Black and Filipino men and pregnant women (second or third trimester) are at higher risk for coccidiomycosis. Just like most other infections which hit those with HIV, this infection probably occurred in childhood or young adulthood, and lies sleeping inside the body, waking up when the immune system weakens.
Signs and Symptoms of Coccidiomycosis
Coccidiomycosis will usually cause a pneumonia, so look for a fever, cough, or shortness of breath. If coccidiomycosis infects the brain, the person will complain of a headache, neck stiffness, or seem lethargic (not quite alert). Watch for nausea, vomiting, or jaundice (a yellow color to skin or whites of eyes) which may indicate the liver is infected. Also watch for skin sores and large lymph nodes.
Diagnosis of Coccidiomycosis
The diagnosis is made from a blood test or from blood or tissue cultures. Cerebrospinal fluid (fluid that surrounds the brain and spinal cord) may also be tested if the person has symptoms of brain and spinal cord infection.
Treatment for Coccidiomycosis
Drugs used to treat this coccidiomycosis are as follows: fluconazole, itraconazole; if these drugs do not work, the drugs posaconazole and voriconazole will be used. In those with severe illness, the drug amphotericin B will be given directly into the person’s veins until they show improvement; then the person will be switched to the above oral drugs. HIV drugs will also be given at the same time.
The length of treatment for coccidiomycosis is 12 months and treatment cannot be stopped unless the CD4 rises above 250 and remains at 250 or higher for at least 6 months.
Cytomegalovirus (CMV)
Cytomegalovirus (CMV) is a viral infection that can occur in the patient with AIDS with a CD4 count less than 50. The cause is a virus--a type of herpes virus, that “re-awakens” in the person once their immune system becomes weak.
Cytomegalovirus is spread person to person by way of infected body fluids--saliva, blood, tears, urine, semen, vaginal fluids, and breast milk. It may be spread from a mother to her unborn baby. The virus is easily spread in day care centers, when workers change urine-soaked diapers and do not wash their hands afterward. It is commonly spread by sexual activity. Uncommonly, it may be spread by organ transplant and a blood transfusion.
The person with cytomegalovirus was probably exposed to the virus as a child or young adult and the virus caused a very mild illness or no problems, but the virus remains “asleep” in the body forever. A healthy immune system keeps the virus from causing major illness. If the immune system weakens, the virus can become active and cause damage. This is what happens with HIV/AIDS. Nearly 50% to 100% of us (depending which country you come from or live in) have this virus in our body.
Once cytomegalovirus becomes active in a person with AIDS, the virus can attack the eyes and can cause permanent blindness. CMV may also attack the lungs, the tube that runs from the mouth to the stomach (the esophagus), the intestines, the brain, nerves, adrenal glands, and liver.
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Before the HIV 3-drug cocktails, most people survived only about a year once they had CMV. Most of the time, the virus will infect only one eye; however, if the CMV is not treated, the other eye will usually be affected within 6 months.
Signs and Symptoms of Cytomegalovirus (CMV) in the Eyes.
Around one-half of those with CMV in their eyes (also called CMV retinitis) will have no symptoms at all. Others will say they see floating black spots, or will see things as distorted or out-of-shape. They may have blind spots, or see sparks and flashes of color or light. They may lose part of their peripheral vision (what you see to your sides as you look straight ahead) or even pieces of what they see as they look straight ahead.
If cytomegalovirus attacks the brain, the person or his caregiver will tell of one or more of these symptoms: headaches, trouble concentrating, personality changes, withdrawing from social activity, sleepiness, or an unusual laziness. If CMV attack the digestive tract, the person or caregiver will tell of one or more of these symptoms: sores in the mouth, painful and/or difficulty swallowing, abdominal or rectal pain, bloody diarrhea, weight loss, or fever. CMV in the lungs will cause: shortness of breath, difficulty breathing with mild exertion, and a dry cough. Other symptoms to watch for are leg weakness, problems urinating (either losing control of urine or difficulty urinating), jerky muscle movements, and low back pain.
Diagnosis of Cytomegalovirus (CMV) in the Eyes
Everyone with a CD4 of 50 or less should get an eye exam soon. In our clinic, if the CD4 is less than 50, we order a blood test called a CMV-PP-65 antigen test. If the test results are positive, or the patient has a new vision problem, we call the eye doctor and get the patient seen within 24 hours. If the results are negative, the patients can wait a couple of weeks or so to be seen.
The only way to diagnose CMV in the eyes is with an eye exam. The eye doctor should be one with enough experience to know what CMV in the eyes looks like. The eye doctor must use drops to dilate the pupils. If the person has CMV in the eyes, the doctor will see swelling, hemorrhages, inflammation, or other damage to the tissue lining the inside of the eye. Some describe that the inside of the eye looks like “cottage cheese and Ketchup.”
CMV in other parts of the body must be diagnosed by a biopsy of tissue from the lungs, esophagus, intestine, brain, etc. Magnetic resonance imaging (MRI) is used to take pictures inside the body. A lumbar puncture (a needle is placed inside the lower spine area to sample fluid that surrounds the brain) may be needed.
Treatment for Cytomegalovirus
The main treatment is starting HIV medicines right away. Your health care provider may put this off for a couple weeks or so just to be sure you don’t have a problem taking the CMV medicine, but the HIV medicines are an absolute must.
The drugs used to treat CMV are as follows: oral valganciclovir (most common drug used), ganciclovir, foscarnet, and cidofovir. The last three drugs are rarely used and are given directly into the vein (IV). If the person has severe CMV eye disease, eye implants containing medicine may be used, in addition to valganciclovir pills. The drug valganciclovir (Valcyte) must be taken twice a day for 3 weeks, then once a day.
A word about valganciclovir. This medicine may cause severe side effects so you will need to get your blood checked once or twice a week every week for the first three weeks, then every one to two weeks afterward. The valganciclovir may be stopped after the CD4 count goes over 100-150 and stays there at least 6 months.
Those with CMV in the eyes should expect to be getting frequent eye exams. Also, it is important to watch for any new vision problem, even if you are taking the CMV medication.
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