Nursing Pharmacology:  Antiviral Drugs

• Antiviral Drugs

  • Anti-viral drugs with activity against HIV (Human Immunodeficiency Virus)

    • HIV-1 Pathophysiology/Pathogenesis:  HIV Disease Presentations

      • Pulmonary Disease (continued)

        • Fungal Infections of the Lung²

          • There are, other than PCP (Pneumocystis jirovecci), additional fungal infections in the lung are observed in AIDS patients.²  

            • For example, some patients exhibited pulmonary cryptococcal infection.

              • Cryptococcosis is a frequently observed opportunistic infection in AIDS patients.¹³ 

                • However, the infection can also be observed in immunosuppressed individuals.¹³  

                  • Most cases are caused by encapsulated yeast.

                  • Cryptococcus neoformans is the primary causative agent of pulmonary crpytococcal infection, although Cryptococcus gattii also causes some cases.

                    • Cryptococcocisis (Cryptococcus neoformans) of lung in an AIDS Patient¹⁴

                      CDC/ Ewing, Jr. EP (Public Domain-USGOV-HHS-CDC) "Cryptococcosis of lung in patient with AIDS. "Mucicarine stain "Histopathology of lung shows widened alveolar septum contain a few inflammatory cells and numerous yeats of Crytococcus neoformans. "The inner layer of the yeast capsule stains red." (1984)"

                       

                      Cryptococcus gattii

                      Lindsberg J Hagen F Laurens A Stenderup J Boekhout T Crytococcus gatti Risk for Tourists Visiting Vancourver Island, Candaa A) "Chest radiograph and B) "Computed tomography scan of the patient showing 3 nodular Crytococcus gattii infiltrates near pleura"

                    • The most frequent presentation is severe meningioencephalitis.¹³  

                      • Cryptococcal Menningitis¹⁶

                        Attribution:  Meintjes G Update on cryptococcal disease in patients with HIV https://www.youtube.com/watch?v=si_IJiJ65Co (6/2014) HIV/AIDS YouTube Channel:  https://www.cdc.gov/hiv/basics/whatishiv.html

                    • Pulmonary cryptococcosis is likely underdiagnosed in HIV-seropositive patients.¹³  

                      • Furthermore, absent appropriate treatment, severe disseminated disease may ensue.

                        • Although radiological presentations appear varied and nonspecific, depending on the underlying immune status of the individual, diagnosis may be made based on other approaches.

                        • Typically, diagnosis centers on isolation in a pulmonary specimen of Cryptococcus directly from or detection of cryptococcal antigen.¹³  

                        • This finding along with other clinical radiological histopathological findings allow for diagnosis.

              • These patients present with the following symptoms:

                • Fever

                • Cough

                • Hemoptysis

                • Dyspnea.

              • In chest x-ray in over 90% of patients, a focal or diffuse interstitial infiltrate may be documented.

                • The presentation may also include:

                  • Lobular disease

                  • Cavitary disease

                  • Pleural effusions and

                  • Hilar or mediastinal adenopathy.²  

                •  

                  Chest X-ray:  Pulmonary Cryptococcal Infection¹¹

                  Cryptcoccosis, Mycology Online, Pulonmary Cryptocoocal infection, right upper lobe The University of Adelaide http://www.mycology.adelaide.edu.au/Mycoses/Opportunistic/Cryptococcosis/

          • A mold, Coccidioides immitis, found in the Southwest of the United States may induce pulmonary reactivation syndrome in HIV patients.²  

            • These patients may exhibit CD4+ T cell counts <250/μl.

              • Clinical presentations here include:

                • Fever

                • Weight loss

                • Extensive and

                • Diffuse reticulonodular infiltrates (on chest x-ray) and

                • Cough.²  

          • Primary lung infection is also noted with histoplasmosis, typically in disseminated disease, probably due to reactivation.²  

            • Respiratory symptoms tend to be limited, as cough and dyspnea occur in only between 10%-30% of individuals.

            • However, chest x-ray exhibits pathology and about 50% of individuals with diffuse interstitial infiltrate or diffuse small module represent primary presentations here.²

              • Chest X-ray:  Acute histoplasmosis¹²

                CDC/ Renz M "This chest film shows diffuse pulmonary infiltration due to acute histoplasmosis caused by H.. capsulatum. 1963 http://commons.wikimedia.org/wiki/File:Chest_X-ray_acute_pulmonary_histoplasmosis_PHIL_3954.jpg

          • Idiopathic interstitial pneumonia has been described in HIV patients.²  

            • Idiopathic interstitial pneumonia has been mainly of two types:

              • Lymphoid interstitial pneumonia (LIP) and nonspecific interstitial pneumonia (NIP).

                • Although common in children, LIP is noted in about 1% of adult patients not undergoing treatment for HIV.²

References

Flexner C Antiretroviral Agents and Treatment of HIV Infection, Chapter 59  in Goodman & Gilman's The Pharmacological Basis of Therapeutics, 12th edition (Brunton LL Chabner BA Knollmann BC, eds; Brunton LL, ed; Blumenthal DK  Murri N Hilal-Dandan R, assoc eds, Knollmann BC, consulting ed, on-line edition) The McGraw-Hill Companies, 2011. Fauci AS Lane HC Chapter 189, Human Immunodeficiency Virus Disease:  AIDS and Related Disorders, in Harrison's Online   (Dan L. Longo, Anthony S. Fauci, Dennis L. Kasper, Stephen L. Hauser, J. Larry Jameson, Joseph Loscalzo, Eds.),  Harrison's Principles of Internal Medicine, 18th edition, The McGraw-Hill Companies, Inc. 2012. Longo DL Fauci AS  188, The Human Retroviruses, in Harrison's Online   (Dan L. Longo, Anthony S. Fauci, Dennis L. Kasper, Stephen L. Hauser, J. Larry Jameson, Joseph Loscalzo, Eds.),  Harrison's Principles of Internal Medicine, 18th edition, The McGraw-Hill Companies, Inc. 2012. Safrin S Antiviral Agents, Chapter 49 in Basic & Clinical Pharmacology, 12 e (Katzung BG Masters SB Trevor AJ) The McGraw-Hill Companies, 2012 (on-line edition). Cochrane A Retroviruses Chapter 28 in Fundaments of Molecular Virology, 2e, Acheson NH, ed., John Wiley & Sons pp 342-353 2011. Cochrane A Human Immunodeficiency Virus Chapter 29  in Fundaments of Molecular Virology, 2e, Acheson NH, ed., John Wiley & Sons pp 354-364 2011. Ryan KJ, Ray C. Chapter 18. Retroviruses: Human T-Lymphotropic Virus, Human Immunodeficiency Virus, and Acquired Immunodeficiency Syndrome. In: Ryan KJ, Ray C. eds. Sherris Medical Microbiology (Part editor, Ahmad N Ray CG Drew WL), 5e. New York, NY: McGraw-Hill; 2010. Butel JS Chapter 44:  AIDS and Lentiviruses (Brooks FG, Carroll KC Butel JS Morse SA, Mietzner TA in Jawetz, Melnick & Adelberg's Medical Microbiology, 26th edition), 2013, on-line edition. Petri Jr WA Sulfonamides, Trimethoprim-Sulfamethoxazole, Quinolones, and Agents for Urinary Tract Infections  in Goodman & Gilman's The Pharmacological Basis of Therapeutics, 12th edition (Brunton LL Chabner BA Knollmann BC, eds; Brunton LL, ed; Blumenthal DK  Murri N Hilal-Dandan R, assoc eds, Knollmann BC, consulting ed, on-line edition) The McGraw-Hill Companies, 2011. Segreti J Chapter 40.  Pulmonary Complications of HIV Disease in Current Diagnosis & Treatment in Pulmonary Medicine (Hanley ME Welsh CH, eds). The McGraw-Hill Companies, Inc. 2003. on-line edition. Cryptcoccosis, Mycology Online, Pulonmary Cryptocoocal infection, right upper lobe; The University of Adelaide; http://www.mycology.adelaide.edu.au/Mycoses/Opportunistic/Cryptococcosis/  CDC/ Renz M "This chest film shows diffuse pulmonary infiltration due to acute histoplasmosis caused by H.. capsulatum. 1963; http://commons.wikimedia.org/wiki/File:Chest_X-ray_acute_pulmonary_histoplasmosis_PHIL_3954.jpg Jarvis JN Harrison TS Pulmonary Cryptococcosis. Semin Respir Crit Care Med 29(2) 141-150, Spr. 2008. CDC/ Ewing, Jr. EP (Public Domain-USGOV-HHS-CDC) Cryptococcosis of lung in patient with AIDS. http://commons.wikimedia.org/wiki/File:Cryptococcosis_of_lung_in_patient_with_AIDS._Mucicarmine_stain_962_lores.jpg Lindberg J, Hagen F, Laursen A, Stenderup J, Boekhout T. Cryptococcus gattii risk for Tourists Visiting Vancouver Island, Canada [letter]. Emerg Infect  Dis . 2007 Jan Meintjes G Update on cryptococcal disease in patients with HIV; https://www.youtube.com/watch?v=si_IJiJ65Co

 

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