Secuencia didáctica para el fortalecimiento de la CMI

Anti-PCP prophylaxis (chronic maintenance therapy) should be given to all patients who have had an episode of PCP. Prophylaxis should be continued for life, unless immune reconstitution occurs as a result of ART and the CD4 count has been >200 cells/µL for more than 3 months.

In patients with stable CD4 count of >200 cells/µL on effective ART, it is recommended that PCP prophylaxis be discontinued because it offers little clinical benefit but may cause drug toxicity, drug interactions, and selection of drug-resistant pathogens, plus it

adds to the cost of care and to the patient’s pill burden.

If PCP occurred at a CD4 count of >200 cells/ µL, it is recommended to continue prophylaxis for life despite immune reconstitution;

however, data to support this approach are limited.

Prophylactic therapy

• TMP-SMX DS: 1 tablet PO TIW (e.g., Monday, Wednesday, Friday)

• Dapsone* 100 mg PO QD, or 50 mg PO BID • Dapsone* 50 mg PO QD + pyrimethamine

50 mg PO once weekly + leucovorin 25 mg PO once weekly

• Dapsone* 200 mg PO + pyrimethamine 75 mg + leucovorin 25 mg, all once weekly • Aerosolized pentamidine 300 mg once

monthly, via Respirgard II nebulizer (note: does not prevent toxoplasmosis) (Warning: May increase the risk of extrapulmonary pneumocystosis, pneumothorax, and bronchospasm.)

• Atovaquone 1,500 mg PO QD (with or without pyrimethamine 25 mg PO QD + leucovorin 10 mg PO QD)

* Use with caution in G6PD deficiency.

Primary Prophylaxis

• Primary prophylaxis against PCP should be given to all HIV-infected patients with a CD4 count of <200 cells/µL, CD4 percentage of <14%, or a history of oral candidiasis; see chapter Opportunistic Infection Prophylaxis.

Pneumocystis Pneumonia | 501 Sec tion 6: C omor bidities , Coinf ec tions , and C omplications

Patient Education

• Patients should be instructed to take all medications exactly as prescribed. • Patients should call their health care

provider if symptoms worsen.

• Patients being treated with TMP-SMX or dapsone who develop rash, fever, or other new symptoms should call their provider to be evaluated for a drug reaction.

• Patients should understand that taking anti- PCP prophylaxis is extremely important for preventing repeat episodes of illness. Patients should not stop taking these medicines without talking with their health care provider, and should not let their supply of medications run out.

• Patients should be counselled about the importance of ART in restoring immune system function to reduce the likelihood of illness and death from PCP and other OIs.

References

• Leoung GS. Pneumocystosis and HIV. In: Coffey S, Volberding PA, eds. HIV InSite Knowledge Base [textbook online]; San Francisco: UCSF Center for HIV Information; April 2005. Available at hivinsite.ucsf.edu/InSite?page=kb- 00&doc=kb-05-02-01.

• Masur H. Pneumocystosis. In: Dolin R, Masur H, Saag MS, eds. AIDS Therapy, 2nd Edition. Philadelphia: Churchill Livingstone; 2003:403-418.

• Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Available at aidsinfo.nih.gov/guidelines. Accessed December 1, 2013.

• Zolopa A, Andersen J, Powderly W, et al. Early antiretroviral therapy reduces AIDS progression/death in individuals with acute opportunistic infections: a multicenter randomized strategy trial. PLoS One. 2009;4(5):e5575.

Sec tion 6: C omor bidities , Coinf ec tions , and C omplications

Progressive Multifocal

Leukoencephalopathy

Background

Classic PML

Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system (CNS) caused by reactivation of latent infection with JC virus, a polyomavirus that infects and lyses oligodendrocytes. Demyelination can occur along any part of the white matter, and often does so at multiple sites (hence the term multifocal). The severity of symptoms increases as demyelination progresses.

Among HIV-infected patients, PML occurs classically and most frequently in those with CD4 counts of <200 cells/µL who are not receiving antiretroviral therapy (ART), but it can occur in patients with higher CD4 counts and in those on suppressive ART. Patients typically present with multiple focal deficits of the cerebrum and brainstem, such as cognitive decline, focal weakness, and cranial nerve palsies, with one focal deficit often predominating. Symptoms typically progress over the course of several weeks. Imaging studies show noninflammatory, nonenhancing white matter lesions, without mass effect, with an anatomical location that maps to deficits on the neurological examination. A presumptive diagnosis of PML often can be made on the basis of the patient’s clinical presentation and results of neuroimaging studies. Cerebrospinal fluid (CSF) often tests positive for JC virus DNA by polymerase chain reaction (PCR), although brain biopsy is sometimes needed for definitive diagnosis.

Among untreated patients, the interval between the first manifestation of neurologic symptoms and death may be as short as 3-4 months. Although the prognosis for patients with PML has improved with the use of potent ART, there is no specific treatment for PML, and mortality rates remain high. Patients who survive PML are likely to have permanent neurologic deficits.