What is the recommended treatment for coccidioides (Cocci) pleural infection?

Treatment of Coccidioidal Pleural Infection

For patients with coccidioidal pleural infection, the recommended treatment includes prompt surgical decortication with resection of the cavity when possible, combined with oral azole therapy such as fluconazole. 1

Surgical Management

• For patients with ruptured coccidioidal cavity causing pleural infection, prompt surgical decortication and resection of the cavity is strongly recommended as the primary intervention 1
• If the pleural space is massively contaminated, decortication combined with prolonged chest tube drainage may be more appropriate than immediate resection 1, 2
• When surgical management is undertaken, a video-assisted thoracoscopic surgery (VATS) approach should be attempted if the surgeon has significant expertise in VATS 1
• Surgical consultation should be obtained early in the course of treatment to assess the need for intervention 1

Antifungal Therapy

• Oral azole therapy is recommended for all patients with coccidioidal pleural infection 1, 3
• Fluconazole at doses of 400-800 mg daily is typically the first-line agent due to better tolerability and fewer drug interactions 1, 4
• For patients who do not tolerate oral azole therapy or whose disease requires two or more surgical procedures for control, intravenous amphotericin B is recommended 1, 3
• Treatment duration is typically prolonged, with a mean of 323 days at 200 mg fluconazole and 433 days at 400 mg in clinical studies 4

Special Considerations

• If the patient has concurrent extrapulmonary disease, treatment should be tailored to the most severe site of infection 1
• Itraconazole may be slightly more effective than fluconazole for skeletal coccidioidomycosis (63% vs 50% response rate at 8 months), which may influence treatment choice if there is bone involvement 5
• For immunocompromised patients, particularly those with HIV or transplant recipients, higher doses of antifungal therapy and longer duration of treatment may be necessary 1
• Monitoring of treatment response should include clinical assessment, imaging studies, and serologic testing 1

Treatment Algorithm

1. Initial Assessment:

   • Confirm diagnosis of coccidioidal pleural infection through culture or histopathology 1
   • Evaluate extent of disease with chest imaging (CT preferred) 2
   • Assess for extrapulmonary dissemination 1

2. Immediate Management:

   • Obtain surgical consultation for evaluation of decortication and cavity resection 1
   • Initiate oral fluconazole 400 mg daily (if normal renal function) 1
   • Consider amphotericin B for severely ill patients or those with rapidly progressive disease 3

3. Surgical Approach:

   • For localized disease: VATS decortication and resection 1
   • For extensive contamination: Decortication with prolonged chest tube drainage 1

4. Post-Surgical Management:

   • Continue oral azole therapy for at least 12 months 4
   • Monitor for treatment response with serial imaging and clinical assessment 1
   • Consider increasing fluconazole dose to 800 mg daily if inadequate response 5

Common Pitfalls and Caveats

• Relapse rates after discontinuation of therapy are high (18-37%), so extended treatment courses are often necessary 4, 5
• Surgical intervention should not be delayed, as ruptured cavities can lead to significant morbidity and mortality 1
• Drug interactions with azoles should be carefully monitored, particularly with immunosuppressants in transplant recipients 1, 6
• Patients may require lifelong suppressive therapy if they are immunocompromised or have recurrent disease 1
• Amphotericin B should be reserved for severe cases due to its significant toxicity profile 3