treat blastomycosis with amphotericin followed by itraconazole

Treatment of blastomycosis is based on severity and spread. For isolated pulmonary and skin disease with mild symptoms, oral therapy with itraconazole is recommended. For more severe symptoms—including any forms of ARDS or respiratory failure, bone disease, or central nervous system disease—lipid preparation amphotericin B is recommended for a minimum of 30 days. Transition to oral therapy with itraconazole can occur when improved (except for CNS-based disease).

Treatment for life-threatening blastomycosis, including ARDS, is liposomal amphotericin B until clinical improvement, then itraconazole for 6 to 12 months. For patients with severe pulmonary blastomycosis, such as ARDS, adjunctive corticosteroid treatment (prednisone 40-60 mg/day [or equivalent] for 1-2 weeks) should be considered. IV voriconazole can be used to treat invasive aspergillosis. Aspergillus species usually produce thin, septate, acute-angle branching hyphae, not seen in this case.

Although oral fluconazole may be used to treat mild cases of coccidioidomycosis (spherules, 10-100 µm, containing multiple endospores), cryptococcosis (oval yeasts, 5-10 µm, with narrow-based budding), or candidemia (3to 5-µm yeasts, often with pseudohyphae), it is not appropriate for life-threatening illness.

Oral itraconazole effectively treats mild cases of histoplasmosis (oval, 2-4 µm yeasts with narrow-based buds), coccidioidomycosis, cryptococcosis, aspergillosis, or blastomycosis but is not recommended for treatment of life-threatening illness.123

Footnotes

  1. SEEK Questionnaires ↩

  2. Guarner J, Brandt ME. Histopathologic diagnosis of fungal infections in the 21st century. Clin Microbiol Rev. 2011;24(2):247-280. PubMed ↩

  3. Limper AH, Knox KS, Sarosi GA, et al; American Thoracic Society Fungal Working Group. An official American Thoracic Society statement: treatment of fungal infections in adult pulmonary and critical care patients. Am J Respir Crit Care Med. 2011;183(1):96-128. PubMed ↩