What is the treatment for coccidioidomycosis posadasii?

Treatment of Coccidioidomycosis Posadasii

For coccidioidomycosis caused by Coccidioides posadasii, oral azole therapy, particularly fluconazole at 400 mg daily, is the recommended first-line treatment for most clinical presentations. 1

Treatment Approach Based on Disease Presentation

Pulmonary Disease

• For uncomplicated pulmonary coccidioidomycosis, observation without antifungal therapy is often sufficient as most immunocompetent patients will recover spontaneously 1
• For symptomatic chronic cavitary coccidioidal pneumonia, fluconazole 400 mg daily for at least 1 year is recommended 1, 2
• For severe pulmonary disease, initial therapy with intravenous amphotericin B should be considered, with eventual transition to long-term azole therapy 3

Extrapulmonary Disease

• Antifungal therapy is recommended in all cases of extrapulmonary soft tissue coccidioidomycosis (strong recommendation) 1
• Oral azoles, particularly fluconazole or itraconazole at 400 mg daily, are the first-line therapy for extrapulmonary soft tissue infection 1
• For bone and joint coccidioidomycosis, azole therapy is recommended unless the patient has extensive or limb-threatening skeletal disease 1
• For severe osseous disease, amphotericin B is recommended as initial therapy, with eventual transition to long-term azole therapy 1

Special Populations

Immunocompromised Patients

• For HIV-infected patients with CD4+ counts <250 cells/μL, antifungal therapy is recommended for all coccidioidal infections 1
• Antifungal therapy should be continued as long as the CD4+ count remains <250 cells/μL 1
• For organ transplant recipients in endemic areas without active coccidioidomycosis, prophylactic fluconazole 200 mg daily for 6-12 months is recommended 1

Refractory Disease

• For cases refractory to standard therapy, posaconazole has shown a 73% success rate (complete or partial response) in patients who failed previous therapy with amphotericin B and/or other azoles 4
• Posaconazole should be considered as an important agent for treatment of refractory coccidioidomycosis 4

Treatment Duration

• For most forms of coccidioidomycosis, treatment should continue until resolution of all clinical and radiographic manifestations 2
• For chronic cavitary disease, treatment should continue for at least 1 year 2
• For meningeal disease, lifelong therapy is recommended due to high risk of recurrence 5

Monitoring During Treatment

• Serial monitoring of complement fixation titers and chest radiography is recommended until patients stabilize and symptoms resolve 6
• In patients treated with antifungals, complement fixation titers should be followed for at least two years 6

Common Pitfalls and Caveats

• Inadequate dosing (less than 400 mg daily) of fluconazole for severe disease may lead to treatment failure 2
• For coccidioidal cavities that persist >2 years despite antifungal treatment, surgical options should be considered 2
• The incidence of coccidioidomycosis is increasing in endemic areas, with expanding geographic distribution beyond traditional endemic regions 7
• Obtaining a travel history to endemic areas is critical for diagnosis, as no person-to-person transmission occurs 6

Risk Factors for Severe Disease

• Individuals with suppressed cellular immunity (HIV infection, immunosuppressive medications, solid organ transplant recipients) 8
• Pregnant women and African-American men have been identified as groups at increased risk for symptomatic and severe infection 8
• Non-Caucasian races, especially African Americans and Filipinos, have higher risk of disseminated disease 7