Table of Common Opportunistic Infections

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Pathogen	Cause	Who gets?	Signs & Symptoms	Diagnosis	Treatment 1st choice	Length of tx	Prevention
Pneumocystis jirovecii pneumonia (PCP)	Fungus and protozoa	CD4 < 200	Gradual onset symptoms Fever SOB Dry cough	Decreased SAO2 esp with exercise CXR-ground glass infiltrates ABGs Increased LDH immunofluorescent monoclonal antibody test (DFA) to detect Pneumocystis carinii in induced sputum.	TMP/SMX (Bactrim) HD  2 DS tabs tid--First choice. Intravenous Pentamidine--first choice after Bactrim in patients with severe PCP.  Clindamycin + Primaquine Trimethoprim + Dapsone Atovaquone (Mepron)--mild or moderate PCP. Steroids with low PaO2	21 days	Bactrim DS 1 a day Dapsone 100 mg a day Mepron 1500mg a day monthly aerosolized pentamidine  may stop prophylaxis after CD4>200 for 3 mo
Coccidio- mycosis	Fungus	CD4 < 250 Black men Filipino men pregnant women	Pneumonia--Fever and/or cough and/or SOB Brain--headache and/or stiff neck Liver--N/V and/or, jaundice Also, skin sores lymphadenopathy	Blood test Complement fixation Blood or tissue cultures CSF fluid	Fluconazole Itraconazole Amphotericin B (severe) Posaconazole Voriconazole	at least 12 mo and CD4 > 250 for 6 mo	none
cryptosporidium	Cryptosporidium a protozoan parasite.    c. hominis c. parvum c. meleagridis  eating or drinking water contaminated with cryptosporidium oocysts.	CD4 <100	sudden or slow onset diarrhea  stools watery & frequent but not bloody. Nausea, vomiting, fever, and lower abdominal cramping may also be present. cryptosporidium can infect biliary tract, pancreatic ducts, or the lungs causing major infections in these organs.	stool sample or biopsy of the small intestine   special stain that causes the oocyst to look red.   Other methods include: immunofluorescence (better), enzyme linked immunosorbent assays (ELISAs), and polymerase chain reaction (newest method).  In those with severe diarrhea, one stool sample is usually enough to make a diagnosis but in those with milder diarrhea, several stool samples may be needed.	Getting the CD4 count to above 100 will usually resolve cryptosporidium diarrhea.   Replacement of the fluids lost with diarrhea is of utmost importance.   Oral and perhaps even intravenous fluids will be necessary.   The drug nitazoxanide may be given for at least 2 weeks.   In addition, anti-diarrhea drugs like loperamide, diphenoxylate with atropine, and  tincture of opium may be tried.  total parenteral nutrition (TPN) may be needed to give vital nourishment until the person recovers some of their eating and drinking abilities.	Nitazoxanide of limited benefit unless CD4 goes up.	Wash hands avoid people and animals with diarrhea avoid: petting zoos, cattle, calves, sheep, lambs, other farm animals wash fruits and veggies  avoid raw fruits/veg unless you have washed them yourself drink bottled water or boil water if water source questionable
Bacterial Pneumonia	streptococcus pneumoniae  Haemophilus influenzae pseudomonas aeruginosa staphylococcus aureus  legionella (rare) mycoplasma (rare) chlamydia (rare)	Any CD4	Fast onset Fever Chills dry or wet cough chest pain with deep breath	CXR (infiltrate) SAO2 ABGs  Increased WBC	IV ceftriaxone +  azithromycin or clarithromycin or erythromycin ampicillin/sulbactam aztreonam ceftazidime cefepime cefotaxime ciprofloxacin clindamycin doxycycline imipenem levofloxacin linezolid meropenem moxifloxacin piperacillin/tazobactam  vancomycin	10 to 14 days	Pneumovax annual flu shot Bactrim helps Azithromycin helps DC smoking
Cytomegalovirus (CMV)	type of herpes virus--can attack eyes, brain, intestines	CD4 <50	No symptoms Vision: Floating black spots, distorted shapes, sparks, light flashes, loss of periph vision headaches sores in mouth dysphagia abd/rectal pain bloody diarrhea weight loss fever	CMV pp 65 ag blood test Must have eye exam for definitive dx in eyes tissue biopsy of lungs, esophagus, intestines, brain MRI LP	Valganciclovir or Ganciclovir  (IV) Foscarnet (IV) Cidofovir (IV) Drug implants-eye--severe dz	3 weeks of twice daily (900 mg bid) Valganciclovir then 900 mg daily May stop when CD4  > 100-150 at least 6 mo.  Must monitor  for anemia (H&H), neutropenia (ANC), renal (BUN/Cr) while taking.	None
Esophageal candidiasis	fungus--a form of yeast, called candida albicans*, glabrata, tropicalis, parapsilosis, krusei, and lusitaniae *most common	Thrush more common in patient with higher CD4 count--200 to 500. as the CD4 lowers to < 100, patients will get candidal esophagitis.	burning pain extending down center of chest over breastbone.  thick whitish plaques extending into throat may be difficult to eat or drink.  no fever.   acidic drinks/foods may make pain worse.   Thrush may have no symptoms at all	white cottage cheese-like patches that stick to the roof of the mouth, the tongue, and the mucous linings between the teeth and the cheeks. easily scrape off with tongue blade and leave red base endoscopy	fluconazole      itraconazole  Failure?--May have “resistant” infection.   Other options: Voriconazole Capsofungin Amphotericin B Anidulafungin Micafungin Posaconazole	14-21 days Treatment for oral thrush can be for 7 to 10 days.	Usually, no
Histoplasmosis	fungus, histoplasma capsulatum, lives in soil.  The dirt becomes contaminated by bird and bat droppings.  The person inhales the dust from soil	OH and MS River valleys Central US Mid- Atlantic states south-central US, from Alabama to SW Texas Canadian Provinces of Quebec, Ontario  Mexico Central and S. America Africa East Asia Australia Construction  workers farm workers	common--fever, weight loss, fatigue, cough, and shortness of breath Signs of serious infection involving body organs other than the lungs are: 1) sores on the skin or inside the mouth; 2) swollen glands; 3) nausea, diarrhea, abdominal pain; 4) problems with brain function--memory or learning problems; problems with speech, movement, or walking;  5) the liver or spleen may be enlarged.	histoplasma antigen in urine   blood, fluids from lungs,  CSF fluid Cultures of the blood, bone marrow, or above mentioned fluids tissue (biopsy) from lymph nodes, liver, skin sores, lungs, or bone marrow	mild or moderate histoplasmosis--itraconazole, PO tid for 3 days then decreased to twice a day for 3 months.  severe disease involving more than one body area, amphotericin B IV for several days, then PO itraconazole for the remainder of the 3 mo.   fluconazole PO QD Brain--amphotericin B QD for 3 mo. Itraconazole and fluconazole are not to be used in the first 3 mo of pregnancy	3 months then lower dose medicine for life	None
Mycobacterium avium complex (MAC)	bacteria mycobacteria avium or mycobacteria intracellulare inhaled or eaten bacteria in the water and soil shower heads!	CD4 < 50	The symptoms are  similar to that of TB and include fever, night sweats, and weight loss.  Diarrhea and abdominal pain are also common.	culture from blood, sputum, stool, cells from the lungs, bone, or lymph nodes   culture results take 10-21 days high alkaline phosphatase level  anemia.	Clarithromycin* + Ethambutol and maybe Rifabutin* or azithromycin + ethambutol Resistant MAC: moxifloxacin levofloxacin ciprofloxacin amikacin streptomycin	Tx may be stopped after 12 months if the CD4 count rises above 100 and remains there for at least 6 months. Once person has had MAC,  must restart treatment if CD4 again goes below 100.	Yes--azithromycin 1200 mg PO once a week  or Clarithromycin  or rifabutin or azithromycin and rifabutin   These drugs to prevent MAC, in someone who has never had MAC, may be stopped when the CD4 goes over 100 for more than 3 months, and should be restarted if the CD4 count decreases below 100.
Progressive multifocal leucoencepalo-pathy (PML)	JC virus destroys oligodentrocytes in the brain	CD4 < 100	Symptoms come on slowly--weeks or months Weakness on one side of the body Visual field problem:  When one is looking straight ahead, there is a “piece” of their vision missing. Cognitive problem:  remembering, thinking, knowing, reasoning, judgment, awareness.   difficulty walking  language problems.   one out of five will have a seizure.	CT or MRI (better choice) of the brain.   many fluffy ‘hypodense” (less bright than normal) abnormal tissue areas will be present in the white matter no edema LP will be done to rule out other dz. CSF tested for JC virus  a JC virus viral load can be done to determine just how much virus is present in the brain.    brain bx	fatal without ARV HIV medicines	NA	None
Toxoplasmosis	Protozoan--toxoplasma gondii eating undercooked meat  accidentally eating “oocysts” from cat feces or in water and soil.   inhale the oocyst into lungs, where it will cause infection there.	CD4 < 50	Brain infection but may also affect lungs or eyes Headache most common symptom nervous system problems, depending on where the infection located in brain.   Fever confusion memory problems  muscle movement problems weakness tremors and even seizures may be present. Severe cases may lead to a coma.	symptoms plus toxoplasmosis gondii immunoglobulin (IgG) antibodies  (positive toxo IgG Ab) plus CT or MRI of the brain showing one or several spots in the brain tissue--spots usually have white looking “rings” and swelling around them.   brain bx LP	Pyrimethamine + Sulfadiazine + Leucovorin* or  Pyrimethamine + Clindamycin + Leucovorin* or  Trimethoprim/Sulfamethoxazole (TMP/SMX or Bactrim) or  Atovaquone (Mepron) + Pyrimethamine + Leucovorin* or Atovaquone (Mepron) + Sulfadiazine or Clarithromycin or Azithromycin + Pyrimethamine + Leucovorin* *Leucovorin is folic acid and needed to prevent blood problems that can be caused by the drug pyrimethamine.  Steroids if there is lots of swelling in the brain. Seizure medicines if had a seizure-- Levetiracetam (Keppra)	6 weeks then all doses of medicines are usually decreased and these smaller doses of toxoplasmosis medicines are continued until the spots on the brain have cleared up, the person no longer has toxoplasmosis symptoms, and the CD4 count has remained above 200 for more than 6 month	Yes--Bactrim DS one a day If allergic and Toxo ab is +, take dapsone one a day + pyrimethamine with leucovorin once a week. prophylaxis until CD4 count > 200 for at least 3 months.  Atovaquone (Mepron) can be used to prevent both PCP and toxo. Avoid eating meat that is undercooked avoid cat litterbox wash hands wash fruits & veg