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General Considerations
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Loiasis is a chronic filarial disease caused by infection with Loa loa The infection occurs in humans and monkeys in rainforest areas of West and central Africa An estimated 3 13 million persons are infected The disease is transmitted by chrysops flies, which bite during the day Over 6 12 months after infection, larvae develop into adult worms, which migrate through subcutaneous tissues, including the subconjunctiva (leading to the term eye worm ) Adults can live for up to 17 years
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Clinical Findings
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A Symptoms and Signs
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Many infected persons are asymptomatic, although they may have high levels of microfilaremia and eosinophilia Transient subcutaneous swellings (Calabar swellings) develop in symptomatic persons The swellings are nonerythematous, up to 20 cm in diameter, and may be preceded by local pain or pruritus They usually resolve after 2 4 days but occasionally persist for several weeks Calabar swellings are commonly seen around joints and may recur at the same or different sites Visitors from nonendemic areas are more likely to have allergic-type reactions, including pruritus, urticaria, and angioedema Adult worms may be seen to migrate across the eye, with either no symptoms or conjunctivitis, with pain and edema The most serious complication of loiasis is encephali-
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Fungal infections have assumed an increasingly important role as use of broad-spectrum antimicrobial agents has increased and the number of immunodeficient patients has risen Some pathogens (eg, Cryptococcus, Candida, Pneumocystis, Fusarium) rarely cause serious disease in normal hosts Other endemic fungi (eg, Histoplasma, Coccidioides, Paracoccidioides) commonly cause disease in normal hosts but tend to be more aggressive in immunocompromised ones Superficial mycoses are discussed in 6 Successful management of most systemic fungal infections requires knowledge of the natural history of these diseases as well as familiarity with the unique pharmacokinetics, adverse effects, and drug interactions of the various therapeutic agents Furthermore, most affected individuals usually have significant underlying illnesses Consequently, clinicians with extensive experience in the management of these disorders should be consulted
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Mycotic Infections
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When no other underlying cause is found, persistent oral or vaginal candidiasis should arouse a suspicion of HIV infection
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Clinical Findings & Treatment
A Mucosal Candidiasis
Esophageal involvement is the most frequent type of significant mucosal disease Presenting symptoms include substernal odynophagia, gastroesophageal reflux, or nausea without substernal pain Oral candidiasis, though often associated, is not invariably present Diagnosis is best confirmed by endoscopy with biopsy and culture Therapy depends on the severity of disease If patients are able to swallow and take adequate amounts of fluid orally, fluconazole, 100 mg/d (or itraconazole solution, 10 mg/mL, 100 mg/d), for 10 14 days will usually suffice In the individual who is more ill or in whom esophagitis has developed while taking fluconazole, options include oral or intravenous voriconazole, 200 mg twice daily; intravenous amphotericin B, 03 mg/kg/d; or intravenous caspofungin, 50 mg/d; or intravenous micafungin, 150 mg/d Relapse is common with all agents when there is underlying HIV infection without adequate immune reconstitution Vulvovaginal candidiasis occurs in an estimated 75% of women during their lifetime Risk factors include pregnancy, uncontrolled diabetes mellitus, broad-spectrum antimicrobial treatment, corticosteroid use, and HIV infection Symptoms include acute vulvar pruritus, burning vaginal discharge, and dyspareunia Various topical azole preparations (eg, clotrimazole, 100 mg vaginal tablet for 7 days, or miconazole, 200 mg vaginal suppository for 3 days) are effective One 150 mg oral dose of fluconazole has been shown to have equivalent efficacy with better patient acceptance Disease recurrence is common but can be decreased with weekly fluconazole therapy (150 mg weekly)
CANDIDIASIS
ESSENTIALS OF DIAGNOSIS
Common normal flora but opportunistic pathogen Gastrointestinal mucosal disease, particularly esophagitis, most common Catheter-associated fungemia occurs in patients who have sustained mucosal injury or received broadspectrum antibiotics
General Considerations
Candida albicans can be cultured from the mouth, vagina, and feces of most people Cutaneous and oral lesions are discussed in s 6 and 8, respectively The risk factors for invasive candidiasis include prolonged neutropenia, recent abdominal surgery, broad-spectrum antibiotic therapy, renal failure, the presence of intravascular catheters (especially when providing total parenteral nutrition), and injection drug use Cellular immunodeficiency predisposes to mucocutaneous disease
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