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Amphotericin B as Alternative to Itraconazole in Secondary Prophylaxis of Neurohistoplasmosis in HIV-Positive Patients with Antiretroviral Therapy

2011; OMICS Publishing Group; Volume: 02; Issue: 03 Linguagem: Inglês

10.4172/2155-6113.1000121

2155-6113

Jose Luis Puerto Alonso, Francisco Téllez, Maria Perez, Sandra Lorenzo-Moncada, D. Miragaya,

Parasitic Diseases Research and Treatment

Itraconazole; Nonnucleoside reverse-transcriptase inhibitorsHistoplasma is a dimorphic pathogenic fungus wich causes human infection worldwide, mainly in ecuatorial countries [1].In immunocompetent patients the most commun clinical manifestations consist in a lack of symptoms or a self-limited flu-like profile.However, disseminated histoplasmosis, wich represents the 0.05% of the acute infections, is observed in immunosuppressed patients (most of them HIV infected or treated with immunosuppressive drugs), and the illness manifestations are indistinguishable from tuberculosis.Central nervous system (CNS) involvement is exceptional and affects 5-10% of patients with disseminated illness and only 26 previous cases of meningitis caused by this microorganism were described in the last decade [2].The majority of these patients are treated with nonnucleoside reverse-transcriptase inhibitors, and it is necessary to notice that interaction between this drugs and itraconazole (used in the prophylaxis of these infections) exists.Although this drug-drug interaction is really presumed, the international literature review using MEDLINE database and EMBASE (keywords: interaction ± itraconazole ± nonnucleoside ± reverse-transcriptase ± inhibitors) showed only 3 previous cases [3][4][5].It is interesting to report here, because of its rareness, one case of acute meningitis due to Histoplasma, whose treatment and prophylaxis failed initially because of drug-drug interaction between itraconazole and nonnucleoside reverse-transcriptase inhibitors.A 32-year-old Bolivian man, who lived in Spain for the last three years, with a medical history in his youth of Guillain-Barré syndrome, a doubtful pulmonary tuberculosis, malaria, without sequels, and a recent HIV infection classified as CDC stage C3, whose initial manifestation six months before was a septic shock caused by a disseminated infection due to a filamentous dimorphic fungus identified as Histoplasma (the microorganism grew in bronchial aspirated, blood and bone marrow samples), was admitted into our hospital because of headache, vomiting, walking instability and disrupted speech.He received prophylactic itraconazole oral solution, 200 mg twice a day, and highly-active antiretroviral therapy (HAART) with tenofovir/emtricitabine/efavirenz, with a good virological response and a CD4 cell count around 200.The physical examination revealed a temperature of 38.0ºC, neck stiffness, dysarthria and ataxia.Lumbar puncture showed a clear cerebrospinal fluid (CSF) with a white blood cell count of 110/μl (90% mononuclear), proteins 384 mg/dl, glucose 24 mg/dl and adenosine deaminase (ADA) 18 U/l.Cultures, bacilloscopies, India ink staining and serology for Treponema sp. in CSF were negative.Simple radiologic study of thorax showed fibrotic lesions in both upper pulmonary lobes and residual granulomas.The brain scanner only evidenced cortico-subcortical atrophy.Sputum and blood cultures were finally negative.Meningoencephalitis by mycobacteria was suspected and a treatment with isoniazid, rifampicin, pyrazinamide and ethambutol was initiated.Two weeks later the patient was discharged because of CSF and clinical recovery.However, two moths later, the patient was admitted again with a similar clinical profile, while the newly obtained CSF showed 100 cells (90% mononuclears), glucose 35 mg/dl, proteins 310 mg/dl and ADA 14 U/l.