Treatment of systemic mycoses in patients with AIDS

Far and away the most common fungal infection associated with HIV infection is candidiasis. This tends to produce mucosal topical infections and local treatment may be enough to control them. Generally we prefer courses of 1-2 weeks rather than chronic suppression, for fear of eliciting overgrowth of resistant isolates. Fluconazole resistant Candida species may be an increasing problem over the next decade. For cryptococcoses the problem is both simpler and more complicated. Fluconazole is highly effective for chronic suppression, but not very effective for initial therapy. Here a short course of amphotericin B, just 2 weeks in length, is followed by chronic azole suppression. Fluconazole appears excellent, but itraconazole may also be effective. For histoplasmosis itraconazole appears to be the most advantageous drug, with excellent clinical response within 2 weeks. A role for fluconazole is unclear. Coccidioidomycosis is uncommon, but difficult. I cannot offer any suggestions on "ideal" therapy here. Other diseases, such as aspergillosis, are extremely uncommon but still are AIDS associated mycoses. It is my personal fear that as we go along identifying the AIDS virus and its complications, aspergillosis and zygomycosis may establish themselves as the future "black hats" for which we will need to pull something out of the "box". What to pull is not very clear.