Coccidioidomycosis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: ; Vidit Bhargava, M.B.B.S [2]Aditya Ganti M.B.B.S. [3]


Antifungals are the mainstay of treatment. The drug therapy is guided by the severity of symptoms and the immune status of the patient. Since most patients are asymptomatic or mildly affected, no treatment or a single drug azole therapy (fluconazole or itraconazole) may be sufficient in these cases. More recently resistant cases are being treated with voriconazole or posaconazole.[1]. However, patients with HIV, immune-compromised, those on steroids or pregnant females need much more aggressive approach. More severe cases may require intravenous amphotericin B, with or without simultaneous oral azole therapy. Meningitis or vasculitis often need initial inpatient treatment with oral azoles plus intravenous amphotericin B with or without intrathecal amphotericin B. Untreated cases may sometimes be fatal.

Pregnant females are treated by Intravenous amphotericin B only.

Indications for antifungal therapy

Antimicrobial Regimen

  • 1. Primary pulmonary infection [2]
  • 1.1 Patients with low risk of complications or dissemination
  • For many (if not most) patients, management may rely on periodic reassessment of symptoms and radiographic findings to assure resolution without antifungal treatment.
  • A management plan that incorporates regular medical follow-up, health education, and a plan for physical reconditioning (strong, low)
  • 1.2 Patients with high risk of complications or dissemination
  • 1.2.1 Mild to moderate pneumonia
  • Preferred regimen (1): Itraconazole solution 200 mg PO bid or IV q12h
  • Preferred regimen (2): Fluconazole 400 mg PO q24h for 3–12 months
  • 1.2.2 Locally severe or disseminated pneumonia
  • 2. Meningitis[2]
  • 2.1 Adult
  • 2.2 Child
  • Preferred regimen: Fluconazole PO (Pediatric dose not established, 6 mg per kg q24h used)
  • Alternative regimen: Amphotericin B 3-5 mg/kg IV q24 hrs PLUS 0.1–0.3 mg daily intrathecal (intraventricular) via reservoir device OR Itraconazole 400–800 mg q24h OR Voriconazole
  • 3. Special considerations for HIV/AIDS patients[3]
  • 3.2 Severe, non-meningeal infection (diffuse pulmonary infection or severely ill patients with extrathoracic, disseminated disease)
  • Preferred regimen: Amphotericin B deoxycholate 0.7–1.0 mg/kg IV q12hrs OR Lipid formulation Amphotericin B 4–6 mg/kg IV q24hrs. Duration of therapy: continue until clinical improvement, then switch to an azole.
  • Alternative regimen: Some specialists will add a triazole (Fluconazole or Itraconazole, with Itraconazole (preferred for bone disease) 400 mg per day to Amphotericin B therapy and continue triazole once Amphotericin B is stopped
  • Note (1): Therapeutic drug monitoring and dosage adjustment may be necessary to ensure triazole antifungal and antiretroviral efficacy and reduce concentration-related toxicities.
  • Note (2): Therapy should be continued indefinitely in patients with diffuse pulmonary or disseminated diseases because relapse can occur in 25%–33% of HIV-negative patients. It can also occur in HIV-infected patients with CD4 counts >250 cells/μL
  • 3.3 Meningeal Infections
  • Preferred regimen: Fluconazole 400–800 mg IV or PO daily
  • Alternative regimen: Itraconazole 200 mg PO tid for 3 days THEN 200 mg PO bid OR Posaconazole 200 mg PO bid OR Voriconazole 200–400 mg PO bid OR Intrathecal Amphotericin B deoxycholate when triazole antifungals are ineffective.
  • Note (1): Intrathecal amphotericin B should only be given in consultation with a specialist and administered by an individual with experience with the technique.
  • Note (2): Some patients with meningitis may develop hydrocephalus and require CSF shunting
  • Note (3): Therapy should be lifelong in patients with meningeal infections because relapse occurs in 80% of HIV-infected patients after discontinuation of triazole therapy
  • 3.4 Chronic Suppressive Therapy


  1. Chen, S.; Erhart, LM.; Anderson, S.; Komatsu, K.; Park, B.; Chiller, T.; Sunenshine, R. (2011). "Coccidioidomycosis: knowledge, attitudes, and practices among healthcare providers--Arizona, 2007". Med Mycol. 49 (6): 649–56. doi:10.3109/13693786.2010.547995. PMID 21247229. Unknown parameter |month= ignored (help)
  2. 2.0 2.1 Galgiani JN, Ampel NM, Blair JE, Catanzaro A, Johnson RH, Stevens DA; et al. (2005). "Coccidioidomycosis". Clin Infect Dis. 41 (9): 1217–23. doi:10.1086/496991. PMID 16206093.
  3. "Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents" (PDF).

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