What is the treatment for Penicillium species mold infection in the lungs?

Treatment of Penicillium Species Lung Infection

Initiate voriconazole or liposomal amphotericin B immediately at full therapeutic doses (not prophylactic doses) for suspected or confirmed Penicillium pulmonary infection, using the same dosing regimen as for proven invasive mold infections. 1

First-Line Antifungal Therapy

• Voriconazole or liposomal amphotericin B are the recommended first-line agents for Penicillium species lung infection, as recommended by the American College of Oncology 1
• Use full therapeutic dosing identical to that used for proven invasive mold infections—prophylactic doses are inadequate for active infection 1
• Do not delay treatment while awaiting culture confirmation in high-risk patients with compatible clinical and radiographic findings, as early treatment significantly improves survival 1

Patient Risk Stratification and Treatment Urgency

• Immunocompromised patients require immediate empiric mold-active therapy when pulmonary infiltrates are identified, including those with:
  • Neutropenia 1
  • Diabetes mellitus 1, 2
  • HIV infection 1
  • Corticosteroid therapy 1
• Febrile neutropenic patients with lung infiltrates not typical for bacterial pneumonia should receive prompt mold-active therapy, as delayed treatment worsens survival 1

Breakthrough Infection Management

• If breakthrough infection occurs while on azole prophylaxis, switch to liposomal amphotericin B rather than continuing or escalating the azole 1
• Measure antifungal drug levels in patients on azole prophylaxis who develop suspected breakthrough infection to ensure adequate treatment 1
• This approach is critical because azole resistance or inadequate drug levels may be contributing to treatment failure 1

Alternative Antifungal Options Based on Case Reports

While guidelines prioritize voriconazole and amphotericin B, case reports demonstrate successful outcomes with other agents in specific circumstances:

• Itraconazole successfully treated a case of P. digitatum pulmonary infection in a pregnant patient with COVID-19 co-infection 3
• Amphotericin B showed efficacy in a patient with chronic granulomatous disorder and Penicillium pulmonary infection 4
• Sequential therapy with fluconazole followed by caspofungin successfully treated a P. capsulatum fungus ball in a diabetic patient after surgical resection 2

However, these alternative agents should only be considered after consultation with infectious disease specialists, as the guideline-recommended first-line agents have stronger supporting evidence 1

Critical Management Considerations

• Assess clinical response daily during initial treatment, but do not repeat imaging earlier than 7 days after starting therapy, as radiographic improvement lags behind clinical improvement 1
• Maintain broad-spectrum antibacterial coverage alongside antifungal therapy because co-infections are common in these patients 1
• Consider surgical intervention when feasible, particularly for localized disease such as fungus balls, as surgery combined with antifungal therapy may improve outcomes 4, 2

Common Pitfalls to Avoid

• Never use prophylactic dosing for active infection treatment—therapeutic doses are required 1
• Do not continue the same azole if breakthrough infection occurs during azole prophylaxis; switch to a different class (amphotericin B) 1
• Do not wait for culture results before initiating therapy in high-risk patients with compatible clinical presentation 1
• Be aware that Penicillium species (excluding P. marneffei, now reclassified as Talaromyces marneffei) are rare causes of invasive infection, so ensure proper species identification through molecular methods when possible 3, 2