Download Microsporidiosis

Guidelines for Prevention and Treatment of Opportunistic
Infections in HIV-Infected Adults and Adolescents
Microsporidiosis Slide Set
Prepared by the AETC National Coordinating Resource Center based on
recommendations from the CDC, National Institutes of Health, and HIV
Medicine Association/Infectious Diseases Society of America
About This Presentation
These slides were developed using recommendations
published in May 2013. The intended audience is clinicians
involved in the care of patients with HIV.
Users are cautioned that, because of the rapidly changing
field of HIV care, this information could become out of date
quickly. Finally, it is intended that these slides be used as
prepared, without changes in either content or attribution.
Users are asked to honor this intent.
-AETC National Resource Center
http://www.aidsetc.org
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Microsporidiosis
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Epidemiology
Clinical Manifestations
Diagnosis
Prevention
Treatment
Considerations in Pregnancy
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Microsporidiosis: Epidemiology
 Protists, related to fungi
 Many species, including Enterocytozoon bieneusi,
Encephalitozoon cuniculi, Encephalitozoon intestinalis
 Ubiquitous, may be zoonotic and/or waterborne
 Risk greatest with CD4 count <100 cells/µL
 Incidence dramatically lower in areas with widespread
use of effective ART
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Microsporidiosis: Clinical
Manifestations
 Most common: diarrheal illness
 Other manifestations: cholangitis, hepatitis, encephalitis,
ocular infection, sinusitis, myositis, disseminated infection
 Clinical syndromes may vary by species
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Microsporidiosis: Diagnosis
 Microscopic identification of stool or tissue samples
 Identification requires high magnification (1,000×), selective
stains to differentiate spores from cellular debris
 Electron microscopy, PCR, Ab-specific stains can determine
species
 Evaluate 3 stool samples
 Small bowel biopsy if stool studies are negative and
suspicion is high
 Urine examination may be useful if cause is
Encephalitozoon or Trachipleistophora spp
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Microsporidiosis: Prevention
 Preventing exposure
 Handwashing; avoidance of undercooked meat or seafood
and exposure to infected animals
 Patients with CD4 counts of <200 cells/μL should avoid
drinking untreated water
 Primary prophylaxis
 Appropriate initiation of ART before severe
immunosuppression should prevent disease
 No chemoprophylaxis known to be effective
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Microsporidiosis: Treatment
 ART with immune restoration (to CD4 count >100
cells/µL)
 Should be offered to all as part of initial management
 If severe dehydration, malnutrition, wasting: hydration,
nutritional support (IV therapies may be needed)
 Antimotility agents, if needed for diarrhea control
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Microsporidiosis: Treatment (2)
 E bieneusi GI infections:
 ART and fluid support as above
 no specific antimicrobial;
 Fumagillin 60 mg PO QD or TNP-470: some evidence of
efficacy but not available in United States
 Nitazoxanide: limited data; cannot be recommended with
confidence
 Nonocular infection caused by microsporidial other than
E bieneusi and V corneae:
 Albendazole 400 mg PO BID
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Microsporidiosis: Treatment (3)
 Disseminated disease caused by Trachipleistophora or
Anncaliia
 Itraconazole 400 mg PO QD + albendazole 400 mg PO BID
 Ocular infection: fumagillin (Fumidil B) eye drops 70
mcg/mL + albendazole 400 mg PO BID
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Microsporidiosis: Starting ART
 ART should be offered as part of initial management of
this infection
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Microsporidiosis: Adverse Events
 Albendazole: adverse effects are rare; monitor hepatic
enzymes
 Fumagillin
 Topical: no known substantial side effects
 Oral: thrombocytopenia
 IRIS: 1 report
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Microsporidiosis: Treatment Failure
 Supportive treatment
 Optimization of ART
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Microsporidiosis: Prevention of
Recurrence
 Ocular:
 If CD4 >200 cells/µL on ART, consider discontinuing
treatment after ocular infection resolves; restart if CD4 drops
to <200 cells/µL
 Other manifestations:
 Safety of treatment discontinuation after immune restoration
with ART is not known
 Reasonable to discontinue maintenance therapy in
asymptomatic patients on ART with increase in CD4 count
to >200 cells/µL for ≥6 months (no data to support this
approach)
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Microsporidiosis: Considerations in
Pregnancy
 Initiate ART to restore immune function
 Albendazole:
 Embryotoxic and teratogenic in animals
 Not recommended in 1st trimester, use during later
pregnancy only if benefits expected to outweigh risks
 Systemic fumagillin: growth retardation in rats: should not
be used with pregnant women
 Topical fumagillin appears safe
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Microsporidiosis: Considerations in
Pregnancy (2)
 Itraconazole: avoid in 1st trimester
 Loperamide: possible risk of hypospadias with 1sttrimester exposure
 Avoid in 1st trimester, unless benefits expected to outweigh
risks
 Preferred antimotility agent during late pregnancy
 Tincture of opium not recommended during late
pregnancy
 Opiate exposure during late pregnancy associated with
neonatal respiratory depression; chronic exposure may
result in neonatal withdrawal
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Websites to Access the Guidelines
 http://www.aidsetc.org
 http://aidsinfo.nih.gov
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About This Slide Set
 This presentation was prepared by Susa Coffey, MD, and
Oliver Bacon, MD, for the AETC National Coordinating
Resource Center in May 2013
 See the AETC NCRC website for the most current
version of this presentation: http://www.aidsetc.org
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