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Treatment of microsporidiosis

Treatment of microsporidiosis
  Drug Adult dose Pediatric dose
Ocular (Encephalitozoon hellem, Encephalitozoon cuniculi, Vittaforma [Nosema] corneae)
Drug of choice: Fumagillin (Fumidil B) in saline equivalent to fumagillin 70 mcg/mL eye drops* 2 drops every 2 hours for 4 days, then 2 drops 4 times per day  
PLUS for management of systemic infection
AlbendazoleΔ 400 mg orally with fatty meal twice per day 15 mg/kg per day in 2 divided doses (maximum 400 mg/dose)
Intestinal (Enterocytozoon bieneusi, Encephalitozoon [Septata] intestinalis)
E. bieneusi
Drug of choice: Fumagillin◊ 20 mg orally three times per day for 14 days  
E. intestinalis
Drug of choice: AlbendazoleΔ 400 mg orally on empty stomach twice per day for 21 days 15 mg/kg per day in 2 divided doses (maximum 400 mg/dose)
Disseminated (E. hellem, E. cuniculi, E. intestinalis, Pleistophora spp, Trachipleistophora spp, and Anncaliia [Brachiola] vesicularum)
Drug of choice:§ AlbendazoleΔ Immunocompromised: 400 mg orally with fatty meal twice per day for 14 to 28 days. Continue treatment until CD4+ count >200 cells/microL for >6 months after initiation of potent antiretroviral therapy.
Immunocompetent: 400 mg orally with fatty meal twice per day for 7 to 14 days. Symptoms may resolve with no therapy. (Refer to the UpToDate topic on microsporidiosis.)		 15 mg/kg per day in 2 divided doses (maximum 400 mg/dose)
The mainstay of treatment of microsporidiosis in HIV-infected patients with severe immunosuppression is successful ART for immune restoration of CD4+ counts to greater than 100 cells/microL, which is associated with resolution of symptoms of enteric microsporidiosis, including that caused by E. bieneusi.
* Available as an investigational agent (non-US Food and Drug Administration [FDA] approved) in the United States from Leiter's Park Avenue Pharmacy (a custom compounding pharmacy), San Jose, CA (800-292-6773, www.leiterrx.com). Ocular lesions due to E. hellem in HIV-infected patients have responded to fumagillin eyedrops prepared from Fumidil B (bicyclohexyl ammonium fumagillin) used to control a microsporidial disease of honey bees.[1,2] For lesions due to V. corneae, topical therapy is generally not effective and keratoplasty may be required.[3]
¶ Not FDA approved for this indication.
Δ For treatment of systemic infection, albendazole must be taken with food; a fatty meal increases oral bioavailability. For treatment of intestinal infection with no systemic involvement, albendazole should be taken on an empty stomach.
◊ Oral fumagillin (Flisint, Sanofi-Aventis, France) is not available in the United States. It has been effective in treating E. bieneusi in patients with HIV or solid organ transplants[4,5] but has been associated with thrombocytopenia and neutropenia. Potent antiretroviral therapy may lead to microbiologic and clinical response in HIV-infected patients with microsporidial diarrhea. Octreotide (Sandostatin) has provided symptomatic relief in some patients with large-volume diarrhea.
§ There is no established treatment for Pleistophora.[6] For disseminated disease due to Trachipleistophora or Anncallia, itraconazole 400 mg orally once per day plus albendazole may also be tried.[7]
References:
  1. Chan CM, Theng JT, Li L, Tan DT. Microsporidial keratoconjunctivitis in healthy individuals: a case series. Ophtalmology 2003; 110:1420.
  2. Garvey MJ, Ambrose PG, Ulmer JL. Topical fumagillin in the treatment of microsporidial keratoconjunctivitis in AIDS. Ann Pharmacother 1995; 29:872.
  3. Davis RM, Font RL, Keisler MS, Shadduck JA. Corneal microsporidiosis. A case report including ultrastructural observations. Ophthalmology 1990; 97:953.
  4. Molina JM, Tourneur M, Sarfati C, et al. Fumagillin treatment of intestinal microsporidiosis. N Engl J Med 2002; 346:1963.
  5. Lanternier F, Boutboul D, Menotti J, et al. Microsporidiosis in solid organ transplant recipients: two Enterocytozoon bieneusi cases and review. Transpl Infect Dis 2009; 11:83.
  6. Molina JM, Oksenhendler E, Beauvais B, et al. Disseminated microsporidiosis due to Septata intestinalis in patients with AIDS: clinical features and response to albendazole therapy. J Infect Dis 1995; 171:245.
  7. Coyle CM, Weiss LM, Rhodes LV 3rd, et al. Fatal myositis due to the microsporidian Brachiola algerae, a mosquito pathogen. N Engl J Med 2004; 351:42.
Adapted with special permission from: Treatment of microsporidiosis. In: Drugs for parasitic infections, 2nd Ed. New Rochelle, NY: The Medical Letter, Inc; 2010:44-45. www.medicalletter.org.
Additional content from: Centers for Disease Control. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR 2009; 58(RR-4):1-207. Available at: http://www.cdc.gov/mmwr/PDF/rr/rr5804.pdf.
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