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• Coccidioidomycosis Return to Top

• 1.Primary pulmonary infection in patients low risk persistence/complication: Antifungal treatment not generally recommended. Treat fever weight loss and/or fatigue.

1.1 Uncomplicated acute coccidioidal pneumonia 1.1.1 For many (if not most) patients, management may rely on periodic reassessment of symptoms and radiographic findings to assure resolution without antifungal treatment. 1.1.2 Indications for antifungal therapy:

• Immunosupression (AIDS,therapy with high-dose corticosteroids, receipt of TNF-alpha, receipt of an organ transplant)
• Diabetes
• Preexisting cardiomyopathy
• Pregnancy (third trimester)
• Filipino or african
• weight loss of 110%, 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,

1.1.3 Antifungal regimenes

• Preferred: oral azole antifungal agents at dosages of 200–400 mg per day. Courses of typically recommended treatment range from 3 to 6 months.

• 1.1 Primary pulmonary infection in patients with increased risk of complications or dissemination:

• Preferred regimen in mild to moderate disease: Itraconazole solution 200 mg PO bid or IV q12h Template:OR Fluconazole 400 mg PO q24h for 3–12 months
• Locally severe or disseminated disease: Amphotericin B 0.6–1 mg/kg per day by 7 days THEN 0.8 mg/kg every other day or liposomal amphothe B 3-5 mg/kg/d IV or ABLC 5 mg/kg/d IV, until clinical improvement (usually several wks or longer in disseminated disease), followed by itra or flu for at least 1 year.
• Note (1): Some use combination of Ampho B & Flu for progressive severe disease; controlled series lacking.
• Note (2): Consultation with specialist recommendation, surgery may be required.

• Meningitis:

• Adult:

• Preferred regimen: Fluconazole 400–1,000 mg po q24h indefinitely
• Alternative regimen: Amphotericin B IV as for pulmonary (above) + 0.1–0.3 mg daily intrathecal (intraventricular) via reservoir device Template:OR itra 400–800 mg q24h Template:OR Voriconazole
• Note (1): Some use combination of Amphotericin B and Flu for progressive severe disease; controlled series lacking.

• Child:

• Preferred regimen: Fluconazole PO (Pediatric dose not established, 6 mg per kg q24h used)
• Alternative regimen: Amphotericin B IV as for pulmonary (above) + 0.1–0.3 mg daily intrathecal (intraventricular) via reservoir device Template:OR itra 400–800 mg q24h Template:OR Voriconazole

• 2.Special considerations for HIV/AIDS patients

• 2.1 Focal Pneumonia
• 2.1.1 Mild Infections: Fluconazole 400 mg PO daily OR Itraconazole 200 mg PO BID
• 2.1.2 Severe Non-Meningeal Infection: Amphotericin B deoxycholate 0.7–1.0 mg/kg IV daily, Lipid formulation amphotericin B 4–6 mg/kg IV daily, Duration of therapy: continue until clinical improvement, then switch to an azole

• 2.2 Meningitis AIDS patients

• Preferrered regimen: Induction phase, Amphotericin B 0.7 mg/kg IV + flucytosine 25 mg/kg PO four times a day × 2 wks, then fluconazole 400 mg PO once daily × 8 wks, then 200 mg PO once daily until CD4 >200 × >6 mos.
• Note (1): Monitor 5-FC levels and CBC to avoid bone marrow suppression.

• Alternative regimen: Above without flucytosine, but need to treat for 4-6 wks of ampho B or 12 wks of fluconazole 1200 mg/day (especially if neutropenic).
• Fluconazole alternative: itraconazole (not as effective). Ampho B alternative liposomal AmB 4-6 mg/kg/day IV.
• Maintenance phase: fluconazole 200 mg PO once daily life long or discontinue maintenance fluconazole when CD4 >200 × 6 mos and completed 10 wks rx minimum and asymptomatic. CSF pressure OP > 250 mm H2O: remove CSF fluid until pressure drops 50%, then daily LP with same rule until OP <200 mm H2O.