                   AIDS INFORMATION NEWSLETTER
                   Michael Howe, MSLS, Editor
                     AIDS Information Center
                VA Medical Center, San Francisco
                     (415) 221-4810 ext 3305
                       September 27, 1996

              Opportunistic Infections (Part XXXII)
                           Appendix IV

              Patient Health Education Fact Sheets

[Editor's Note:  These are two of a series of Information Sheets
prepared by the National AIDS Treatment Information Project (NATIP)
with funding from the Henry J. Kaiser Family Foundation.  The
materials are designed for self-education by HIV-infected persons
and for counseling by community advisors, case managers, social
workers, and clinicians.  For more information about NATIP, call
617-667-5520 or write:  Helen E. Woods Wogan, Project Manager,
Libby 317, Beth Israel Hospital, 330 Brookline Avenue, Boston, MA
02215.  Fax: 617-667-2885.  Internet:  hwoods@bih.harvard.edu]


                     CRYPTOCOCCAL INFECTION

     * What is cryptococcal infection?
     * How is cryptococcosis spread?
     * How does Cryptococcus affect people with HIV disease?
     * What are the symptoms and signs of cryptococcal disease?
     * How is cryptococcal disease diagnosed?
     * How is cryptococcal disease treated?
     * Can cryptococcosis be prevented?

What is cryptococcal infection?

Cryptococcal meningitis is an infection of the tissues around the
spinal cord that is caused by a fungus called Cryptococcus
neoformans. Although meningitis is most common, cryptococcal
infection can occur in other parts of the body, and the general
name for this condition is cryptococcosis.

How is cryptococcosis spread?

Cryptococcal organisms are present throughout the environment.
Pigeons and other birds are major carriers of the organism, but it
does not make them sick. Soil often contains Cryptococcus,
especially if it is contaminated with bird droppings. Cryptococcus
probably gets into the body when you breath air containing dust
particles from dried soil or bird droppings. Cryptococcus does not
appear to spread directly from person to person.

How does Cryptococcus affect people with HIV disease?

Cryptococcal disease is common in people with AIDS. It most often
occurs in HIV-infected persons with a T-cell count below 100 and
is rare when the T-cell count is above 200. While cryptococcal
infection usually affects the lining of the spinal cord, it may
also cause pneumonia or widespread disease.

What are the symptoms and signs of cryptococcal disease?

Symptoms of cryptococcal meningitis may include fever, tiredness,
headache, stiff neck, nausea and vomiting, problems with vision,
and confused thinking. In many cases, these symptoms are mild and
develop gradually. Pneumonia may result in cough, shortness of
breath, and chest pain. Signs of infection may also include sores
on the skin and other findings depending on the body sites
affected.

How is cryptococcal disease diagnosed?

Because the symptoms and signs of cryptococcal disease are common
in many other conditions, laboratory tests are necessary to
establish the diagnosis. Most often a spinal tap (lumbar puncture
or LP) is performed to determine if meningitis is present. The
purpose of this procedure is to get a sample of spinal fluid, which
surrounds your brain and spinal cord (also called  cerebrospinal
fluid or CSF) to test for Cryptococcus. In addition, blood or fluid
from the lungs, skin lesions, or other body tissues may be tested.

To perform a spinal tap, your doctor will have you lie on your side
with your knees against your chest and insert a needle in the
middle of your back just above the level of your hips. The needle
passes between your backbones and into the spinal canal. CSF flows
through the needle and into tubes that are sent to the laboratory
for cryptococcal antigen (CRAG) testing and cryptococcal stain and
culture (see below). The CSF may also be evaluated for other
infections, including herpes simplex virus, syphilis, bacteria, and
tuberculosis. 

Although a spinal tap may sound frightening to some people, it is
a very common procedure, and permanent harm is extremely rare. To
reduce discomfort, doctors inject a numbing medicine (anesthetic)
before inserting the spinal tap needle. A common side effect of a
spinal tap is a headache that may last several days. This headache
can sometimes be avoided if you lay down for one or two hours after
the procedure.

Laboratory tests used to identify cryptococcal disease include the
CRAG test and cryptococcal stain and culture. The cryptococcal
fungus has a characteristic protein called an antigen, which can
be detected in blood and other body fluids. The CRAG test is quick,
and results are often available the same day. A positive CRAG test
indicates that cryptococcal infection is present.

If you have cryptococcal meningitis and are treated, the CRAG level
may go down. However, treatment only suppresses the fungus but does
not completely get rid of it. Some doctors perform CRAG tests
regularly on AIDS patients without evidence of cryptococcal
infection, but most experts believe that routine screening of
people is not useful.

If your blood or body fluid has many cryptococcal organisms growing
in it,the organism may be detected by placing a sample on a
microscope slide, staining it, and looking for fungus under the
microscope. The doctor may also send a sample of your blood or
other body fluid to the laboratory for culture. This test is done
by placing the specimen in a dish with nutrients and seeing if
Cryptococcus will grow. It may take a week or more to become
positive.

How is cryptococcal disease treated?

Treatment for cryptococcal disease, including meningitis, is most
effective if it is started before the disease becomes very serious.
This is why it is important to get symptoms evaluated quickly. If
you have mild cryptococcal infection, your doctor will probably
treat you with the drug fluconazole, which you can take by mouth.
Fluconazole is generally very well tolerated, but side effects may
include nausea, vomiting, diarrhea, and liver function test
abnormalities.

If your cryptococcal disease is more severe, your doctor will
likely treat you with amphotericin B. In such cases, it is a more
effective drug than fluconazole but usually has significant side
effects (fever, chills, low blood pressure, kidney dysfunction,
chemical abnormalities) and must be given through an intravenous
(IV) line. For very serious cryptococcal infection, some doctors
add a second drug called flucytosine in addition to amphotericin
B.

Treatment of cryptococcal meningitis requires at least 12 weeks of
amphotericin B or high-dose fluconazole, followed by a lower daily
dose of fluconazole for the rest of your life. If you stop taking
this medication, the infection will usually come back. At follow-up
visits, your doctor will monitor your symptoms and laboratory
studies.

Can cryptococcosis be prevented?

Because Cryptococcus is so widely present in the environment, you
probably cannot avoid contact with the organism. You can reduce the
chance of getting cryptococcal infection by taking fluconazole as
a preventive medication, although there is no evidence that this
prolongs survival. Some doctors feel that persons with AIDS should
take this medication when their T-cell count drops below 50.
However, using fluconazole preventively can cause other problems;
the most common are yeast infections (thrush, vaginitis) that are
resistant to fluconazole therapy and can only be treated with
amphotericin B.


                    CRYPTOSPORIDIAL INFECTION

     * What is Cryptosporidium?
     * How might I become infected with Cryptosporidium?
     * How is cryptosporidial infection related to HIV disease?
     * What are the symptoms of cryptosporidial infection?
     * How is cryptosporidial infection diagnosed?
     * How is cryptosporidial infection treated?
     * How can cryptosporidial infection be prevented?

What is Cryptosporidium?

Cryptosporidium is the name of an organism that causes diarrhea in
people with HIV infection, and the disease caused by it is called
cryptosporidiosis. In advanced HIV disease or AIDS, the diarrhea
may be severe and difficult to treat. Cryptosporidium is a
parasite, which is larger than a bacterium or virus, but still so
small that you cannot see it without a microscope.

How might I become infected with Cryptosporidium?

Cryptosporidium gets into the gastrointestinal tract (gut) through
your mouth from uncooked or unwashed food or contaminated water.
When you swallow the organism, it moves into your intestine, where
it reproduces and causes disease.

Cryptosporidium is introduced into the environment when infected
people or animals pass it in their bowel movements. The organism
can survive in soil, water, and even ice for months. Infected
people can spread it to others by not washing their hands carefully
after using the bathroom, handling dirty laundry, or having sexual
contact with the rectal area. People with contaminated hands can
pass the infection to others by preparing food or touching the hand
of another person.

It takes only a few Cryptosporidium in your body to cause disease,
and it is very easy to spread the infection. There are cases of the
infection passing from one person to many others in day care
centers, households, and hospitals. Infection of some people has
also occurred from contaminated well water, municipal water
supplies, and swimming pools. 

How is cryptosporidial infection related to HIV disease?

When people without HIV infection get cryptosporidiosis, they
usually have diarrhea for a few days to weeks, and then their
immune system eliminates the organism. In early HIV disease, the
body is still able to fight the parasite, but in advanced disease
this ability is reduced, resulting in long term infection.

What are the symptoms of cryptosporidial infection?

Some people with cryptosporidiosis have no symptoms or very mild
ones. The most common complaints are diarrhea and cramping
abdominal pain. Occasionally fever, tiredness, nausea, vomiting,
and yellow discoloration of eyes and skin (jaundice) may also be
present. There are many conditions other than cryptosporidiosis
that can result in similar symptoms, so laboratory tests are
necessary to determine their cause.

How is cryptosporidial infection diagnosed?

If you have cramping abdominal pain or diarrhea and if it is severe
or does not go away in a few days, you should go for medical
evaluation. Your doctor may want to determine if other infections
or medication side effects are causing these symptoms before
testing for Cryptosporidium.

A stool sample will be requested to look for evidence of bacterial
infection, cryptosporidiosis, and other pathogens. Laboratory
technicians diagnose Cryptosporidium infection by putting a sample
of your stool on a microscope slide, staining it, and reviewing it
carefully. Doctors call this examination an ova and parasite (O&P)
test. One stool sample is often not enough to find Cryptosporidium
or other parasites. Most specialists recommend that you provide
three samples of stool, each on a separate day.

To produce a good stool sample, you should get a container from the
laboratory or from your clinic or doctor's office. Usually there
will be some liquid preservative in the container and directions
on exactly how to use it. The preservative keeps the parasites in
the stool from breaking up between the time you produce the stool
and bring it to the laboratory. You can catch your stool directly
in the container, or you can move your bowels in a bedpan and use
a tongue blade to scoop some stool into the container. These
supplies can be requested from your primary care provider.

How is cryptosporidial infection treated?

There are no medications that have been shown to cure
cryptosporidiosis. Paromomycin helps suppress the infection in some
people, but it is not always effective. Azithromycin has also been
used with some success. If your immune system function is
reasonably good, it may control or eliminate the infection.
Sometimes starting antiretroviral therapy may give your immunity 
a temporary boost.

To control diarrhea, you should avoid things that make the problem
worse, including foods such as caffeinated drinks, milk products,
alcohol and drugs, and certain medications. For mild diarrhea,
medicines like Pepto-bismol or Kayopectate may help. Stronger
medications that are sometimes necessary include diphenoxylate
hydrochloride (Lomotil), loperamide (Immodium), deodorized tincture
of opium (DTO), and camphorated tincture of opium (Paregoric).
However, these agents may have side effects in some people,
including constipation and drowsiness, and can be addicting.

If you are having a lot of diarrhea, it is important to drink
liquids to replace lost fluid and nutrients. If this is not
possible, you should see your doctor right away because you may 
need fluid replacement through an intravenous (IV) line.

How can cryptosporidial infection be prevented?

There are no medications that you can take to prevent
cryptosporidial infection. However, you can decrease exposure to
the organism. Avoid contact with human or animal waste products.
Wash your hands after bathroom use, handling animals, and such
activities as changing diapers, handling dirty laundry, and
gardening. Wash vegetables before eating them to assure they are
not contaminated by soil.

In some cities, problems with water purification systems have
caused contamination of tap water by sewage, resulting in many
people becoming infected by Cryptosporidium. Overall the risk from
tap water is low. If a city announces that a contamination accident
has occurred, you should not drink tap water. You can check with
your doctor or health department to find out the safety of your
local water supply.

If you are HIV-infected, especially if your T-cell count is below
300, you should consider the following steps to avoid contaminated
water: 1) Drink water that has been boiled for at least one minute;
2) drink distilled water; or 3) drink water that has been filtered
properly. This means water that has gone through filters called
"absolute 1-micron filters" or filters meeting "National Sanitation
Foundation (NSF) standard number 53 for cyst removal." You can buy
water that has been filtered in this way or purchase filtering
equipment. Bottled drinking water is not necessarily safe unless
it has been treated in one of the above ways.

Swimming in lakes and rivers that may collect animal and human
sewage poses some risk of cryptosporidial infection. Although
uncommon, swimming pools can also become contaminated and spread
cryptosporidiosis because chlorine does not kill the organism.

Pets and farm animals can be infected with Cryptosporidium. The
risk of exposure is relatively small and is not a reason to give
up pets, but you should consider the following recommendations: 1)
Do not adopt stray animals without first having them evaluated; 2)
If you decide to have a pet, get one that is more than 6 months old
or have a veterinarian examine its stool for Cryptosporidium before
bringing it into your home; and 3) Do not bring a pet into your
home if it has diarrhea.

If you are infected with Cryptosporidium, you should avoid
spreading it to others by careful hand washing and cleanliness, not
being involved in risky sexual contact, not going into public
swimming pools, and not preparing food for others.
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