Fungal Infections

What Are Fungal Infections?

Fungi (singular is fungus) are a kind of germ. Many fungi exist normally in and on our bodies, and in the surrounding environment, for example in soil, dust, food, water, plants. Most fungi are harmless to humans, but there are several that can cause harmful infections, especially in people living with HIV (HIV+).

Candidiasis (includes yeast infections and thrush)

Candidiasis is a very common fungal infection usually caused byCandida albicans. This yeast-like fungus is found in all healthy people. The immune system and bacteria normally found in the body generally keep Candida in check. When Candida is not in check, it can cause problems like yeast infections or thrush, which are described below.

When there is an overgrowth of Candida, it can cause problems in the mouth, food pipe, or vagina. This happens more often when the immune system is weakened by HIV or when you take antibiotics which can kill the helpful bacteria.

The medications used to fight Candida are anti-fungal drugs called “azoles.” Examples are Nizoral (ketoconazole), Diflucan (fluconazole), Sporanox (itraconazole), Vfend (voriconazole), or Noxafil (posaconazole). Azoles should not be used in pregnant women. In addition, many of the anti-fungal drugs interact with HIV drugs.

Candidiasis can come back repeatedly. Some health care providers prescribe anti-fungal drugs on a long-term basis, but this can lead to drug-resistant Candida that is more difficult to treat.

Candidiasis of the Vagina (Vaginal Candidiasis, Vaginitis, or Yeast Infection)

• May occur with normal CD4 cell counts (above 500), but more likely to develop at lower CD4 counts
• Symptoms include itching, burning, and pain around the vagina, labia, or anal area and thick, whitish, sometimes curd-like vaginal discharge
• Antibiotics, steroids, birth control pills, and foods high in sugars or starches (breads, pastas, and alcohol) all promote the growth of Candida
• Douching reduces levels of helpful bacteria in the vagina and is not recommended
• Alcohol and nicotine promote the growth of yeast
• Because yeast grows best in moist areas, wearing looser-fitting pants or underwear can help prevent yeast infections. Cotton underwear breathes better than underwear made of polyester or nylon, and can also help minimize yeast growth.

Treatment:

• Local treatment with over-the-counter creams like Monistat (miconazole) or Gyne-Lotrimin (clotrimazole) or prescription anti-fungal creams
• For difficult-to-treat infections, use prescription oral anti-fungal drugs
• Alternative treatment: Acidophilus which is a live bacterial culture found in supplements, yogurt, or kefir

Candidiasis of the Mouth (Thrush)

• Whitish coating of the tongue and/or the inside of the cheeks
• Usually occurs with CD4 cell count less than 300
• May affect appetite and make food taste funny
• More likely to occur in diabetics and when steroid medications such as prednisone or certain asthma inhalants are being taken
• Because sugar is food for Candida and helps it grow, limiting how much sugar you eat can help prevent thrush. Sugars are found in foods such as candies and sweets, soft drinks, fruit juices, and maple syrup. Read the label to help you limit other forms of sugar, including fructose, glucose, and corn syrup.
• Eating yogurt or drinking kefir with active, live bacterial cultures like acidophilus can help prevent thrush. “Friendly” or “good” bacteria like acidophilus can help control the growth of Candida.

Treatment:

• Local treatment with clotrimazole lozenges
• Oral anti-fungal medications that work throughout the body
• In most severe cases, amphotericin B is used, but it can have serious side effects
• Alternative treatments:
  • Mouthwash containing gentian violet, which stains the mouth purple and can stain clothing
  • Mouthwash containing tea-tree oil
  • Saltwater rinse using 1/2 teaspoon salt to 1 cup warm water
  • Placing lemon juice in the mouth several times a day

Candidiasis of the Esophagus (Esophageal Candidiasis)

• Usually occurs at very low CD4 cell counts (less than 100)
• An AIDS-defining opportunistic infection
• Major symptom is painful swallowing
• Often diagnosed by history and clinical exam, can be confirmed by gastrointestinal endoscopy
• Possible in anyone who has thrush and a low CD4 cell count, but can occur even when thrush cannot be seen in the mouth.

Treatment:

• Oral anti-fungal medications; fluconazole is most commonly used

Cryptococcal Meningitis

The fungus Cryptococcus neoformans is very common. It is found in soil and bird droppings. While most people have been exposed to this fungus, they generally have immune systems that are healthy enough to prevent Cryptococcus from causing disease.

In immune-compromised people, especially HIV+ people with less than 100 CD4 cells, Cryptococcus can cause a serious infection called meningitis – an inflammation or swelling of the lining of the spinal cord and brain. If it is not treated quickly and correctly, cryptococcal meningitis can cause coma or death.

Symptoms:

• Fever
• Headache
• Vision problems
• Confusion
• Nausea
• Vomiting

Let your health care provider know if you experience any of these symptoms.

Diagnosis:

• Spinal tap to gather and test a little sample of the fluid that surrounds the brain and spine
• Blood tests will usually show a high level of serum cryptococcal antigen

Treatment:

• In most cases, a two-week regimen of intravenous amphotericin B and 5-flucytosine is used
• Afterwards, fluconazole is used for secondary prevention of recurrent disease
• In milder cases of meningitis, oral fluconazole is sometimes used from the beginning

Histoplasmosis

Histoplasmosis is caused by infection with the Histoplasma capsulatum fungus, which is common in the soil of the Mississippi and Ohio River valleys, the Caribbean, and Central and South America.

In a healthy person, the infection is usually confined to the lungs, causing only mild symptoms. In HIV+ people with low CD4 cell counts (below 200), the infection can be life threatening. However, histoplasmosis is not a common disease in HIV+ people.

Symptoms:

• Fever
• Fatigue
• Shortness of breath
• Cough
• Weight loss

Diagnosis:

• Finding the organism in a sample of blood, sputum, or other tissue

Treatment:

• Initial treatment with intravenous amphotericin B, then change to long term therapy with oral itraconazole (sometimes fluconazole)

Aspergillosis

Aspergillosis is caused by Aspergillus, a very common group of fungi. In people with healthy immune systems, it usually causes mild or moderate lung problems. In people with suppressed immune systems, it can be life threatening. Aspergillosis was more common in the earlier days of AIDS. Today it is rarely seen in HIV+ people.

Symptoms:

• Pain in the sinuses, nose, or ear canal
• Facial swelling
• Pneumonia-type symptoms such as cough, difficulty breathing, and fever

Diagnosis:

• Sputum or nasal secretions that are tested for Aspergillus

Treatment:

• Intravenous amphotericin B or oral voriconazole

Coccidioidomycosis (Valley Fever)

Coccidioidomycosis, commonly called Valley Fever, is a fungal infection caused by either Coccidioides immitis or Coccidioides posadasii. These fungi or molds grow in soil found in the southwestern United States, in Mexico, and in Central and South America. You get infected by breathing fungal particles (spores) into your lungs, where the infection starts.

In people with healthy immune systems, coccidioidomycosis involves mild to moderate lung problems. In those with weakened immune systems, it can cause more serious lung problems and also spread to other areas, including the skin, bones, lining of the brain and spinal cord, and lymph nodes.

Symptoms:

• Fever
• Headache
• Backache
• Cough
• Fatigue
• Joint stiffness and pain
• Small, tender, raised, red bumps under the skin called erythema nodosum

Diagnosis:

• Blood tests to look for signs of infection with Coccidioides
• Sputum sample tested for presence of Coccidioides

Treatment:

• Intravenous amphotericin B
• In milder cases of coccidioidomycosis, oral fluconazole is sometimes used from the beginning

Conclusion

Fungal infections can be common, and in some cases, very serious for HIV+ people. However, on-going medical care allows for the effective prevention or early diagnosis and treatment of these infections. In addition, most of the more serious fungal infections are more likely to occur in HIV+ people with low CD4 cells (especially less than 100). One way to prevent fungal infections from occurring is to keep the immune system healthy by using HIV drugs when necessary and seeing your health care provider on a regular basis.