Histoplasmosis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Mild to moderate cases of acute pulmonary histoplasmosis will often resolve without treatment; however, treatment is indicated for moderate to severe acute pulmonary, chronic pulmonary, disseminated, and central nervous system (CNS) histoplasmosis.[1] Typical treatment of severe disease first involves treatment with amphotericin B, followed by oral itraconazole.[2] In many milder cases, simply itraconazole is sufficient. Asymptomatic disease is typically not treated. Past infection results in partial protection against ill effects if reinfected.
Medical Therapy
Antimicrobial Regimen
- Acute pulmonary histoplasmosis
- Moderately severe or severe
- Preferred regimen: Lipid amphotericin B (Lipid AmB) 3.0–5.0 mg/kg daily for 1–2 weeks OR Amphotericin B deoxycholate 0.7–1.0 mg/kg daily 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
- Note: Methylprednisolone 0.5–1.0 mg/kg daily IV during the first 1–2 weeks of antifungal therapy is recommended for patients who develop respiratory complications, including hypoxemia or significant respiratory distress.
- Mild to moderate
- Preferred regimen:
- For symptoms of <4 weeks, none
- For symptoms of >4 weeks, Itraconazole 200 mg PO 3 times daily for 3 days and then 200 mg once or twice daily for 6–12 weeks
- Chronic cavitary pulmonary histoplasmosis
- Preferred regimen: Itraconazole 200 mg PO 3 times daily for 3 days and then once or twice daily for at least 1 year
- Pericarditis
- Moderately severe to severe
- Preferred regimen(1): Prednisone 0.5–1.0 mg/kg daily (maximum, 80 mg daily) in tapering doses over 1–2 weeks
- Note(1): Itraconazole 200 mg PO 3 times daily for 3 days and then once or twice daily for 6–12 weeks is recommended if corticosteroids are administered
- Note(2): Tamponade requires drainage of pericardial fluid
- Note(3): Antifungal therapy is given to reduce possible dissemination caused by prednisone induced immunosuppression
- Mild
- Preferred regimen: Nonsteroidal anti-inflammatory agents
- Rheumatologic histoplasmosis
- severe
- Preferred regimen: Prednisone 0.5–1.0 mg/kg daily (maximum, 80 mg daily) in tapering doses over 1–2 weeks is recommended in severe cases
- Note: Itraconazole 200 mg 3 times daily for 3 days and then once or twice daily for 6–12 weeks is recommended if corticosteroids are administered
- Mild
- Preferred regimen: Nonsteroidal anti-inflammatory agents
- Note: Corticosteroids are rarely needed
- Mediastinal lymphadenitis
- Mild symptoms of <4 weeks
- Preferred regimen: None
- Symptoms of >4 weeks
- Preferred regimen: Itraconazole 200 mg 3 times daily for 3 days and then 200 mg once or twice daily for 6–12 weeks
- Symptoms warranting treatment
- Preferred regimen: Prednisone 0.5–1.0 mg/kg daily in tapering doses over 1–2 weeks AND Itraconazole 200 mg 3 times daily for 3 days and then 200 mg once or twice daily for 6–12 weeks
- Mediastinal granuloma
- Asymptomatic
- Preferred regimen: None
- Symptomatic
- Preferred regimen: Itraconazole 200 mg PO 3 times daily for 3 days and then 200 mg once or twice daily for 6–12 weeks
- Mediastinal fibrosis
- Preferred regimen: The placement of intravascular stents is recommended for selected patients with pulmonary vessel obstruction
- Note(1): Antifungal treatment is not recommended
- Note(2): Itraconazole 200 mg PO once or twice daily for 12 weeks is recommended if clinical findings cannot differentiate mediastinal fibrosis from mediastinal granuloma
- Broncholithiasis
- Preferred regimen: Antifungal treatment is not recommended
- Bronchoscopic or surgical removal of the broncholith is recommended
- Pulmonary Nodules (Histoplasmomas)
- Preferred regimen: Antifungal treatment is not recommended
- Note: Must be differentiated from malignancy
- Progressive disseminated histoplasmosis
- Moderately severe to severe
- Preferred regimen: Liposomal amphotericin B 3.0 mg/kg daily for 1–2 weeks, followed by Itraconazole 200 mg PO 3 times daily for 3 days and then 200 mg twice daily for a total of at least 12 months
- Alternative regimen: Amphotericin B deoxycholate 0.7–1.0 mg/kg daily for 1–2 weeks, followed by Itraconazole 200 mg PO 3 times daily for 3 days and then 200 mg twice daily for a total of at least 12 months
- Note: Longer treatment may be required in patients with persistent immunodeficiency
- Mild to moderate
- Preferred regimen: Itraconazole 200 mg PO 3 times daily for 3 days and then twice daily for at least 12 months.
- Note: Longer treatment may be required in patients with persistent immunodeficiency.
- CNS histoplasmosis
- Preferred regimen: Liposomal amphotericin B 5.0 mg/kg daily for a total of 175 mg/kg given over 4–6 weeks followed by Itraconazole 200 mg PO 2 or 3 times daily for at least 12 months and until resolution of CSF abnormalities, including Histoplasma antigen levels.
- Note: Blood levels of itraconazole should be obtained to ensure adequate drug exposure
References
- ↑ Information for Healthcare Professionals about Histoplasmosis. Centers for Disease Control and Prevention. 2015. Available at: http://www.cdc.gov/fungal/diseases/histoplasmosis/health-professionals.html. Accessed February 2, 2016.
- ↑ "Histoplasmosis: Fungal Infections: Merck Manual Home Edition".
- ↑ Parry WH, Martorano F, Cotton EK, Parry WH, Martorano F, Cotton EK (1976). "Management of life-threatening asthma with intravenous isoproterenol infusions". Am. J. Dis. Child. 130 (1): 39–42. PMID 2007.
- ↑ "www.idsociety.org" (PDF).