Internal Medicine

0521779407-B01 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:52

Blastomyces Dermatitidis 245

differential diagnosis

■Distinguish from other fungal infections of the lung (Histo, Crypto-

coccus, Cocci)

■Distinguish from mycobacterial diseases of the lung, other chronic

pneumonias, pyogenic pneumonia, malignancy

■Skin disease similar to pyoderma gangrenosum, leishmaniasis, M

marinum infection, squamous cell carcinoma

management

What to Do First

■Establish diagnosis, differentiate from malignancy and other fungal

infections

General Measures

■Withholding therapy for acute pulmonary disease in normal host is

controversial

specific therapy

Treatment Options

■Itraconazole or ketoconazole or fluconazole for mild to moderate

pulmonary disease and mild to moderate non-CNS disseminated

disease, usually for at least 6 mo

■Amphotericin B for serious pulmonary, CNS disease, or serious non-

CNS disseminated disease, change to itraconazole after patient’s

condition has stabilized

Side Effects & Complications

■Amphotericin B (conventional): infusion-related toxicities (often

ameliorated with hydrocortisone in IV bag), nephrotoxicity,

hypokalemia, hypomagnesemia, nephrotoxicity (can be dose-

limiting)

■Azoles: transaminitis, many drug interactions

follow-up

During Treatment

■Close clinical follow-up

Routine

■Relapses can be common, close follow-up especially in first two years

after stopping azole therapy

■Consider long-term suppressive therapy in AIDS patients, other

severely immunosuppressed patients