What is the recommended treatment for Valley fever?

Treatment of Valley Fever (Coccidioidomycosis)

Primary Treatment Decision: Observation vs. Antifungal Therapy

For immunocompetent patients with mild to moderate symptoms, antifungal therapy is not required—most infections resolve spontaneously without treatment. 1, 2

When to Withhold Antifungal Treatment

• Immunocompetent patients with mild disease should be managed with observation and symptomatic care only, as unnecessary antifungal treatment leads to adverse effects without clinical benefit 1, 2
• Patient education about expected disease course (fever typically lasting 10 days, fatigue being most persistent) and when to seek further care is essential for all patients 1, 3
• Symptoms typically appear 1-3 weeks after exposure and resolve spontaneously in most cases 3, 4

Indications Requiring Antifungal Therapy

Initiate treatment for:

• Severe primary pulmonary disease with significant symptoms 1, 2
• Patients at risk for dissemination (immunocompromised, pregnant, non-Caucasian races including African Americans and Filipinos, HIV, transplant recipients) 2, 5
• Disseminated disease (skin, bones/joints, central nervous system involvement) 2, 5
• Rapidly progressive disease 1, 2
• Failure to improve or worsening after initial observation period 6

First-Line Antifungal Treatment

Fluconazole is the standard first-line drug of choice for most cases requiring treatment. 1, 2, 4, 6

Fluconazole Dosing Algorithm

• Mild-moderate disease: 400 mg daily 1, 2
• Severe disease: 800 mg daily 1, 2
• Duration: 3-12 months typically, with monitoring until symptoms resolve and imaging stabilizes 6
• Coccidioidal meningitis requires lifetime treatment 6

Alternative Azole Therapy

• Itraconazole 200 mg twice daily may be more effective specifically for skeletal infections 1, 2
• Itraconazole is an acceptable alternative when fluconazole is contraindicated 6

Second-Line Treatment for Severe or Refractory Disease

Liposomal amphotericin B is recommended for:

• Critically ill patients 1, 2
• Rapidly progressive disease 1, 2
• Patients who fail to respond to azole therapy 1, 2
• Pregnancy (azoles are contraindicated) 4, 6

Monitoring During Treatment

• Monitor complement fixation titers and chest radiography periodically until patients stabilize and symptoms resolve 6
• In patients treated with antifungals, follow complement fixation titers for at least 2 years 6
• Erythrocyte sedimentation rate can be used to monitor improvement 3
• Clinical parameters (fever resolution, respiratory symptom improvement, fatigue) should be monitored regularly 1, 3

Surgical Intervention

Consider surgical intervention for persistent symptomatic cavities present for more than 2 years or when symptoms recur after stopping antifungal treatment. 1, 2

Critical Pitfalls to Avoid

• Do not delay treatment in high-risk patients while awaiting laboratory confirmation if clinical suspicion is high 2
• Do not prescribe antifungals for immunocompetent patients with mild disease—this causes harm without benefit 1, 2
• Do not discontinue monitoring too early—complement fixation titers must be followed for at least 2 years in treated patients 6
• Do not misdiagnose as bacterial pneumonia—obtain travel history to endemic areas (southwestern US, parts of Mexico, Central and South America) when evaluating community-acquired pneumonia 6, 5
• Do not use azoles during pregnancy—switch to liposomal amphotericin B 4, 6