Discontinuation of secondary prophylaxis for penicilliosis marneffei in AIDS patients responding to highly active antiretroviral therapy

Is stopping secondary prophylaxis safe in HIV-positive talaromycosis patients? Experience from Myanmar

Objectives

The aim of the study was to determine whether it is safe to stop secondary prophylaxis in patients with talaromycosis after immune reconstitution with a sustained increase in CD4 count to ≥ 100 cells/µL after antiretroviral therapy (ART).

Methods

A retrospective cohort analysis was performed in HIV‐infected patients treated for talaromycosis between June 2009 and June 2017 in Medical Action Myanmar (MAM) clinics.

Results

Among a cohort of 5466 HIV‐infected patients, 41 patients were diagnosed with and treated for clinical talaromycosis. All the patients were on ART and had a CD4 count < 100 cells/µL. Of these 41 patients, 24 patients (71%) were skin smear positive for talaromycosis, while results were negative in 17 patients. Median CD4 count and haemoglobin concentration were 24 cells/µL and 7.7 g/dL, respectively. Seventy‐three per cent (30) were male. Among the 41 patients, 11 (27%) died and six (15%) were transferred to other centres. Twenty‐four patients (58% of the total diagnosed) stopped itraconazole secondary prophylaxis after starting active ART with CD4 counts > 100 cells/µL for at least 1 year. Throughout the duration of follow‐up post itraconazole cessation, the observed incidence of relapse was zero with a total follow‐up of 93.8 person‐years (95% confidence interval 0–4 per 100 person‐years). The median (25th, 75th percentile) duration of follow‐up post‐prophylaxis discontinuation was 2.8 (2.1, 6.3) years.

Conclusions

Secondary prophylaxis can be safely stopped in patients with talaromycosis after immune reconstitution with a sustained increase in CD4 count to ≥ 100 cells/µL after highly active antiretroviral therapy.

Systemic mycoses in immunodepressed patients (AIDS)

Infectious and noninfectious skin diseases are observed in about 90% of HIV patients, and their incidence increases and is more severe as the immune system weakens. Cutaneous manifestations are considered good clinical predictors for the immunological condition of the patient with AIDS and the introduction of highly effective antiretroviral therapy totally changed the prognosis of the mycoses, among other diseases associated with AIDS, permitting longer survival and acceptable level of quality of life for these patients. This contribution describes the systemic mycoses that are more frequent in the seropositive population, that is, patients with HIV/AIDS, which are cryptococcosis, histoplasmosis, coccidioidomycosis, blastomycosis, paracoccidioidomycosis, sporotrichosis, penicilliosis, and aspergillosis. Their causative agents, mode of transmission, clinics, laboratorial diagnosis and therapy, in the aspects related to immunodepressed patients, are reviewed.

Emerging systemic fungal infections

Systemic mycoses are a heterogeneous group of infections caused by different species of fungi that mainly affect individuals with primary or secondary alterations of immunity. In recent years, there has been an increase in the incidence of infections related to migration, AIDS, and other causes of immunosuppression, such as solid organ and bone marrow transplantation; oncological, hematological, and autoimmune diseases; and the use of new drugs. In this paper, we outline the microbiological and epidemiological characteristics of 3 fungi: Aspergillus spp, Fusarium spp, and Penicillium spp. We describe the clinical manifestations of disease with emphasis on those that should alert the dermatologist to make an early diagnosis. We detail the various tools for early diagnosis, prevention, and the epidemiology of different antifungals available for treatment and their mechanism of action and therapeutic efficacy.

Penicillium marneffei infection in HIV

PURPOSE OF REVIEW

Since the start of the HIV pandemic, systemic infection with Penicillium marneffei has developed from a very rare diagnosis to the third most common opportunistic infection in HIV co-infected patients in South East Asia. HIV patients who have travelled to or lived in Asia may present with this infection in nonendemic countries, and it has therefore become important for all those working in the field of HIV to recognize, understand and treat this emerging disease.

RECENT FINDINGS

The clinical features, diagnosis and treatment of this infection are reviewed. Recent data exploring antigen-based serodiagnostics, the role of newer antifungals such as voriconazole, and the possibility of discontinuation of secondary prophylaxis after immune restoration from highly active antiretrovirals are discussed.

SUMMARY

Large series from endemic areas and case reports from nonendemic regions have been published and provide insights into clinical features and presentation. Novel diagnostics are evolving, with galactomannan and other assays looking promising. Present therapy is largely based on noncontrolled studies, and further research into optimal therapy and the potential to discontinue secondary itraconazole prophylaxis is required.

Discontinuation of secondary prophylaxis against penicilliosis marneffei in AIDS patients after HAART

A retrospective cohort study was conducted to determine the relapse rate of penicilliosis marneffei after the discontinuation of itraconazole secondary prophylaxis in 33 HIV-infected patients who received HAART and had CD4 cell counts of 100 cells/mul or greater for at least 6 months. The observed incidence of relapse of penicilliosis marneffei was zero cases per 641 person-months (95% confidence interval 0-0.6 cases per person-month) after a median follow-up of 18 months (range 6-45).

Cutaneous Infections Associated with HIV/AIDS

With diminished and dysregulated cell-mediated immunity, HIV-infected individuals are susceptible to a myriad of skin infections. These infections include the conditions encountered in immunocompetent patients, as well as infections seen almost exclusively in the setting of HIV infection. The HIV/AIDS pandemic has made some previously rare infections more prominent. Although antiretroviral therapy has been helpful in relieving the burden of cutaneous infections in HIV-infected patients, it does not prevent all opportunistic infections in the skin and also has created new dilemmas.

First case of Penicillium marneffei fungemia in Greece and strain susceptibility to five licensed systemic antifungal agents and posaconazole

We report the first case of Penicillium marneffei infection in a Greek bisexual man who is a frequent traveler to China. Penicilliosis and AIDS were diagnosed and antifungal treatment plus highly active antiretroviral therapy were administered successfully. In nonendemic areas travel history, clinical suspicion and laboratory alertness are critical for infection management.

An abdominal mass owing to Penicillium marneffei in an HIV-infected 7-year-old boy: case report

A 7-year-old boy, referred with lymphoma, presented with prolonged fever and intra-abdominal lymphadenopathy demonstrated on computed tomography (CT) of the abdomen. Blood culture isolated Penicillium marneffei. The patient was subsequently proven serologically to be positive for human immunodeficiency virus (HIV). Treatment with amphotericin B followed by itraconazole was successful. A high level of clinical suspicion and awareness is necessary for early diagnosis of penicilliosis, especially in an era of an increasing prevalence of HIV in this region.

Endemic fungal infections caused by Cryptococcus neoformans and Penicillium marneffei in patients infected with human immunodeficiency virus and treated with highly active anti-retroviral therapy

This study compared the clinical presentations of 58 episodes of cryptococcosis in 50 patients and 26 episodes of penicillosis in 25 patients infected with human immunodeficiency virus (HIV) between June 1994 and June 2004, and assessed the safety of discontinuation of secondary prophylaxis for endemic fungal infections in those patients responding to highly active anti-retroviral therapy (HAART). Neurological symptoms were seen more commonly in patients with cryptococcosis, whereas respiratory symptoms, lymphadenopathy, hepatomegaly and/or splenomegaly, and non-thrush-related oral presentations were seen more commonly in patients with penicillosis. Patients with penicillosis were more likely to have abnormal chest radiography results and radiographic presentations of interstitial lesions, cavitations, fibrotic lesions and mass lesions. At the end of the study, maintenance antifungal therapy had been discontinued in 27 patients with cryptococcosis and in 18 patients with penicillosis in whom the median CD4 count had increased to 186 cells/microL (range, 9-523 cells/microL) and 95 cells/microL (range, 15-359 cells/microL), respectively, after HAART. Only one episode of penicillosis recurred (a relapse rate of 1.72/100 person-years; 95% CI, 1.44-2.10/100 person-years) after a median follow-up duration of 35.3 months (range, 2.6-91.6 months). No relapses occurred in patients with cryptococcosis after a median follow-up duration of 22.3 months (range, 1-83.4 months). These findings suggest that there are differences in the clinical presentations between endemic cryptococcosis and penicillosis in patients with HIV infection, and that it is safe to discontinue secondary antifungal prophylaxis for cryptococcosis and penicillosis in patients responding to HAART.

Disseminated Penicillium marneffei infection in an HIV-positive Italian patient and a review of cases reported outside endemic regions

We describe a case of disseminated Penicillium marneffei in a human immunodeficiency virus (HIV)-positive Italian man who stayed for 4 years in Chiang Ray province, northern Thailand. A review of the literature shows that penicilliosis, although unusual, may represent an emerging opportunistic infection among HIV-positive people traveling to endemic areas.

Mucosal and Systemic Fungal Infections in Patients with AIDS

In countries where highly active antiretroviral therapy (HAART) is widely available, a decrease in the incidence of fungal infections has been observed in the last 5 years compared with countries that cannot afford this treatment. Even refractory fungal infections may be controlled when HAART is given to patients, and end-stage AIDS infections, such as aspergillosis, are now only infrequently seen. In contrast, fungal infections in certain regions, such as penicilliosis in Southeast Asia or cryptococcosis in Sub-Saharan Africa, are a growing problem. Antifungal therapy for documented infections has not changed very much during recent years; however, new drugs such as caspofungin and voriconazole may be more effective in the treatment of opportunistic fungal infections, in particular, those involving resistant organisms. Secondary antifungal prophylaxis for many opportunistic pathogens can now be temporarily or even permanently discontinued in many HIV-positive patients who have a marked improvement in immune function parameters, such as CD4(+) cell counts, after initiation of HAART. The link between effective virustatic control of HIV infection and a decreasing incidence of fungal infections has been recognised; and so, despite the availability of very effective new antifungal drugs, the cornerstone of treatment and prevention of opportunistic fungal infections in patients with HIV infection is effective antiretroviral therapy including protease inhibitors.