Opportunistic Infections in Patients with the Acquired Immunodeficiency Syndrome

476 Pages·1989·13.904 MB·\476

by  Gifford Leoung (Editor), John Mills (Editor)

OPPORTUNISTIC INFECTIONS IN
PATIENTS WITH THE ACQUIRED
IMMUNODEFICIENCY SYNDROME
INFECTIOUS DISEASE AND THERAPY
Series Editors
Brian E. Scully, M.B., B.Ch. Harold C. Neu, M.D.
College of Physicians College of Physicians
and Surgeons and Surgeons
Columbia University Columbia University
New York, New York New York, New York
Volume 1 Parasitic Infections in the Compromised Host, edited by Peter D.
Walzer and Robert M. Genta
Volume 2 Nucleic Acid and Monoclonal Antibody Probes: Applications in
Diagnostic Microbiology, edited by Bala Swaminathan and Gyan
Prakash
Volume 3 Opportunistic Infections in Patients with the Acquired Immuno-
deficiency Syndrome, edited by Gifford Leoungand John Mills
Additional Volumes in Preparation
OPPORTUNISTIC INFECTIONS IN
PATIENTS WITH THE ACQUIRED
IMMUNODEFICIENCY SYNDROME
edited by
GIFFORD LEOUNG
University of California, San Francisco
San Francisco, California
JOHN MILLS
University of California, San Francisco
and
San Francisco General Hospital
San Francisco, California
MARCEL DEKKER New York and Basel
Library of Congress Cataloging-in-Publication Data
Opportunistic infections in patients with the acquired immunodeficiency
syndrome / edited by Gifford Leoung and John Mills.
p. cm. —(Infectious disease and therapy ; v. 3)
Includes index.
ISBN 0-8247-8080-9 (alk. paper)
1. AIDS (Disease) 2. Opportunistic infections. I. Leoung
Gifford. II. Mills, John. III. Series.
[DNLM: 1. Acquired Immunodeficiency Syndrome—complications.
2. Infection—complications. W1 IN406HMN v. 3/WD 308 062]
RC607.A26067 1989
616.97'92—dc20
DNLM/DLC
for Library of Congress 89-7793
CIP
This book is printed on acid-free paper.
Copyright © 1989 by MARCEL DEKKER, INC. All Rights Reserved
Neither this book nor any part may be reproduced or transmitted in any form
or by any means, electronic or mechanical, including photocopying, microfilm-
ing, and recording, or by any information storage and retrieval system, without
permission in writing from the publisher.
MARCEL DEKKER, INC.
270 Madison Avenue, New York, New York 10016
Current printing (last digit):
1098765 43 2 1
PRINTED IN THE UNITED STATES OF AMERICA
Series Introduction
Marcel Dekker, Inc., has for many years specialized in the publication of
high-quality monographs in tightly focused areas in a variety of medical dis-
ciplines. These have been of great value to both the practicing physician and
the research scientist as sources of detailed and up-to-date information pre-
sented in an attractive format. During the last decade, there has been a ver-
itable explosion in knowledge in the various fields related to infectious dis-
eases and clinical microbiology. Antimicrobial resistance, antibacterial and
antiviral agents, AIDS, Lyme disease, infections in immunocompromised
patients, and parasitic diseases are but a few of the areas in which an enor-
mous amount of significant work has been published. This new Infectious
Disease and Therapy series will cover carefully chosen topics which should
be of interest and value to the practicing physician, the clinical microbiolo-
gist, and the research scientist.
Brian Ε. Scully, M.B., B.Ch.
Harold C. Neu, M.D.
iii

Foreword
The epidemic of HIV infection poses challenges to the medical system that
we are still just beginning to appreciate. We find ourselves asked to respond
to an ever-growing number of patients infected with the virus for which we
have no uniformly effective therapy—a virus which in the absence of this
treatment may kill most of those affected. Moreover, many of these patients
will experience numerous episodes of opportunistic infections and malig-
nancies that are either difficult or impossible to eradicate.
The remarkably complex set of medical problems seen in AIDS has been
accompanied by rapid changes in diagnostic and therapeutic options and
strategies, often employing drugs that are either newly approved or still in-
vestigational. Adding yet more to the challenge is the high frequency and
unique nature of the toxic drug reactions so common in the setting of the
HIV infection.
For these and other reasons, many physicians in some hospitals have been
reluctant to become involved in the care of patients with AIDS or other mani-
festations of HIV infection. This reluctance is understandable, given the
many complexities in the field of AIDS and the small number of physicians
who feel competent in dealing with these issues. Thus, it is critical for the
medical system to make it as easy as possible for the practicing physician to
care for the AIDS patient.
Certainly, one of the areas that we can best control is the dissemination of
accurate and up-to-the-minute information to help in the clinical manage-
ment of AIDS-associated problems. Considering the high frequency of ser-
ious opportunistic infections in the setting of HIV and the enormous com-
plexity in diagnosing and managing these patients, Opportunistic Infections
in Patients with the Acquired Immunodeficiency Syndrome should find a
place in many physicians' offices. It summarizes many of the latest develop-
ments in the diagnosis and management of AIDS-related opportunistic in-
fections, with contributions by leaders in each specific area. Furthermore,
the book is organized to provide ready access to this information.
ν
vi FOREWORD
The first part provides clinically relevant overviews of essential background
information on the epidemiology, biology, and pathophysiology of HIV in-
fection.
In Part II, the spectrum of HIV disease from acute infection to specific
syndromes is presented along with details of management schemes. A frame-
work is offered for managing patients who present with common symptom
complexes such as neurologic or cutaneous disease, and a separate chapter
discusses the unique features of HIV infection in pediatric populations.
The final parts of the book review the management of specific opportun-
istic infections and offer guidelines for the use of laboratory diagnostic tests.
Information in this is again practical in content while also pointing out the
context of these infections in the AIDS epidemic, i.e., the often unique pre-
sentations and toxicities in the HIV-infected population.
Taken as a whole, this book is a substantial and welcome addition to the
information available to the physician community. It is hoped that this type
of resource will enable additional practicing physicians to offer expert care
for the AIDS patients that the epidemic seems destined to give us.
Paul Volberding, M.D.
Associate Professor of Medicine
Chief AIDS Activities Division
San Francisco General Hospital
Preface
In the decade since it was recognized as a distinct clinical entity, AIDS has
become an enormous international health problem. The total number of per-
sons with AIDS in the United States will probably exceed 100,000 this year,
and the worldwide total may be several times that number. Millions of persons
are already infected with the human immunodeficiency virus (HIV), and most
of those infected will eventually develop AIDS.
Opportunistic infections are the paramount clinical problem confronting
physicians caring for AIDS patients. Pneumocystis carinii pneumonia alone
accounts for 65% of index AIDS diagnoses, and over 80% of patients will
have at least one episode. Opportunistic infections will dominate the clinical
picture of HIV infection until highly effective and nontoxic antiretroviral
drugs, or a vaccine against HIV, can be developed.
Some physicians feel that aggressive treatment of opportunistic infections
in the HIV-infected subject is unnecessary, given the inexorable progression
of the underlying viral infection and its fatal outcome. However, all clini-
cians who have cared for patients infected with this retrovirus are aware that
treatment of opportunistic infections decreases suffering and prolongs life,
and that successful prevention of these infections has an even more dramatic
effect on length of survival and quality of life. As there are currently avail-
able numerous nontoxic and inexpensive drugs that are active against most
opportunistic pathogens, the likelihood is high that chemotherapy will be
successful.
For these reasons, we felt that there was a clear need for a book that fo-
cused on the unique problems of managing opportunistic infections in HIV-
infected patients. Our main intention was to provide a practical approach to
patient management, although basic science and pathophysiologic issues have
been discussed where relevant. Hence, full details of diagnostic testing, drug
dosing, and laboratory monitoring have been supplied. The authors, who
are all authorities in their respective areas, bring experience in direct patient
care to their writing.
vii