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This program is funded through Health Resources and Services Administration, US Department of Health and Human Services. Discuss best treatment options for HIV-infected patients with acyclovir-resistant herpes simplex virus infections. Figure 1Figure 1 - Persistent Facial LesionLarge, gradually expanding superficial ulcerated lesion on face that did not respond to high-dose oral acyclovir. Which one of the following would be the most effective therapy at this point for presumptive acyclovir-resistant herpes simplex virus infection? Famciclovir (Famvir) 500 mg PO tid.IncorrectMost acyclovir-resistant herpes simplex virus infections result from decreased viral production of thymidine kinase, the enzyme responsible for the first phosphorylation step in converting acyclovir to its active triphosphorylated form acyclovir triphosphate. Valacyclovir (Valtrex) 1000 mg PO tid.IncorrectValacyclovir (Valtrex) is an acyclovir prodrug (it is the L-valine ester of acyclovir). Figure 1Figure 1 - Mechanism of Action of AcyclovirIn this HSV-infected human cell, the acyclovir molecules enter the cell and are converted to acyclovir monophosphate by the HSV enzyme thymidine kinase (TK).
Figure 2Figure 2 - Common Mechanism of Acyclovir Resistance in Herpes Simplex Virus InfectionThe most common types of acyclovir-resistant HSV infection involve either absent production of viral thymidine kinase (TK-negative mutants), or partially reduced production of viral thymidine kinase (TK-partial mutants).
Figure 6Figure 6 - Therapy for Acyclovir-Resistant Mucocutaneous HSVSource: This table is based on recommendations from Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. The drug acyclovir (Zovirax) does not have activity against viral pathogens until it is converted to the active form acyclovir triphosphate. All of the drugs that require initial activation by HSV thymidine kinase (acyclovir, famciclovir, and valacyclovir) generally produce ineffective results against HSV strains that have absent or decreased thymidine kinase production. Cidofovir (Vistide), formerly HPMPC, is an antiviral compound that reaches the cell in a monophosphorylated form whereby it is activated by cellular kinases.
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America Conference, and serving on the Mycology Research Laboratories scientific advisory board.
These guidelines were developed by a panel of specialists from the United States government and academic institutions. ART drugs, leading to subtherapeutic serum levels and the development of antiretroviral drug resistance. OIs that occur after patients have been started on ART can be categorized into three groups.
Physiologic changes during pregnancy can complicate the recognition of OIs and complicate pharmacokinetics.
Increased cardiac output by 30%--50% with concomitant increase in glomerular filtration rate and renal clearance. Increased plasma volume by 45%--50% while red cell mass increases only by 20%--30%, leading to dilutional anemia. Young children with cryptosporidial diarrhea might infect adults during diapering and cleaning after defecation. Among persons with profuse diarrheal illness, a single stool specimen is usually adequate for diagnosis. He has a history of recurrent herpes simplex infection and has received multiple courses of oral acyclovir (Zovirax).


Famciclovir (Famvir) is a prodrug of penciclovir and because activation of penciclovir also depends on viral thymidine kinase, acyclovir resistance generally also causes famciclovir resistance. Foscarnet does not require activation by viral thymidine kinase and thus retains activity against herpes simplex virus strains with absent or altered production of viral thymidine kinase. Following absorption of valacyclovir, it is almost completely converted to acyclovir during first-pass hydrolysis in the liver and intestines.
Enzymes in the human cell add two more phosphates to eventually form the active drug acyclovir triphosphate. In this illustration, the notation TK- refers to deficient production of viral thymidine kinase, either through TK-negative mutants or TK-partial mutants.
Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. If acyclovir resistance is suspected, testing for HSV should include a viral culture of the sample, since resistance testing will require isolation of virus. Drugs that require activation via a similar viral kinase, such as ganciclovir (Cytovene) and valganciclovir (Valcyte), are also ineffective. Because cidofovir does not require activation by a viral kinase, it should theoretically have activity against acyclovir-resistant HSV infections.
Resistance of herpes simplex viruses to nucleoside analogues: mechanisms, prevalence, and management.
Resistance of herpes simplex virus infections to nucleoside analogues in HIV-infected patients. Genotypic characterization of UL23 thymidine kinase and UL30 DNA polymerase of clinical isolates of herpes simplex virus: natural polymorphism and mutations associated with resistance to antivirals. Resistance to antiviral drugs of herpes simplex virus isolated from a patient treated with acyclovir. Acyclovir-resistant genital herpes among persons attending sexually transmitted disease and human immunodeficiency virus clinics.
Acyclovir-resistant herpes simplex virus infections in patients with the acquired immunodeficiency syndrome. Herpes simplex virus type 2 meningoencephalitis resistant to acyclovir in a patient with AIDS. Mucocutaneous dissemination of acyclovir-resistant herpes simplex virus in a patient with AIDS. Foscarnet therapy for acyclovir-resistant mucocutaneous herpes simplex virus infection in 26 AIDS patients: preliminary data.
A controlled trial comparing foscarnet with vidarabine for acyclovir-resistant mucocutaneous herpes simplex in the acquired immunodeficiency syndrome. Foscarnet therapy for severe acyclovir-resistant herpes simplex virus type-2 infections in patients with the acquired immunodeficiency syndrome (AIDS). A randomized, double-blind, placebo-controlled trial of cidofovir gel for the treatment of acyclovir-unresponsive mucocutaneous herpes simplex virus infection in patients with AIDS. Treatment with intravenous (S)-1-[3-hydroxy-2-(phosphonylmethoxy)propyl]-cytosine of acyclovir-resistant mucocutaneous infection with herpes simplex virus in a patient with AIDS.
Pilot study of topical trifluridine for the treatment of acyclovir-resistant mucocutaneous herpes simplex disease in patients with AIDS (ACTG 172).


However, IRIS has occurred weeks after ART was started and in sequestered sites such as bone. The tidal volume increase of 30%--40% should be considered if ventilatory assistance is required.
Methylprednisolone at 75% of the respective prednisone dose can be used if parenteral administration is necessary. Certain clinicians prefer IV pentamidine because of convincing data regarding its high degree of efficacy. Failure attributed to lack of drug efficacy occurs in approximately 10% of those with mild-to-moderate disease. The absence of IgG antibody makes a diagnosis of toxoplasmosis unlikely but not impossible.
Person-to-person transmission is common, especially among sexually active men who have sex with men (MSM). Nationally distributed brands of bottled or canned carbonated soft drinks are safe to drink.
He increased his acyclovir dose from 400 mg PO three times daily to 800 mg PO three times daily, but the lesion expanded further (Figure 1).
Although oral valacyclovir has a relative bioavailability 3 to 5 times greater than acyclovir (and oral doses can generate relatively high serum levels of acyclovir), it would not likely override the acyclovir resistance.
The acyclovir triphosphate competes with 2-deoxyguanosine triphosphate (dGTP) as a substrate for viral DNA polymerase, as well as acting as a chain terminator. As a result of the deficient production of TK, the HSV strains fail to effectively generate acyclovir triphosphate and thus acyclovir does not effectively inhibit viral DNA polymerase. Acyclovir triphosphate has a two-pronged mechanism of action: (1) it competes with 2-deoxyguanosine triphosphate (dGTP) as a substrate for viral DNA polymerase and (2) once it becomes incorporated into the replicating viral DNA, it acts as a chain terminator because it does not have a terminal 3' hydroxyl group. Rarely, acyclovir-resistant HSV infections result from altered viral thymidine kinase and these strains of HSV could theoretically respond to famciclovir. This lesion is now painful and culture of the lesion has grown herpes simplex virus type 1.
In actual infection, the HSV releases its naked capsid that delivers DNA to the human nucleus; the active drug acyclovir triphosphate exerts its action on the viral DNA located in the nucleus.
In contrast, penciclovir, the active component of the prodrug famciclovir (Famvir), does not act as a chain terminator because it has a terminal 3' hydroxyl group that permits viral primer-template extension. Because foscarnet does not require activation by viral thymidine kinase, it retains activity against HSV strains with absent, partially reduced, or altered production of thymidine kinase.
Foscarnet (Foscavir) is a pyrophosphate analog that directly inhibits viral DNA polymerase by reversibly blocking the pyrophosphate binding site of the viral polymerase (in addition to inhibiting the cleavage of pyrophosphate from deoxynucleotide triphosphates).



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