Histoplasmosis

Prevention of Exposure
(1) Although HIV-infected persons living in or visiting histoplasmosis Šendemic areas cannot completely avoid exposure to Histoplasma capsulatum, those whose CD4+ T-lymphocyte counts are < 200 cells/uL should avoid activities known to be associated with increased risk (e.g. creating dust when working with surface soil, cleaning chicken coops that are heavily contaminated with droppings, disturbing soil beneath bird-roosting sites, cleaning, remodeling or demolishing old buildings, and cave exploring) (CIII).

Prevention of Disease
(2) Routine skin testing with histoplasmin and serologic testing for antibody or antigen in histoplasmosis-endemic areas are not predictive of disease and should not be performed (DII).

(3) Data from a prospective randomized controlled trial indicate that itraconazole can reduce the frequency of histoplasmosis among patients who have advanced HIV infection and who live in H.capsulatum endemic areas (55). However, no survival benefit was observed in those receiving itraconazole. Prophylaxis with itraconazole may be considered in patients with CD4+ T-lymphocyte counts < 100 cells/uL who are at especially high risk because of occupational exposure or who live in a community with a hyperendemic rate of histoplasmosis (> 10 cases per 100 patient-years) (CI).

Prevention of Recurrence
(4) Patients who complete initial therapy for histoplasmosis should be administered lifelong suppressive treatment (i.e. secondary prophylaxis or chronic maintenance therapy) with itraconazole (200 mg bid) (AI) (54).

Discontinuation of Secondary Prophylaxis (chronic maintenance therapy)
(5) Although patients receiving secondary prophylaxis (chronic maintenance therapy) may be at low risk for recurrence of systemic mycosis when their CD4+ T-lymphocyte counts increase to < 100 cells/uL on HAART, the numbers of patients who have been evaluated are insufficient to warrant a recommendation to discontinue prophylaxis in such patients.

Notes

Pediatric Note
(6) Because primary histoplasmosis can lead to disseminated infection in children, it is reasonable to administer lifelong suppressive therapy after an acute episode of the disease (AIII).

Note Regarding Pregnancy
(7) Because of the embryotoxicity and teratogenicity of itraconazole in animal systems, primary prophylaxis against histoplasmosis should not be offered during pregnancy (DIII). These data as well as the observation of craniofacial and skeletal abnormalities in infants following prolonged in-utero exposure to fluconazole should be considered when assessing the need for chronic maintenance therapy in HIV-infected pregnant women with histoplasmosis. In such patients, therapy with amphotericin B may be preferred, especially during the first trimester. Effective birth control should be recommended to all HIV-infected women on azole therapy for histoplasmosis (AIII).

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