For prophylaxis, several international health agencies recommend one double-strength trimethoprim-sulfamethoxazole tablet orally daily for certain groups of HIV-infected pregnant women. These include women with CD4+ T-lymphocyte counts <2001LL, those whose CD4+ T lymphocytes constitute < 14 percent, or if there is an AIDS-defining illness, particularly oropharyngeal candidiasis (Centers for Disease Control and Prevention, 2016a).
Any of several fungi can cause pneumonia. In pregnancy, this is usually seen in women with HIV infection or who are oth erwise immunocompromised. Infection is usually mild and self-limited. It is characterized initially by cough and fever, and dissemination is infrequent (Mansour, 2015).
Histoplasmosis and blastomycosis do not appear to be more frequent or more severe during pregnancy (Youssef, 2013). Data concerning coccidioidomycosis are conlicting (Bercovitch, 2011; Patel, 2013). In a case-control study from an endemic area, Rosenstein and associates (2001) reported that pregnancy was a signiicant risk factor for disseminated disease. In another study, however, Caldwell and coworkers (2000) identified 32 serologically confirmed cases during pregnancy and documented dissemination in only three cases. Women with associated erythema nodosum have a better prognosis, whereas mediastinal lymphadenopathy may more likely relect disseminated disease (Caldwell, 2000; Mayer, 2013). Finally, Crum and Ballon-Landa (2006) reviewed 80 cases of antepartum coccidioidomycosis and found that almost all women diagnosed in the third trimester had disseminated disease. Although the overall maternal mortality rate was 40 percent, it was only 20 percent for 29 cases reported since 1973. Spinello (2007) and Bercovitch (201a1) with their colleagues have provided reviews of coccidioidomycosis in pregnancy.
Most cases of cryptococcosis reported during pregnancy manifest as meningitis. Otherwise healthy pregnant women occasionally have cryptococcal pneumonia (Asadi Gharabaghi, 2014; Ely, 1998). Diagnosis is diicult because clinical presentation is similar to that of other community-acquired pneumonias.
Treatment. The 2007 IDSNATS guidelines recommend itraconazole as preferred therapy for disseminated fungal infections (Mandell, 2007). Pregnant women have also been given IV amphotericin B or ketoconazole (Paranyuk, 2006; Pilmis, 2015). Amphotericin B has been used extensively in pregnancy with no embryofetal efects. Because of evidence that fluconazole, itraconazole, and ketoconazole may be embryo toxic in large doses in early pregnancy, Briggs and coworkers (2015) recommend that irst-trimester use should be avoided if possible.
hree echinocandin derivatives-caspofongin, micaongin, and anidulafungin-are efective for invasive candidiasis (Pilmis, 2015; Reboli, 2007). They are embryotoxic and teratogenic in laboratory animals, and use in human pregnancies has not been reported (Briggs, 2015).