO daly. inca Mi iectons (og, focal ‘pnsumeni: + Fuconaae 400 mg PO aay or * teaconazole 200m PO bi Severe Nnmeningel nection tse ana ineeton or severe! Patents with exatarace, tdssorinated cae) + Ampnoteriin B deoxycholate 07-10 mgs da + Up formation amphoterin B 4.6 mg Vda Drton of hrapy: Cone unt clive improvement, then sth oan ok, Meningeal etn: 1 Fuconaae 00-800 mg W PO cally, + ron SuppressneTherape Fiuconazale 400 m9 PO ely, or Ieazonaale 200 ng PO bd Prefered Therapy * Vovanaole 8 gi Van or 1 dy. then 4 mg W 12h lowed by vr- Eenarae 200 mg PO @t2h ter cna improvement, + buraton of Therapy: + Unt COA cal court 3200 cosa ara ‘he infection appears tobe resales. -Arphotercin 8 cholesteryl uate cutee 3 mgig W da, ‘Atemativs fo eacanazoe or Maint tance Therapy or Tetnent of Lass Severe Disease \ericanazl 400mg PO bi 1 dy, ‘then 200m bor Posacanazle 400 mg PO bi Flvconazle 800 mg 0 daly Mesingts No atemate tespy rscammendston, Long-Term Supresin Therapy Flvzonazle 409 mg 0 daly. i fection al pura for ‘ants a fated respon oP fora a raconza Posaconazle 200m PO i, or ercanaol 200m PO bd Severe Nonmeninget net (ise ‘ulnar infection or seve i tens wih extatorace disominated sisease ‘Some specialists wil ad ale ‘fucorazle or waconzoe, wth a ‘canaol prfred for bone dssas) 400 mg pray to ampatern 8 therapy and canoe tazle once anptotnen Beppe, Meningeal iecions: a orate T Traconazale 200 mg PO i for 3 days, ‘on 200 mg PO bi Posaconazle 200 my PO bis. or ercanaole 200-400 mg Pb, or Inratheel amphoterin 8 deoxeno- In, when aa singe ae sect, (hvoni suppressive therapy Posaconazle 200 mg PO is or Verano 20 m9 PO bi a Lis orion of amphoteric 8 mga daly, or Amphoterin 8 deonehalete 1 mak Nay or {aspetungin 70mg V1 tne, than $0 imglv dah. Miatungin 100-150 mg W aly, elitr 200 mg N 1 tv, then 100g daly or Posacanazle 200 mg PO ai, thn a= ‘er conan improved 400 mg PO i ‘ungal nd ARV etfcaoy and to reduce concent irl tants fangam serum concentaion of raconazle + nyroyraonazle shoul be > pa Clea exoerence wi vorcoazle or prsacon- zl ine eaten of histoplasmosis std ‘cul pulmonary histoplasmosis in HV-fcted patents with CDS caurs 300 cel shou be managed as ronimmurocompromised hes ‘Some patents with merngs may develo hy: rooephalus and requre CSF shantng. Therapy shoul be cortnued indeely in ‘ens wth ete pulmonary ar esarnaies = sases because lapse can occur 254334 of Hvénegaive patie, ca alo ozcur Hn {eco patlnts wlth G4 counts ~250 cal, “Therapy shoul e flog in patents wih menir= geal irtectons because relapse ocus in 0% of veined pains after deomnuton ft ‘zoe thera. Iraconazoie,posaconazle, an voriconazle may rave lnteanneractons wth cern ARV Agents. Tess interaction are complex and can Be bidrecton. Terapeute drug moniting and dosage adjustment may be necessary o ensure ‘izaleattungl and anteeoirlecay and {io redue encen-aton~elate tones, Ingathecalarpotercin 3 sald given anya ‘angulaton wih a spcast and sould ea minstre by an not with experience wih ‘ne tecngue Potential fr sgiteant pharmacokinetic ineae- ‘ions between can ARY agents and vorcor- saz hey shoud used cast nese st Uatons. Consider therapeutic ug maritorng ana dosage austment i necessany, ented 25 siopiosig pur sated2s Acquired Immunodeficiency Syndrome @ @ TABLE 2 Treatment of AIDS-Associated Opportunistic Infections — cont'd Opportunistic Infection Preferred Therapy ‘Alternative Therapy Other Comments av deease GUN Rati auction Thora or ‘AN Ret action Therap ~The coe of teapy fr CMY ais shoud be lnmedat Sight-TreatnngLosons _» Cancldove Sg W 2a for 14-21 ingle, based on cation and severity of (acento re ope nerv or foves fy, or thelesions vel ot munosapresson, and + Corsttophtaologst: gaceiovrin~ + Foscanet 80 mghy W el2hor 0 mg cher factors (29. concomitant mediates ans lant no lnger aval: bn for 1421 aye or ait to adhere fo teatrent. «+ Cancer's mag Vg12h for 14-21. + Giolove § mkv for 2 wk 88+ + The che ofcronie mentenance therapy oxte ays followed by Vlganciovi $00 mine ytraton before and ater heaoy of arnsteaton an dru ences) soa be Pod ‘na proveresié.29 PO Shure Deore made contain tan opine Far Smal PrierlLsions: ose, folowedby gO Zhaws and Considerations shoul ince re aalomi lca- *Valgenckdov S00 mg PO bis for 14-21 8 ours tare eae tlt gh. tian ofthe retnal lesion, von inthe cotalateral As (ote: Tis regen shoulé be avis eye the pains mmunologc and volo sta- + One dove of avira gncclovr can bein pabinish sulla allergy bocaute lus and response a ART. iministeres imately ater sagrsis of erss-hyparsnsvily wih proton Un steady-state plasma gancidowrcon- 2) anton aerieved thea vlganc + Crane Manonance (second po hn pyc: + Civic Maiinance (secondary ropy- + Cancidove mpg W 5-7 times ‘ans weed ar + Valganeidov 800 my Po daly tr small pephera esi. CMY Esephais oF Colts: + Ganilow § mgikg WV g12: may sich ‘ovals 800 mg PO gt2h once patent can cera oa ers, + Duraton: 21-42 days or ul symptoms Foscamet 9-120 mgikg W once day, + Patents wth CHW rts who dscatinve man hav aro. o Tarance harapy shoul under eglr aye x + Malnenance therapy usualy nt neces- + Cidtovr maikg WV eer other we sinatns fo eaty delat of elapse RU sary but shold be considered ater wth ane hyraton and probeneié ‘ial every 8 o an then analy ater lapses. as above irvmunerecarsttuon WaitDecumentod Mitocgicly Cotes UV Eophapts or Cols “FRU may develop nthe eetng of immune recon CH Pearman * Fascane 60 mgikgW e128 60 mg! stv. + Experience fr treatng CMV preumontis Kg ah for patents wit eaten + Treaont of In patentsisterted Use oY gan Iining tants to ganclow or wity + Paocuarcortcoterid or short couse of s- Clio oscametis reasonable ases gander resistance, or fami stera, same a for CMY ret. + Vagal 900 9 PO 2h in + Ital therapy inpatients with CAN retinitis, + Theol duration o therapy andthe mer ssase an I able orate esophagitis cols, and pneumonitis role orl vaenecovirfaveno! een PO therapy ar Clue tation er optimization of AT etabtea + For mld eases, ART canbe intites + WY Heaaoge Disease vat delay consider wioking + NatWest tou be ted MV therapy promot. + Durator: 71-42 dys or unt symp- + GancidouS mph W q12h + (oscarat_ toms have resdve 0 mika W qt2n or 60 mak N ah to stall dose and maiz espace aninue ul symptomatic mprovenent and reson of neuoge spins +The opal duration o therapy andthe rol ¢ ofl vaganclvr ave no been tobe HSV disease Orla Lesions 5-10 ys Far Acyclovir sistant HSV “+ Patan wth HS ete can be reat wt + Valegctors 19 PO bi or + Pratored Tarapy ‘sisi therapy when syrplomati lesan acu, + Famechvir 00 mg PO bd or 1 Foscanet 80-120 mgfgiay Vn 2-3 or wth dal spree therapy to preven re «acyl 400 mg PO te Avice doses ur cial response currence. tal Roar Gentl HSV Yr 5-14 days: + Alernatve Therapy + Topical formulations of wtuitine ard itor + Walasyelov1 9 PO bd, or * Wesfou asa sin CMW rotei- sxe not commercial avalate. * Fare 00 mg P be or ti 07 + Etermporaneous compounding of piel products + beet 400 mg POs + Tele! nun, er can be prepared using ture opthalic so. Seite Muroeutaneus HS: * Topical isoov, ar Tutor athe frat of ison. * In heap ayeoveS maka W gBh + Toil miqimod * ter lesions begin regres, change to + Duration of Terapy Po theraoy a previously. Conte et lesions ar completly Peale. + iron Suppressive Trap or Paints th Seve Recuranceso Genta Her asa for Patents We Want Mime ‘Froguancy of Racurences: \aleoyeorr S00 mg 0 bi Famer 00 mg PO Peyelo 40 mg PO bd Continue inden cegarless of CD& cal count. 21-28 days orange@® @ Acquired Immunodeficiency Syndrome TABLE 2 Treatment of AIDS-Associated Opportunistic Infections—cont’d Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments ‘av dsease Primary Varia inecton (Chckonpag Primary Vaca fection (Deke * Uncomatisted Cases or 5-7 days: + Uncomplestd Cases fl 5-7 dy) + Valeou 190 sa or + eel 800mg PO 8 tesla + Fell 500 ng PO ta Herpes Zoster Singles) * Severo ar Comlcate Cases: hese Locaad Demateral * Aejlove 10-5 mghkg W gh or 7-10 + Far 7-10 days consider longer dura says. tion lesion are slow torso. + May eviten earl, fame Aeon €00 mg POS tines, Elo or acylve after ctevescoce fro events of vcr invatemen Herpes Zoster (Shingles Acute Loczed Dermatol + For 7-10 day; conser ger uraon ifesns are sow torso, + Yalueov 19 Po tor + Feat 500-9 Exonsive Cutaneous Lesion rice i= voter + Aajlor 10-18 malig W ge ut en ‘calimorovement event. + May steno P0 therapy fsaccov, fancier alo afer cline improvement fc, when ao new eile fermatin or improvement of sigs and smplos of visceral V2), complete 10 fo T4y nurse Progressive Ouar Retinal Necrosis: * GanecloveS mag ¢ oscamet 80 igh IV 12h + gancicr 2mi0.05 i= fosaret 1.20.05 ina realinlecton ice wey or + tate or opt A eat tal Neca: * Acyl 10 mika gh for 10-14 cays, flowed by vlc 9 PO ‘or wi, Progressive + Thee ro spect antl therapy for None, ‘mutes AC siete, The ma Weatme futcer= apprcach so evrs th imurasue caphalopthy pression caused by HI cvs” + fete ART nmedatey in AR nave inectons patents. + Optimise ART in patents wha devlon PPL in phase of HV veer on ANT, Th maraing VV roti: Cosuaton wit an opthainaitexpericed i maragemet ot av rests stony recommends. Dato of hrapy or V2 reins is ot wel de ‘ined and shou be gelerinedbaeed on clini, ieoge, immunclgs, ar ephhaolgi re sponses Optmzaton of ARTs recommended or seus and fica to-reat V2 mfectons g rei, sncepals, [ + Cortostercis may be used for PMLARI charac tered by convast enhancement, aera, of ass tet and with elves deerain, ‘ABS card iamnectcy oro: Ato arp, AN abo i wc «ap, CD4 COLT rpc ca OF cal emng unk GA oneal GAS ota noes nt CSE erebapl Mus CPiR4 jeans P40 84 DS dle seg EM arse OSD, kane see svjgese humane "hy ete pia ae cae ant wma 0 soi RS nae eet nly sare mae eee rte 1 mb puncte Aion som erp HSAD now anions eg POP, Poumaste rears Pa se eb Pu Presnosieepr ‘eva: Pt pogerae lloe naencspagsby, PU el 724 pass nbs aor ba A sng Sse erg Te, owen ie ves Gah i roe mes sy TH SU nthopslfscraleY2 vate et a. sy of Ce he ecient ‘one mare anomie tia wh lnc ates an vs Kaos) endpoints I: Om or mae wi degre rerandmie al essa ar su ni gr ical aeoner Inpro "hyemhamine ane Pema ee he ae lores ney.Acquired Immunodeficiency Syndrome FIG, EY Toxoplasmesis, A, A fidsttenuate inversion recovery image shows intense lesions in the right basal ganglia an left pail obe wth surounding ‘sara. B A postgadlinium T1-weightes image shows fit rm erkancerent fright basal ganglaleson 6, A postadalnim TT-weghted image shows @ pial ‘aiget” sign na lef frontal be lesion. From Soto JA, Lucey BC: Enerpeney radoy: he requisites, ed 2, Philscephia, 2017, Elsevier)Acquired Immunodeficiency Syndrome 2702 {ENS signs/symptoms in HV-posive patients Unknown TexoplasmallgG antibody Negative + Postive Request serology and proceed With lgorit that ovors ‘empirical recent unt cr/Ma i results are known contrast (MRI erable) (Fig. E1) a a ees ae MRI is advised) ap ae eae ci Ere mores st meee aaa eerie Seen vores _[oapetecae Riera toner ieee} teas —| iat not available | by 7 doys weeks, followed by eae Consider lumbar puncture ifthe risk for herniation is judged tobe low) PCR for: 7. gordi Epitein-Bare virus Jevine No improvement |< clinically by 10-14 days or clinical deterioration by day 3 EES Fa aoe AFB, Giemsa, Gram stains FIG. €2 Diagnestic approach and manag (CHS) symptoms or signs that might potentially be toxoplasmic en [MRL magnairesonanes imaging; PCR plyerase cain eatin. From Baneat Jel: Mandal, Doulas, and Bonet princes andor a8, Prices, 2015, Wi Saunders) sent algorithm for human immunodeficiency virus (HNY-infected patients with central nervous system alts (TE) AFB, Acts cl: CT. computes trograoty ig. mmnoglbuln & of infectious diseases,Acquired Immunodeficiency Syndrome TiVinfeced pater wih CNS sympioms Dae Tippy coun /HI orl oad 2783 ia ia gies aie nen ea rete a es ioe Tae ; sete Cena eaeoe |x| mmm +, ee Someta) ees |} Les FIG, E2 Management of te human immunedericloncy virus (HI) type T-infected patient with central nervous system (CHS) mass lesions. The elements In taes regresent data thet contbue to the decision-making process (see tet or etal). CSF Cerebrospinal fi CT. computed tomography: LP, mbar puncture 14a magne esonance aging, SPECT single-photon emission computed lomrepny JE Toxoplasma encephals. rom Bennet Jee a: Mandel, Oougls, nd Bennetts princes and practice of infectious ieazes.e6 8, Priscepia, 2015, WB Saunders)