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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, receiptients of TNF-alpha, receiptients 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 regimen: Oral azole antifungal agents at dosages of 200–400 mg qd. Courses of typically recommended treatment range from 3 to 6 months.

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

• 2.1 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
• 2.2 Preferred regimen in locally severe or disseminated disease: 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 (usually several weaks or longer in disseminated disease) 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.

• 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

• 3.Special considerations for HIV/AIDS patients

• 3.1 Focal Pneumonia
• 3.1.1 Preferred regimen in mild Infections: Fluconazole 400 mg PO daily OR Itraconazole 200 mg PO BID
• 3.1.2 Alternative regimen in mild infections for patients who failed to respond 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 ARV agents. These interactions are complex and can be bi-directional
• 3.2 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 qd Lipid formulation amphotericin B 4–6 mg/kg IV daily (AIII) Duration of therapy: continue until clinical improvement, then switch to an azole :::* 3.3 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: 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

• 3.4 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 (BII), or Posaconazole 200 mg PO BID (BIII), or Voriconazole 200–400 mg PO BID (BIII), or Intrathecal amphotericin B deoxycholate, when triazole antifungals are ineffective.
• Note (1): Some patients with meningitis may develop hydrocephalus and require CSF shunting
• Note (2): Therapy should be lifelong in patients with meningeal infections because relapse occurs in 80% of HIV-infected patients after discontinuation of triazole therapy
• 3.5 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

Duration of therapy: continue until clinical improvement, then switch to an azole (BIII)

• 2.2.1 Preferred regimen: Amphotericin B deoxycholate 0.7–1.0 mg/kg IV daily (AII)Lipid formulation amphotericin B 4–6 mg/kg IV daily (AIII) Duration of therapy: continue until clinical improvement, then switch to an azole (BIII)
• 2.2.2 Alternative regimen: 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
• 2.3 Meningeal Infections:
• Preferred regimen:

• 3. Meningingeal infections

• Preferrered regimen: Fluconazole 400–800 mg IV or PO daily
• Alternative regimen:

• Itraconazole 200 mg PO TID for 3 days, then 200 mg PO BID (BII), or

• Posaconazole 200 mg PO BID (BIII), or

• Voriconazole 200–400 mg PO BID (BIII), or

• Intrathecal amphotericin B deoxycholate, when triazole antifungals are ineffective (AIII):::* Chonic suppressive therapy: Fluconazole 400 mg PO daily (AII), or Itraconazole 200 mg PO BID

• 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.