Letters to the Editor

IO7

References I. Prescott JF. Rhodococcus equi and animal and human pathogen, Clin Microbiol Rev I99I ; 4: 2o-34. 2. Golub B, Falk G, Spink WW. Lung abscess due to Corynebacterium equi report of the first human infection. Ann Intern Med I967; 66: I I74-II77. 3. Hillidge CJ. Use of erythromycin-rifampicin combination in treatment ofRhodococcus equi pneumonia. Vet Microbiol I987; I4:337-342. 4. Van Etta LL, Filice GA, Ferguson RM, Gerding DN. Corynebacterium equi: a review of Iz cases of human infection. Rev Infect Dis I983; 5: IOI2-IOI8. 5. Goodfellow M. The taxonomic status of Rhodococcus equi. Vet Microbiol I987; x4: 205-209 .

Cryptococcal meningitis in AIDS occurring despite systemic antifungal therapy Accepted for publication 17 July I99I Sir, Cryptococcal meningitis is the third most common neurological presentation of the acquired immune deficiency syndrome (AIDS), occurring in up to I o % patients. 1 Recently interest has focused on the role of the azoles in the treatment of cryptococcal meningitis and their use as maintenance suppressive therapyf1-4 Nineteen A I D S patients with cryptococcal meningitis have been treated in Parkside Health Authority up to June I99I (incidence 4 %)- Four (2I %) were taking systemic azole antifungal agents as prophylaxis against oral candidosis at the time of diagnosis; three were taking ketoconazole (200 mg daily), and one was taking fluconazole (50 mg daily). T h e development of cryptococcal meningitis has been described in a patient receiving ketoconazole as prophylaxis for chronic mucocutaneous candidosis, ~ but to our knowledge, has not previously been associated with fluconazole prophylaxis. L o w dose oral fluconazole prophylaxis for oral candidosis in this patient did not prevent the development of cryptococcal meningitis. Several studies suggest fluconazole is effective using doses higher than required in the treatment of oral candidosis, in the long-term treatment of A I D S patients with cryptococcal meningitis. 2 3.5 It has been shown to penetrate into all body tissues, and extensive C S F penetration is found. 6 T h e efficacy of ketoconazole has not been established in cryptococcal meningitis, though there have been some encouraging reports, v However, it's distribution to C S F is poor and current experience suggests it is probably ineffective?'8 T h e use of systemic azoles does not prevent development of cryptotococcal meningitis in A I D S patients, and clinical suspicion should be maintained.

* Department of Genito-urinary Medicine, afDepartment of Clinical Immunology, St Mary's Hospital, Praed Street, Paddington, London Wz I N Y , U.K.

R. y. Coker* D. Moulopoulost J. Maint S. M. Murphy* A. y. Pinchingt J. R. W. Harris*

References I. Armstrong D, Gold JWM, Dryjanski J et al. Treatment of infections in patients with the acquired immunodeficiency syndrome. Ann Intern Med I985 ; IO3 : 738-743-

IO8

Letters to the Editor

2. Byrne WR, Wajszczuk CP. Cryptococcal meningitis in the acquired immunodeficiency syndrome (AIDS) : successful treatment with fluconazole after failure of amphotericin B. Ann Intern Med I988; IO8:384-385 . 3- Sugar AM, Saunders C. Oral fluconazole as suppressive therapy of disseminated cryptococcosis in patients with acquired immuno-deficiency syndrome. Am J Med I988 ; 85 : 481-489. 4. Denning DW, Tucker RM, Hanson LH, Hamilton JR, Stevens, DA. Itraconazole therapy for cryptococcal meningitis and cryptococcosis. Arch Intern Med I989; x49: 23oi. 5. van't Wout JW, De Graeff-Meeder ER, Paul LC, Kuis W, van Furth R. Treatment of two cases of cryptococcal meningitis with fluconazole. Scand J Infect Dis I988 ; zo : r93-I98. 6. Brammer KW, Farrow, PR, Faulkner JK. Pharmacokinetics and tissue penetration of fluconazole in humans. Rev Infect Dis I99O; I2 (Suppl 3): 318-326. 7. Caraffa AC, Rehm, S, Keys TF. The acquired irnmunodeficiency syndrome and cryptococcosis. Ann Intern Med I986; IO4: 89I. 8. Perfect JR, Durack DT, Penetration of imidazoles and triazoles into cerebrospinal fluid of rabbits. J Antimicrob Chemother I985 ; z9: 579-83.

F a i l u r e o f t h e I2 m o n t h s c o u r s e o f a n t i t u b e r c u l o u s HIV infection

chemoprophylaxis

in

Accepted f o r publication 17 J u l y I 9 9 I Sir, Antituberculous chemoprophylaxis (isoniazid, 3 o o m g daily for i2 months) is recommended for HIV-infected subjects with a positive intradermal reaction to protein purified derivative (PPD), regardless of any immunological classification. 1'2 This policy invariably includes a significant n u m b e r of those whose immune competence is still substantially retained, while many others are missed as P P D testing may give a negative result due to impairment of cell-mediated immunity (false negativity). Thus, it is clear that whether a subject is considered eligible for such chemoprophylaxis depends not only on past exposure to Mycobacterium tuberculosis but also on residual immunity. It is unlikely that M. tuberculosis will necessarily be eradicated by I2 months isoniazid prophylaxis, and when the variable criteria for inclusion are taken into consideration there appears to be a considerable risk of failure. Since most cases of HIV-associated tuberculosis result from the reactivation of an endogenous infection, 3 the likelihood of this happening is inversely related to the functional level of cell-mediated immunity which results in the risk being greatest later in the course of an H I V infection when antituberculous chemoprophylaxis has probably already been completed. At the Department of Infectious Diseases of the University of Verona we have observed two cases of active tuberculosis which occurred 4 and 7 months after completion of a I2 months course of isoniazid chemoprophylaxis. A 29-year-old male drug abuser was given antituberculous chemoprophylaxis following a proven nosocomial exposure to M. tuberculosis. At that time he had a negative P P D test which converted to positive a m o n t h later; his C D 4 + cell count was 4o4/ml. F o u r months after discontinuing isoniazid (I6 months after the exposure to M . tuberculosis) he presented with a retroperitoneal abscess from which M . tuberculosis was grown. T h e isolate was found to be sensitive to isoniazid by means of direct and indirect susceptibility tests. At the time of diagnosis he had 262 C D 4 + cells/ml. A 32-year-old female, sexual partner of an HIV-infected drug abuser, was given isoniazid chemoprophylaxis because of a positive P P D test ( > 5 mm). At that time her C D 4 + cell count was 385/ml. Seven months after the end of the I s months isoniazid

Cryptococcal meningitis in AIDS occurring despite systemic antifungal therapy.

Letters to the Editor IO7 References I. Prescott JF. Rhodococcus equi and animal and human pathogen, Clin Microbiol Rev I99I ; 4: 2o-34. 2. Golub B,...
144KB Sizes 0 Downloads 0 Views