Treatment of Penicillium Infection of the Bronchus

Voriconazole is the first-line treatment for tracheobronchial Penicillium infection, with amphotericin B formulations as alternative options. 1

Diagnosis and Assessment

Bronchoscopic evaluation is essential for accurate diagnosis of tracheobronchial fungal infections, as radiographic images may not identify the infection in its initial stages 1
Obtain sputum cultures and bronchoscopic samples to confirm Penicillium species and rule out other fungal pathogens 1, 2
High-resolution chest CT should be performed to assess the extent of infection and identify any invasive components 1

Voriconazole is the preferred systemic antifungal therapy for tracheobronchial Penicillium infection based on evidence from treatment of similar Aspergillus infections 1
The recommended dosing for voriconazole is a loading dose of 6 mg/kg IV every 12 hours for 1 day, followed by 4 mg/kg IV every 12 hours or 200 mg oral twice daily 1
Treatment duration should be at least 6-12 weeks, guided by clinical response, imaging findings, and microbiological results 3

Liposomal amphotericin B (LFAB) is recommended if a polyene is considered, particularly in transplant recipients on calcineurin inhibitors 1
Itraconazole can be considered as an alternative azole therapy, particularly for allergic bronchopulmonary disease caused by Penicillium 4, 2
Posaconazole or isavuconazole may be used as alternative options in cases of voriconazole intolerance 1, 3

Aerosolized amphotericin B (either deoxycholate or lipid formulation) may provide benefit for delivering high concentrations of polyene therapy to the infected site, though this approach remains investigational 1
Reduction of immunosuppression, where possible, is an important element in improving therapeutic outcome 1
For patients with bronchiectasis and concomitant Penicillium infection, airway clearance techniques should be optimized 5

Surgical resection of localized lesions may be beneficial in cases of persistent or progressive disease despite antifungal therapy 1
In patients with underlying chronic lung disease (such as COPD or bronchiectasis), treatment of the underlying condition is essential 3
For patients with allergic bronchopulmonary disease due to Penicillium, corticosteroids may be considered in addition to antifungal therapy 1, 3

Regular clinical assessment and radiological follow-up are essential to monitor treatment response 1
Therapeutic drug monitoring for voriconazole is recommended to ensure adequate serum levels while avoiding toxicity 1
Patients should be monitored for adverse effects of antifungal therapy, including hepatotoxicity, visual disturbances (with voriconazole), and nephrotoxicity (with amphotericin B) 1

Confirm diagnosis with bronchoscopy and culture/histopathology 1
Initiate voriconazole therapy as first-line treatment 1
For patients who cannot tolerate voriconazole or have treatment failure, switch to liposomal amphotericin B 1, 2
Consider adjunctive aerosolized amphotericin B for localized tracheobronchial disease 1
Continue treatment for at least 6-12 weeks, guided by clinical response 3
Consider surgical intervention for localized disease not responding to medical therapy 1

Penicillium species are often confused with Aspergillus in clinical specimens; accurate identification is important for targeted therapy 6, 7
Invasive infection due to Penicillium species (other than P. marneffei) is rare but can be fatal, especially in immunocompromised patients 2
Amphotericin B may be more effective than azoles for some Penicillium species, so treatment failure with azoles should prompt consideration of switching to amphotericin B 2
Drug interactions, particularly with voriconazole, should be carefully monitored, especially in transplant recipients on multiple medications 1