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:::* 10.1 '''Moderately severe to severe disease'''
:::* 10.1 '''Moderately severe to severe disease'''
::::* Preferred regimen: Liposomal amphotericin B (3.0 mg/kg daily) is recommended for 1–2 weeks, followed by oral itraconazole (200 mg 3 times daily for 3 days and then 200 mg twice daily for a total of at least 12 months)
::::* Preferred regimen: Liposomal amphotericin B (3.0 mg/kg daily) is recommended for 1–2 weeks, followed by oral itraconazole (200 mg 3 times daily for 3 days and then 200 mg twice daily for a total of at least 12 months)
::::* Note: Substitution of another lipid formulation at a dosage of 5.0 mg/kg daily may be preferred in some patients because of                     cost or tolerability
::::* Note: Substitution of another lipid formulation at a dosage of 5.0 mg/kg daily may be preferred in some patients because of cost or tolerability
::::* Note (2): The deoxycholate formulation of amphotericin B (0.7–1.0 mg/kg daily) is an alternative to a lipid formulation in patients who are at a low risk for nephrotoxicity
::::* Note (2): The deoxycholate formulation of amphotericin B (0.7–1.0 mg/kg daily) is an alternative to a lipid formulation in patients who are at a low risk for nephrotoxicity
::::* 10.2 Immunosupressed patients (Immunosupression cannot be reversed)
::::* 10.2 Immunosupressed patients (Immunosupression cannot be reversed)

Revision as of 20:39, 24 July 2015

  • 1. Acute pulmonary histoplasmosis: [1]
  • 1.1 Moderate severe or severe
  • Preferred regimen: Lipid formulation of amphotericin B (3.0–5.0 mg/kg daily intravenously for 1–2 weeks) followed by itraconazole (200 mg 3 times daily for 3 days and then 200 mg twice daily, for a total of 12 weeks) is recommended.
  • Preferred regimen (2): The deoxycholate formulation of amphotericin B (0.7–1.0 mg/kg daily intravenously) is an alternative to a lipid formulation in patients who are at a low risk for nephrotoxicity (A-III)
  • Preferred regimen (3): Methylprednisolone (0.5–1.0 mg/kg daily intravenously) during the first 1–2 weeks of antifungal therapy is recommended for patients who develop respiratory complications, including hypoxemia or significant respiratory distress (B-III).
  • Note (1): In severe cases, cases accompanied by respiratory insufficiency, or hypoxemia, anecdotal reports [49] suggest that corticosteroid therapy may hasten recovery
  • Note (2): The pulmonary infiltrates should be resolved on the chest radiograph before antifungal therapy is stopped.
  • 1.2 Mild to Moderate:
  • Treatment is usually unnecessary
  • Patients who continue to have symptoms for >1 month: Itraconazole (200 mg 3 times daily for 3 days and then 200 mg once or twice daily for 6–12 weeks)
  • Note (1): Antifungal treatment is unnecessary in patients with mild symptoms caused by acute pulmonary histoplasmosis


  • 2. Chronic Cavitary Pulmonary Histoplasmosis:
  • Preferred regimen: Itraconazole (200 mg 3 times daily for 3 days and then once or twice daily for at least 1 year) is recommended
  • Note (1): Blood levels of itraconazole should be obtained after the patient has been receiving this agent for at least 2 weeks to ensure adequate drug exposure
  • Note (2): Patients with underlying emphysema often develop progressive pulmonary disease, which is characterized by cavities with surrounding inflammation, after infection with Hysotplasma capsulatum


  • 3. Pericarditis:
  • 3.2 Mild cases
  • Nonsteroidal anti-inflammatory therapy is recommended
  • 3.3 Patients with evidence of hemodynamic compromise or unremitting symptoms after several days of therapy with nonsteroidal anti-inflammatory therapy:
  • Prednisone (0.5–1.0 mg/kg daily [maximum, 80 mg daily] in tapering doses over 1–2 weeks)
  • 3.4 If corticosteroids are administered
  • Itraconazole (200 mg 3 times daily for 3 days and then once or twice daily for 6–12 weeks)
  • Note: Pericardial fluid removal is indicated for patients with hemodynamic compromise
  • Note: Pericarditis occurs as a complication of inflammation in adjacent mediastinal lymph nodes in patients with acute pulmonary histoplasmosis.


  • 4. Rheumatologic Syndromes
  • 4.1 Mild cases
  • Nonsteroidal anti-inflammatory therapy
  • 4.2 Severe cases
  • Preferred regimen: Prednisone (0.5–1.0 mg/kg daily [maximum, 80 mg daily] in tapering doses over 1–2 weeks)


  • 5. Mediastinal Lymphadenitis
  • 5.1 Treatment is usually unnecessary
  • 5.2 Patients who have symptoms that warrant treatment with corticosteroids and in those who continue to have symptoms for >1 month (B-III)
  • Itraconazole (200 mg 3 times daily for 3 days and then 200 mg once or twice daily for 6–12 weeks)
  • 5.3 Severe cases with obstruction or compression of contiguous structures
  • Preferred regimen: Prednisone (0.5–1.0 mg/kg daily [maximum, 80 mg daily] in tapering doses over 1–2 weeks)
  • Note: Antifungal treatment is unnecessary in most patients with symptoms due to mediastinal lymphadenitis
  • Note (2): Itraconazole is recommended for 6–12 weeks to reduce the risk of progressive disseminated disease caused by corticosteroid-induced immunosuppression in patients who are given corticosteroids and in patients whose symptoms last longer than 1 month.
  • 6. Mediastinal Granuloma
  • 6.1 Treatment is usually unnecessary
  • 6.2 Symptomatic cases
  • Preferred regimen: Itraconazole (200 mg 3 times daily for 3 days and then once or twice daily for 6–12 weeks)
  • Note: Itraconazole is appropriate for symptomatic cases, but there are no controlled trials to prove its efficacy.
  • Note (2): There is no evidence that mediastinal granuloma evolves into mediastinal fibrosis. Thus, treatment with either surgery or itraconazole should not be used to

prevent the development of mediastinal fibrosis


  • 7. Mediastinal Fibrosis
  • 7.1 Antifungal treatment is not recommended
  • 7.2 If clinical findings cannot differentiate mediastinal fibrosis from mediastinal granuloma
  • Preferred regimen: Itraconazole (200 mg once or twice daily for 12 weeks)
  • Note: The placement of intravascular stents is recommended for selected patients with pulmonary vessel obstruction
  • Note (2): Mediastinal fibrosis is characterized by invasive fibrosis that encases mediastinal or hilar nodes and that is defined by occlusion of central vessels and airways
  • 8. Broncholithiasis
  • 8.1 Antifungal treatment is not recommended
  • Bronchoscopic or surgical removal of the broncholith is recommended
  • 9. Pulmonary Nodules (Histoplasmomas)
  • Antifungal treatment is not recommended
  • Note: Lung parenchymal sites of infection may contract and then persist indefinitely as lung nodules or histoplasmomas....
  • 10. Progressive Disseminated Histoplasmosis
  • 10.1 Moderately severe to severe disease
  • Preferred regimen: Liposomal amphotericin B (3.0 mg/kg daily) is recommended for 1–2 weeks, followed by oral itraconazole (200 mg 3 times daily for 3 days and then 200 mg twice daily for a total of at least 12 months)
  • Note: Substitution of another lipid formulation at a dosage of 5.0 mg/kg daily may be preferred in some patients because of cost or tolerability
  • Note (2): The deoxycholate formulation of amphotericin B (0.7–1.0 mg/kg daily) is an alternative to a lipid formulation in patients who are at a low risk for nephrotoxicity
  • 10.2 Immunosupressed patients (Immunosupression cannot be reversed)
  • Lifelong suppressive therapy with itraconazole (200 mg daily)
  • 10.3 Mild to moderate disease
  • Itraconazole (200 mg 3 times daily for 3 days and then twice daily for at least 12 months)


  • Note (2):



  • 9.


References

  1. Galgiani JN, Ampel NM, Blair JE, Catanzaro A, Johnson RH, Stevens DA; et al. (2005). "Coccidioidomycosis". Clin Infect Dis. 41 (9): 1217–23. doi:10.1086/496991. PMID 16206093.