Coccidioidomycosis in patients with HIV-1 infection in the era of potent antiretroviral therapy

Abstract

Background: Coccidioidomycosis is a common opportunistic infection in human immunodeficiency virus type 1 (HIV-1)-infected individuals living in regions where coccidioidomycosis is endemic. However, there have been no studies on its incidence or clinical expression during the era of potent antiretroviral therapy.

Methods: Clinical data were abstracted from the records of all HIV-1-infected patients attending a single clinic in a region where coccidioidomycosis is endemic from January 2003 through May 2008. Additional follow-up was performed through May 2009 for individuals with active coccidioidomycosis. A case-control study was performed that compared all individuals who attended the clinic with individuals who received a diagnosis of coccidioidomycosis.

Results: Among 257 HIV-1-infected patients seen over a 64-month period, 29 cases (11.3%) of coccidioidomycosis were identified. Twelve patients (4.7%) received a diagnosis of coccidioidomycosis during the study period (annual incidence, 0.9%). Patients with less severe coccidioidomycosis were significantly more likely to have an undetectable HIV RNA level and to be receiving potent antiretroviral therapy than were those with more severe disease (for both, P< .01). Five patients with coccidioidomycosis received no antifungal therapy, and 11 others had antifungal therapy discontinued. All were healthy during follow-up. Patients with coccidioidomycosis had significantly lower CD4 T lymphocyte counts than did control subjects (mean +/- standard deviation, 285 +/- 42 cells/microL vs 477 +/- 21 cells/microL; P= .003).

Conclusions: The incidence of symptomatic coccidioidomycosis in the era of potent antiretroviral therapy has decreased, and its clinical expression is less severe than it was before the potent antiretroviral therapy era. Severity of coccidioidomycosis was inversely associated with control of HIV-1 infection.