Treatment of Mildly Symptomatic Children with Acute Pulmonary Histoplasmosis
Most mildly symptomatic, immunocompetent children with acute pulmonary histoplasmosis do NOT require oral itraconazole, as the illness is self-limited and resolves within 3 weeks in approximately 95% of cases. 1
When Treatment is NOT Necessary
- Immunocompetent children with mild symptoms lasting less than 4 weeks do not require antifungal therapy. 1, 2
- In documented school outbreaks, illness resolved within 3 weeks in ≥95% of cases, with only 1-3.7% requiring hospitalization and minimal antifungal use. 1, 2
- The Infectious Diseases Society of America explicitly states that treatment is usually unnecessary for this population. 1
When to Initiate Itraconazole
Itraconazole (200 mg three times daily for 3 days, then 200 mg once or twice daily for 6-12 weeks) should be given only if symptoms persist beyond 1 month. 1, 2
For children, the dosing is 5.0-10.0 mg/kg daily in 2 divided doses, not to exceed 400 mg daily. 1
Additional Indications for Treatment in Children:
- Any immunocompromised child requires treatment regardless of symptom severity. 3
- Children receiving corticosteroids for inflammatory complications (such as pericarditis or mediastinal adenitis) must receive concurrent itraconazole to prevent progressive disseminated disease from corticosteroid-induced immunosuppression. 2, 4
- Symptoms of moderate-to-severe disease including respiratory distress, hypoxemia, or need for hospitalization warrant amphotericin B rather than itraconazole. 1, 4
Critical Distinction: Disseminated vs. Pulmonary Disease
The evidence provided in guidelines 1 primarily addresses disseminated histoplasmosis in HIV-infected or immunocompromised children, where itraconazole at 6-8 mg/kg/day for 3-12 months has been used effectively. 1 This is a fundamentally different clinical scenario than mild acute pulmonary disease in immunocompetent children.
Common Pitfalls to Avoid
- Do not treat based solely on positive antibody or antigen tests in minimally symptomatic children, as these may reflect past exposure rather than active disease requiring therapy. 2
- Do not confuse acute pulmonary histoplasmosis with chronic pulmonary or disseminated forms, which have different treatment indications and durations. 1
- Itraconazole capsules require high gastric acidity for absorption and should be taken with food or cola; avoid use in children taking antacids, H2 blockers, or proton pump inhibitors. 4
Monitoring if Treatment is Initiated
- Measure itraconazole blood levels after 2 weeks of therapy to ensure adequate drug exposure (target ≥1.0 mg/mL). 1, 4
- Check hepatic enzymes before starting therapy and at 1,2, and 4 weeks, then every 3 months during treatment. 2, 4
- Monitor for gastrointestinal side effects (nausea, vomiting), rash, and rare hematologic toxicity (thrombocytopenia, leukopenia). 1