Treatment of Coccidioidomycosis

Patients with uncomplicated pulmonary coccidioidomycosis should have a management plan that incorporates regular medical follow-up, health education, and a plan for physical reconditioning. ( S , L)

The IDSA recommends patient education, close observation, and supportive measures such as reconditioning physical therapy for patients who appear to have mild or nondebilitating symptoms, or who have substantially improved or resolved their clinical illness by the time of diagnosis. ( S , L)

The IDSA recommends initiating antifungal treatment for patients who, at the time of diagnosis, have significantly debilitating illness ( S , L)

For patients at the time of diagnosis with extensive pulmonary involvement, with concurrent diabetes, or who are otherwise frail because of age or comorbidities, the IDSA recommends initiating antifungal treatment. Some experts would also include African or Filipino ancestry as indications for treatment ( S , L)

If treatment is begun in nonpregnant adults, the treatment should be an orally absorbed azole antifungal (eg, fluconazole) at a daily dose of ≥400 mg ( S , L)

Once there is confirmation that a pulmonary nodule is due to coccidioidomycosis, the IDSA recommends no antifungal treatment for an asymptomatic pulmonary nodule due to coccidioidomycosis. ( S , VL)

The IDSA recommends against the use of antifungal therapy for patients with an asymptomatic cavity. ( S , L)

The IDSA recommends that patients with symptomatic chronic cavitary coccidioidal pneumonia be treated with an oral agent such as fluconazole or itraconazole ( S , M)

The IDSA recommends that surgical options be explored when the cavities are persistently symptomatic despite antifungal treatment. The IDSA recommends that surgical options be considered when cavities have been present for >2 years and if symptoms recur whenever antifungal treatment is stopped. ( S , VL)

The IDSA recommends that when surgical management of cavitary coccidioidal pneumonia is undertaken, a video-assisted thoracoscopic surgery (VATS) approach be attempted if the surgeon has significant expertise in VATS. ( S , L)

For patients with ruptured coccidioidal cavities, oral azole therapy is recommended. For patients who do not tolerate oral azole therapy or patients whose disease requires 2 or more surgical procedures for control, intravenous AmB is recommended. ( S , VL)

The IDSA recommends antifungal therapy in all cases of extrapulmonary soft tissue coccidioidomycosis. ( S , M)

The IDSA recommends oral azoles, in particular fluconazole or itraconazole, for first-line therapy of extrapulmonary soft tissue coccidioidomycosis. ( S , M)

The IDSA recommends intravenous AmB in cases of azole failure, particularly in coccidioidal synovitis. ( S , M)

The IDSA recommends azole therapy for bone and joint coccidioidomycosis, unless the patient has extensive or limb-threatening skeletal or vertebral disease causing imminent cord compromise. ( S , L)

For severe osseous disease, the IDSA recommends AmB as initial therapy, with eventual change to azole therapy for the long term. ( S , L)

The IDSA recommends surgical consultation for all patients with vertebral coccidioidal infection to assist in assessing the need for surgical intervention. ( S , L)

Surgical procedures are recommended in addition to antifungal drugs for patients with bony lesions that produce spinal instability, spinal cord or nerve root compression, or significant sequestered paraspinal abscess. ( S , L)

The IDSA recommends that surgical consultation be obtained periodically during the course of medical treatment. ( S , L)

In patients with recently diagnosed coccidioidal infection, the IDSA recommends lumbar puncture with cerebrospinal fluid analysis only in patients with unusual, worsening, or persistent headache, with altered mental status, unexplained nausea or vomiting, or new focal neurologic deficit after adequate imaging of the central nervous system (CNS). ( S , M)

For coccidioidal meningitis (CM), the IDSA recommends fluconazole 400–1200 mg orally daily as initial therapy for most patients with normal renal function. ( S , M)

For CM, the IDSA recommends azole treatment for life. ( S , M)

In patients with CM who clinically fail initial therapy with fluconazole, higher doses are a first option. ( S , M)

For patients with increased intracranial pressure (ICP) at the time of diagnosis, the IDSA recommends medical therapy and repeated lumbar punctures as initial management. ( S , L)

Because most patients who develop ICP will not resolve this problem without placement of a permanent shunt, the IDSA recommends early magnetic resonance imaging (MRI) of the brain and neurosurgical consultation. ( S , M)

In patients with CM who initially respond to a treatment plan and while on therapy develop acute or chronic neurologic changes, the IDSA recommends that repeat MRI of the brain and possibly the spinal cord, with and without contrast, as well as spinal fluid analysis be obtained either from a lumbar or cisternal aspiration. ( S , L)