infectious diseases
Coccidioidomycosis
Treatment of Coccidioidomycosis
For mild to moderate disease,fluconazoleoritraconazole For severe disease,amphotericin B (See also Antifungal Medications .) Patients with primary coccidioidomycosis and Risk factors for coccidioidomycosis for severe or progressive disease should be treated. Treatment for primary coccidioidomycosis is controversial in low-risk patients. Some experts givefluconazolebecause its toxicity is low and because even in low-risk patients, there is a small risk of hematogenous seeding, especially to bone or brain. In addition, symptoms resolve more quickly in treated patients than in those who are not treated with an antifungal. Others think thatfluconazolemay blunt the immune response and that risk of hematogenous seeding in primary infection is too low to warrant use offluconazole. High complement fixation titers indicate spread and the need for treatment. Mild to moderate nonmeningeal extrapulmonary involvementshould be treated withfluconazoleoritraconazole.Voriconazoleorposaconazoledelayed-release tablets are alternatives but have not been well-studied. Forsevere illness,lipid formulations ofamphotericin Bare preferred over conventionalamphotericin B. Patients can usually be switched to an oral azole once they have been stabilized, usually within several weeks. Patients withHIV- or AIDS-associated coccidioidomycosisrequire maintenance therapy to prevent relapse;fluconazole200 mg orally once a day oritraconazole200 mg orally 2 times a day usually is sufficient, given until the CD4 cell count is > 250/mcL. In pregnant patients, triazole antifungals should be avoided in the first trimester because of the risk of teratogenicity. Women with mild-to-moderate disease in the first trimester typically do not require treatment. For women with severe or extrapulmonary disease in the first trimester, treatment withamphotericin Bis recommended. After the first trimester, an azole antifungal can be considered. Women who acquire infection in the second or third trimester or within 6 weeks postpartum are at risk of disease progression. If not treated, they should be monitored clinically and by checking serial complement fixation titers. ( Treatment reference ). Formeningeal coccidioidomycosis,fluconazoleis used. The optimal dose is unclear; oral doses of 800 to 1200 mg once a day may be more effective than 400 mg once a day. Patients should continue azole maintenance therapy for life because relapses are common and potentially fatal. Surgical removal of involved bone may be necessary to cure osteomyelitis. When residual cavitary pulmonary lesions cause hemoptysis or are likely to rupture, surgery may be necessary. 1.Galgiani JN, Catanzaro A, Cloud GA, et al: Comparison of oralfluconazoleanditraconazolefor progressive, nonmeningeal coccidioidomycosis. A randomized, double-blind trial. Mycoses Study Group.Ann Intern Med133(9):676–686, 2000. doi: 10.7326/0003-4819-133-9-200011070-00009 