Successful Treatment of Disseminated Nonmeningeal Coccidioidomycosis with Voriconazole

Abstract

A 31-year-old Jamaican man with disseminated nonmeningeal coccidioidomycosis that involved the spine, ribs, pelvis, liver, and spleen did not clinically respond to a prolonged course of both amphotericin B deoxycholate and liposomal amphotericin B therapy. After institution of voriconazole monotherapy, the patient had a favorable (albeit slow) radiological and clinical response without adjunctive surgical intervention.Less than 1% of patients infected with Coccidioides immitis develop chronic pulmonary or disseminated coccidioidomycosis [1,2]. For patients unfortunate enough to develop disseminated coccidioidomycosis, successful management often requires a combined medical and surgical approach [3][4][5]. We report the case of an HIV-negative Jamaican man with severe disseminated nonmeningeal coccidioidomycosis who did not respond to amphotericin B therapy but appeared to clinically respond to voriconazole monotherapy without surgical intervention.Case report.On 19 March 2003, a previously healthy 31-yearold black Jamaican man incarcerated in Taft, California, was admitted to a local hospital with a nonproductive cough, shortness of breath, fever, chills, back pain, and a 9-kg weight loss over the preceding 2 months. A chest radiograph revealed diffuse pulmonary infiltrates. Coccidioidomycosis was diagnosed by histopathological examination of specimens obtained by transbronchial biopsy. The findings of an examination of a CSF sample were unremarkable. On 29 March 2003, after 5 days of antifungal therapy, a once-daily, 40-mg regimen of amphotericin B (∼1 mg/kg) was substituted for fluconazole.On day 24 of therapy, the patient was transferred to the Federal Medical Center and Saint Mary's Hospital in Rochester, Minnesota, for further management. He complained of fever, chills, night sweats, and neck pain. Physical examination revealed a small, cachectic-appearing man (weight, 44 kg) with tachycardia, bilateral basilar rales, tenderness to palpation along the cervical spine, and normal neurological findings.The findings of CT and MRI scans and microbiological studies confirmed disseminated coccidioidomycosis (figures 1-3). Multiple lesions were present in the lungs, liver, spleen, ribs, pelvis, left femur, and paraspinous and pelvic musculature. MRI of the head and spine revealed a right cerebellar infarct; an inflammatory mass encasing the right vertebral artery; extensive vertebral osteomyelitis with paravertebral abscesses at C4, C5, T2, and T4; epidural abscesses at T2, T8, and T9, causing spinal cord displacement; and paraspinous muscle abscesses at T7, T8, L5, S2, and S3.A second examination of CSF samples revealed a WBC count of !1 cell/mL, a glucose level of 61 mg/dL, and a total protein level of 30 mg/dL. Complement-fixation antibody titer to Coccidioides species was 1:2 in the CSF sample and 1:1024 in the serum sample. The patient's leukocyte count was 21,200 cells/ mL, with an erythrocyte sedimentation rate (ESR) of 102 mm/ h, an alkaline phosphatase level of 663 U/L, an alanine aminotransferase level of ...

Recent Advances in Our Understanding of the Environmental, Epidemiological, Immunological, and Clinical Dimensions of Coccidioidomycosis

“…After initiation of voriconazole at 400 mg twice daily, improvement was apparent; however, the patient required ventroperitoneal (VP) shunt placement and drainage of a thoracic intradural abscess (180). Subsequent reports support the use of voriconazole for salvage therapy of nonmeningeal coccidioidomycosis (181). From 2009 to 2011, there were two case series published that claimed a response in 6/7 and 14/21 patients treated with voriconazole (182,183).…”

Voriconazole Use for Endemic Fungal Infections

“…Furthermore, in vitro susceptibility to voriconazole was somewhat better than to itraconazole. Voriconazole has not been studied in an animal model of coccidioidomycosis, but it has been used successfully in a few patients (2,18,19).…”

“…18) with meningitis initially improved on voriconazole but died of recurrent disease when switched back to long-term fluconazole (which had previously failed to contain his infection). There are a few other case reports of successful treatment of coccidioidomycosis with voriconazole (2,7,18), including meningitis (7).…”

Treatment of fungal infections in adult pulmonary and critical care patients

“…Среди азоловых производных хорошо изучено действие при кокцидиомиозе кетоконазола, флюко назола и итраконазола. Эффективность вориконазо ла и позаконазола при кокцидиомикозе показана в небольших сериях наблюдений и отдельных случаях трудно поддающегося лечению кокцидиомикоза [18,[89][90][91]. Кетоконазол в терапии кокцидиомикоза почти полностью вытеснен флюконазолом и итра коназолом, причем последний более эффективен, чем флюконазол, при поражении костей и суставов (класс рекомендаций АI) [87].…”