Purpose: The incidence of coccidioidomycosis has increased markedly in recent years. Whereas the disease is typically considered endemic to places such as the southwestern United States, it may occur in people who have traveled to endemic areas. In certain cases, coccidioidomycosis can progress to life-threatening disseminated disease which can be difficult to control with available therapies. This case report describes the successful use of posaconazole (POS) suspension for the treatment of life-threatening, disseminated coccidioidomycosis refractory to standard antifungals like fluconazole. Clinical Problem: A 24-year-old pregnant woman was admitted to the hospital with pulmonary coccidioidomycosis. Despite 5 weeks of amphotericin B therapy (1 to 5 mg/kg/d), she remained persistently symptomatic with leukocytosis and tracheal aspirates repeatedly grew Coccidioides immitis. She experienced repeated episodes of hypoxemia requiring mechanical ventilation and hypotension requiring pressor therapy, developed multiple nosocomial infections, and experienced spontaneous termination of the pregnancy. Mechanical ventilation remained difficult, with the patient requiring high forced inspiratory oxygen and positive end-expiratory pressure, sedation, and paralysis to maintain oxygenation. Intravenous itraconazole (ITZ) 200 mg/d was added to the AMB therapy. No clinical improvement was noted; after 1 week of ITZ therapy, multiple vesicular lesions appeared on her neck and limbs, which grew C. immitis on biopsy. Clinical Approach: Because the patient’s coccidioidomycosis progressed to disseminated disease, indicating a failure of an adequate trial of AMB and ITZ therapy, treatment with POS suspension (400 mg bid) was initiated and administered with nutritional supplements through a feeding tube. AMB and ITZ were discontinued. Patient Outcome: After 1 week of POS therapy, the patient was hemodynamically stable and afebrile and a marked improvement in mechanical ventilation settings was noted. The patient was transitioned to continuous positive airway pressure ventilation on Day 28 of POS therapy. During the next month, leukocyte count steadily decreased, chest radiographs began to show improvement by Day 8 and the skin lesions resolved on Day 20 of POS therapy. The patient was switched to oral POS on Day 29. After a total of 38 days of POS suspension, the patient was transferred from the intensive care unit to inpatient rehabilitation. Conclusions: In this patient, POS 400 mg twice daily resulted in rapid resolution of symptoms associated with a potentially fatal case of disseminated coccidiodomycosis. Successful administration of posaconazole suspension via a feeding tube suggests the potential utility of posaconazole even in sedated or unconscious, critically ill patients who have functional GI tracts. This case is consistent with another preliminary clinical report, which provides additional evidence that POS is effective against C. immitis infections.
Full conference title:
The 15 th Congress of the International Society for Human and Animal Mycology
- ISHAM 15th (2003)