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• Coccidioidomycosis Return to Top

• 1. Primary pulmonary infection

• 1.1 Indications for antifungal therapy

• Immunosupression (AIDS, therapy with high dose corticosteroids, receiptients of TNF-alpha, receiptients of an organ transplant)
• Diabetes
• Preexisting cardiomyopathy
• Pregnancy (third trimester)
• Filipino or African
• Weight loss of > 10%
• Intense night sweats persisting longer than 3 weeks
• Infiltrates involving more than one-half of one lung or portions of both lungs
• Prominent or persistent hilar adenopathy
• Anticoccidiodial complement-fixing antibody concentrations in excess of 1:16

• 1.2 Patients with low risk of complications or dissemination

• For many (if not most) patients, management may rely on periodic reassessment of symptoms and radiographic findings to assure resolution without antifungal treatment.

• 1.3 Patients with high risk of complications or dissemination

• 1.3.1 Mild to moderate pneumonia

• Preferred regimen (1): Itraconazole solution 200 mg PO bid or IV q12h
• Preferred regimen (2): Fluconazole 400 mg PO q24h for 3–12 months

• 1.3.2 Locally severe or disseminated pneumonia

• Preferred regimen: (Amphotericin B 0.6–1 mg/kg PO qd every 7 days THEN 0.8 mg/kg PO every other day OR Liposomal Amphotericin B 3-5 mg/kg IV q24 hrs OR Amphotericin B lipid complex 5 mg/kg IV q24 hrs until clinical improvement) followed by Itraconazole OR Fluconazole for at least 1 year.
• Note (1): Some use combination of Amphotericin B and Fluconazole for progressive severe disease; controlled series lacking.
• Note (2): Consultation with specialist recommendation, surgery may be required.

• 2. Meningitis

• 2.1 Adult

• Preferred regimen: Fluconazole 400–1,000 mg PO q24h indefinitely.
• Alternative regimen: Amphotericin B 3-5 mg/kg IV q24 hrs PLUS 0.1–0.3 mg qd intrathecal (intraventricular) via reservoir device OR Itraconazole 400–800 mg q24h OR Voriconazole
• Note: Some use combination of Amphotericin B and Fluconazole for progressive severe disease; controlled series lacking.

• 2.2 Child

• Preferred regimen: Fluconazole PO (Pediatric dose not established, 6 mg per kg q24h used)
• Alternative regimen: Amphotericin B 3-5 mg/kg IV q24 hrs PLUS 0.1–0.3 mg daily intrathecal (intraventricular) via reservoir device OR itra 400–800 mg q24h OR Voriconazole

• 3. Special considerations for HIV/AIDS patients

• 3.1 Clinically mild infections (e.g., focal pneumonia)

• Preferred regimen: Fluconazole 400 mg PO daily OR Itraconazole 200 mg PO bid
• Alternative regimen (unresponsive to Fluconazole or Itraconazole): Posaconazole 200 mg PO bid OR Voriconazole 200 mg PO bid
• Note: Itraconazole, posaconazole, and voriconazole may have significant interactions with certain antiretro viral agents. These interactions are complex and can be bi-directional

• 3.2 Severe, Non-Meningeal Infection

• 3.2.1 Preferred regimen in severe, Non-Meningeal Infection (Diffuse pulmonary infection or severely ill patients with extrathoracic, disseminated disease): Amphotericin B deoxycholate 0.7–1.0 mg/kg IV q12hrs OR Lipid formulation Amphotericin B 4–6 mg/kg IV q24hrs. Duration of therapy: continue until clinical improvement, then switch to an azole.
• 3.2.2 Alternative regimen in severe, Non-Meningeal Infection (Diffuse pulmonary infection or severely ill Patients with extrathoracic, disseminated disease): Some specialists will add a triazole (Fluconazole or Itraconazole, with Itraconazole (preferred for bone disease) 400 mg per day to Amphotericin B therapy and continue triazole once Amphotericin B is stopped
• Note (1): Therapeutic drug monitoring and dosage adjustment may be necessary to ensure triazole antifungal and antiretroviral efficacy and reduce concentration-related toxicities.
• Note (2): Therapy should be continued indefinitely in patients with diffuse pulmonary or disseminated diseases because relapse can occur in 25%–33% of HIV-negative patients. It can also occur in HIV-infected patients with CD4 counts >250 cells/μL

• 3.3 Meningeal Infections

• Preferred regimen: Fluconazole 400–800 mg IV or PO daily
• Alternative regimen: Itraconazole 200 mg PO tid for 3 days THEN 200 mg PO bid OR Posaconazole 200 mg PO bid OR Voriconazole 200–400 mg PO bid OR Intrathecal Amphotericin B deoxycholate when triazole antifungals are ineffective.
• Note (1): Intrathecal amphotericin B should only be given in consultation with a specialist and administered by an individual with experience with the technique.
• Note (2): Some patients with meningitis may develop hydrocephalus and require CSF shunting
• Note (3): Therapy should be lifelong in patients with meningeal infections because relapse occurs in 80% of HIV-infected patients after discontinuation of triazole therapy

• 3.4 Chronic Suppressive Therapy

• Preferred regimen: Fluconazole 400 mg PO daily (AII), or Itraconazole 200 mg PO BID
• Alternative regimen: Posaconazole 200 mg PO BID or Voriconazole 200 mg PO BID