5-63
Subjective: Symptoms
Chronic, productive cough, +/- bloody sputum; shortness of breath; weight loss; painful mouth or nose ulcers;
hoarseness.
Focused History: Have you ever lived in or visited rural South America? (exposure) How long have you
been coughing? (usually >3 weeks)
Objective: Signs
Vital signs: Normal
Inspection: Ulcerative lesions of the face, mouth, larynx, or pharynx
Auscultation: Rales or decreased breath sounds in the middle or lower lung fields
Assessment:
Differential Diagnosis
Pulmonary disease - tuberculosis (usually have night sweats, no oral lesions), COPD (usually have smoking
history)
Mucocutaneous disease - leishmaniasis, leprosy, syphilis
Plan:
Treatment
Primary: Itraconazole 100-400 mg/day x 3-6 months.
Alternative: Sulfadiazine 4 gm/day for weeks to months, based on clinical response, then 2 gm/day for
3-5 years.
Other sulfa-based antibiotics can be used. Amphotericin B can be used in life-threatening and unresponsive
infections. Ketoconazole 200-400 mg/day and fluconazole 600 mg/day have also been used.
Patient Education
General: Disease is chronic and progressive if not treated
Activity: As tolerated
Diet: No limitations
Medications: Hypersensitivity rashes and bone marrow depression can complicate use of sulfa-based
drugs. See precautions listed for oral azoles (itraconazole, ketoconazole, fluconazole) and intravenous
amphotericin B in the Candidiasis section
No Improvement/Deterioration: Relapse is common. Follow up if disease worsens or recurs
Follow-up Actions
Wound Care: Local care (clean, dry, protect, use topical antibiotics) to prevent secondary bacterial infection.
Return evaluation: Patients should be seen routinely for years.
Consultation Criteria: Required for diagnosis and as clinically indicated.
NOTE: Paracoccidioidomycosis has a less common juvenile form which causes acute, progressive,
disseminated infection similar to acute disseminated histoplasmosis seen with AIDS and in younger
individuals.
ID: Introduction to Viral Infections
LTC Niranjan Kanesa-thasan, MC, USAViruses are minute nucleic acid-containing particles with an outer protein coat that are invisible under