Internal Medicine

0521779407-C03 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:54

366 Coccidioides Immitis

management

What to Do First

■Determine if therapy is warranted, attempt to confirm diagnosis with

tissue or good serology data. Obtain excellent travel/exposure his-

tory.

General Measures

■Establish extent of disease and risk of future complications.

■Prescribe antifungal agents where indicated, consider surgery for

debridement or reconstruction.

■In general population, complications uncommon

■Any risk factors (racial, immunosuppression, third trimester or

recent postpartum) should prompt antifungals.

specific therapy

Treatment Options

■Azole antifungals for mild/chronic disease – probably no efficacy

difference between fluconazole, itraconazole, ketoconazole – dura-

tions of 3–6 m

■Amphotericin B for severe disease

■Meningitis: fluconazole now used initially, shunting for hydro-

cephalus

Side Effects & Complications

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

ameliorated with hydrocortisone in IV bag), nephrotoxicity, hypo-

kalemia, hypomagnesemia, nephrotoxicity (can be dose-limiting)

■Azoles: transaminitis, many drug interactions

follow-up

During Treatment

■Close clinical follow-up, serial CXR, can follow serology titers

Routine

■Close clinical follow-up

complications and prognosis

Complications

■Pulmonary complications rare, can rupture a cavity causing pyop-

neumothorax

■Extrapulmonary disseminated disease, especially meningitis, bones/

joints