0521779407-09 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:13
Histoplasma Capsulatum 721■Distinguish from other fungal lung infections (Cocci, Cryptococ-
cus), other chronic pneumonias (including mycobacterial disease,
PCP)management
What to Do first
■Establish diagnosis.
General Measures
■Consider category of disease and category of host before deciding
on treatment plan.specific therapy
■Acute Pulmonary Histoplasmosis
➣Majority of cases do not require therapy (normal hosts) – bed rest
and antipyretics
➣High inoculum or fevers >1 wk with respiratory compromise,
anorexia, malaise: treat
➣Itraconazole (oral suspension) 4–6 wks (can also consider IV
form)
➣Ketoconazole – more side effects
➣Amphotericin B for intolerance to oral meds or progressive dis-
ease
➣Fluconazole not as active
■Mediastinal Granuloma, Fibrosis, Histoplasmoma
➣Enlarged lymph nodes – only treat if mass effect, itra vs. Ampho
B
➣Fibrosis – no consensus, very difficult
➣Histoplasmoma – surgical resection vs. watchful waiting, con-
sider azole for 2–3 mo after surgery
■Cavitary Pulmonary Histoplasmosis
➣Thin-walled cavities: no intervention necessary
➣Thick-walled, progressive infiltrates, persistent cavities: Itra-
conazole or Ketoconazole for 6 mo
➣Amphotericin B for progression or severely immunocompro-
mised, total dose 2 g
■Acute Progressive Disseminated Histoplasmosis
➣Life-threatening: Amphotericin B, can change to itraconazole
when symptoms improve
➣Less severe illness: Itraconazole; AIDS: lifelong suppression with
itra
No role for caspofungin; posaconazole may be useful as salvage