Posaconazole for Chronic Refractory Coccidioidal Meningitis

Abstract

Coccidioidal meningitis is a potentially lethal infection. Disease progression while taking fluconazole is a common complication and safe, effective, alternative treatments are limited. Posaconazole therapy resulted in symptomatic and laboratory improvement in 2 patients and clinical improvement in a third patient with chronic, previously unresponsive coccidioidal meningitis.

Disseminated coccidioidomycosis presenting with intramedullary spinal cord abscesses: Management challenges

“…Current clinical practice guidelines address treatment of meningitis but there is limited data to guide management of spinal cord or refractory disease [9]. High dose fluconazole remains the primary treatment for meningitis while growing evidence supports the successful use of voriconazole and posaconazole for clinical failures [10], [11]. Intrathecal amphotericin has been used for coccidioidal meningitis though toxicity is significant.…”

Coccidioidomycosis

“…In patients failing high-dose fluconazole therapy, voriconazole has been used and has significant theoretical appeal as rescue therapy at a dose of 4 mg/kg every 12 h [72,73]. Posaconazole 400 mg twice daily has been also used in refractory cases [74]. Intrathecal amphotericin B was the primary therapy of central nervous system (CNS) coccidioidomycosis until supplanted by azole therapy.…”

Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Exposed and HIV-Infected Children

“…53 Some experts would begin at a dose of 15 to 23 mg/kg/day. 24 Successful therapy with posaconazole 54 and voriconazole has been described in adults but there is no published experience in children. 55 Some experts use amphotericin B administered intrathecally 50,56 in addition to an azole.…”

“…65 Posaconazole has also been effective for chronic refractory meningitis unresponsive to fluconazole. 54 Voriconazole was effective in treating coccidioidal meningitis and non-meningeal disseminated disease in adults who did not respond to fluconazole or were intolerant of amphotericin B. 66,67,68 Monotherapy with caspofungin successfully treated disseminated coccidioidomycosis in a renal transplant patient intolerant of fluconazole and other adults in whom conventional therapy failed.…”