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• Histoplasmosis Return to Top

• 1. Acute pulmonary histoplasmosis:

• 1.1 Moderate severe or severe

• Preferred regimen: Lipid formulation of amphotericin B (3.0–5.0 mg/kg daily intravenously for 1–2 weeks) followed by itraconazole (200 mg 3 times daily for 3 days and then 200 mg twice daily, for a total of 12 weeks) is recommended.
• Preferred regimen (2): The deoxycholate formulation of amphotericin B (0.7–1.0 mg/kg daily intravenously) is an alternative to a lipid formulation in patients who are at a low risk for nephrotoxicity (A-III)
• Preferred regimen (3): Methylprednisolone (0.5–1.0 mg/kg daily intravenously) during the first 1–2 weeks of antifungal therapy is recommended for patients who develop respiratory complications, including hypoxemia or significant respiratory distress (B-III).
• Note (1): In severe cases, cases accompanied by respiratory insufficiency, or hypoxemia, anecdotal reports [49] suggest that corticosteroid therapy may hasten recovery
• Note (2): The pulmonary infiltrates should be resolved on the chest radiograph before antifungal therapy is stopped.

• 1.2 Mild to Moderate:

• Treatment is usually unnecessary
• Patients who continue to have symptoms for >1 month: Itraconazole (200 mg 3 times daily for 3 days and then 200 mg once or twice daily for 6–12 weeks)
• Note (1): Antifungal treatment is unnecessary in patients with mild symptoms caused by acute pulmonary histoplasmosis

• 2. Chronic Cavitary Pulmonary Histoplasmosis:

• Preferred regimen: Itraconazole (200 mg 3 times daily for 3 days and then once or twice daily for at least 1 year) is recommended
• Note (1): Blood levels of itraconazole should be obtained after the patient has been receiving this agent for at least 2 weeks to ensure adequate drug exposure
• Note (2): Patients with underlying emphysema often develop progressive pulmonary disease, which is characterized by cavities with surrounding inflammation, after infection with Hysotplasma capsulatum

• 3. Pericarditis:

• 3.2 Mild cases

• Nonsteroidal anti-inflammatory therapy is recommended

• 3.3 Patients with evidence of hemodynamic compromise or unremitting symptoms after several days of therapy with nonsteroidal anti-inflammatory therapy:

• Prednisone (0.5–1.0 mg/kg daily [maximum, 80 mg daily] in tapering doses over 1–2 weeks)

• 3.4 If corticosteroids are administered

• Itraconazole (200 mg 3 times daily for 3 days and then once or twice daily for 6–12 weeks)
• Note: Pericardial fluid removal is indicated for patients with hemodynamic compromise
• Note: Pericarditis occurs as a complication of inflammation in adjacent mediastinal lymph nodes in patients with acute pulmonary histoplasmosis.

• 4. Rheumatologic Syndromes

• 4.1 Mild cases

• Nonsteroidal anti-inflammatory therapy

• 4.2 Severe cases

• Preferred regimen: Prednisone (0.5–1.0 mg/kg daily [maximum, 80 mg daily] in tapering doses over 1–2 weeks)

• 5. Mediastinal Lymphadenitis

• 5.1 Treatment is usually unnecessary
• 5.2 Patients who have symptoms that warrant treatment with corticosteroids and in those who continue to have symptoms for >1 month (B-III)
• Itraconazole (200 mg 3 times daily for 3 days and then 200 mg once or twice daily for 6–12 weeks)
• 5.3 Severe cases with obstruction or compression of contiguous structures
• Preferred regimen: Prednisone (0.5–1.0 mg/kg daily [maximum, 80 mg daily] in tapering doses over 1–2 weeks)
• Note: Antifungal treatment is unnecessary in most patients with symptoms due to mediastinal lymphadenitis
• Note (2): Itraconazole is recommended for 6–12 weeks to reduce the risk of progressive disseminated disease caused by corticosteroid-induced immunosuppression in patients who are given corticosteroids and in patients whose symptoms last longer than 1 month.

• 6. Mediastinal Granuloma

• 6.1 Treatment is usually unnecessary
• 6.2 Symptomatic cases
• Preferred regimen: Itraconazole (200 mg 3 times daily for 3 days and then once or twice daily for 6–12 weeks)
• Note: Itraconazole is appropriate for symptomatic cases, but there are no controlled trials to prove its efficacy.
• Note (2): There is no evidence that mediastinal granuloma evolves into mediastinal fibrosis. Thus, treatment with either surgery or itraconazole should not be used to prevent the development of mediastinal fibrosis