Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents Microsporidiosis Slide Set Prepared by the AETC National 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 Users are cautioned that, because of the rapidly changing field of HIV care, this information could become out of date quickly.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 May 2013 www.aidsetc.org

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 May 2013 www.aidsetc.org

Microsporidiosis: Clinical Manifestations Most common: diarrheal illness Other manifestations: cholangitis, hepatitis, encephalitis, ocular infection, sinusitis, myositis, disseminated infection Clinical syndromes may vary by species May 2013 www.aidsetc.org

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 May 2013 www.aidsetc.org

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 May 2013 www.aidsetc.org

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 May 2013 www.aidsetc.org

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 May 2013 www.aidsetc.org

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 May 2013 www.aidsetc.org

Microsporidiosis: Starting ART ART should be offered as part of initial management of this infection May 2013 www.aidsetc.org

Microsporidiosis: Adverse Events Albendazole: adverse effects are rare; monitor hepatic enzymes Fumagillin Topical: no known substantial side effects Oral: thrombocytopenia IRIS: 1 report May 2013 www.aidsetc.org

Microsporidiosis: Treatment Failure Supportive treatment Optimization of ART May 2013 www.aidsetc.org

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) May 2013 www.aidsetc.org

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 May 2013 www.aidsetc.org

Microsporidiosis: Considerations in Pregnancy (2) Itraconazole: avoid in 1st trimester Loperamide: possible risk of hypospadias with 1st-trimester 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 May 2013 www.aidsetc.org

Websites to Access the Guidelines http://www.aidsetc.org http://aidsinfo.nih.gov May 2013 www.aidsetc.org

About This Slide Set This presentation was prepared by Susa Coffey, MD, and Oliver Bacon, MD, for the AETC National Resource Center in May 2013 See the AETC NRC website for the most current version of this presentation: http://www.aidsetc.org May 2013 www.aidsetc.org