amphotericin-b and Coccidioidomycosis

Coccidioidomycosis is a fungal infection endemic to the southwestern United States and regions of Latin America. Disseminated disease occurs in < 1% of cases. Septic shock is even rarer, with high mortality despite therapy. We describe two cases of coccidioidal septic shock. Both patients were older men of Filipino ancestry presenting with respiratory failure and vasopressor-dependent shock. Antifungal drugs were initiated after failure to improve with empiric antibiotics; in both, Coccidioides was isolated from respiratory cultures. Despite aggressive care, both patients ultimately died of their infections. We provide a review of the published literature on this topic.. Most of the 33 reported cases of coccidioidal septic shock occurred in men (88%) of non-white race and ethnicity (78%). The overall mortality rate was 76%. All survivors received amphotericin B as part of their treatment. Coccidioidomycosis-related septic shock is a rare disease with poor outcomes; delays in diagnosis and treatment are common. Improved diagnostic testing for coccidioidomycosis could enhance recognition of this disease in the future. Although data are limited, early treatment with amphotericin B in cases of coccidioidal septic shock may reduce mortality.

Topics: Aged; Amphotericin B; Antifungal Agents; Coccidioides; Coccidioidomycosis; Humans; Male; Shock, Septic

The recorded history of coccidioidomycosis began in 1892 with the report of the illness of Domingo Escurra by Alejandro Posadas followed by a description of the first North American cases by Rixford and Gilchrist. Originally considered a protozoan, William Ophüls determined that Coccidioides was a fungus and that the lungs were the apparent initial site of infection. During the 1930s, both Gifford and Dickson determined that a self-limited illness, Valley Fever, was caused by the same fungus that caused the often fatal coccidioidal granuloma. Charles Smith, over a period of approximately 2 decades, comprehensively described the clinical and geographic epidemiology of coccidioidomycosis in California. Demosthenes Pappagianis continued this work after Smith's death. In 1957, one year before Marshall Fiese published his masterful monograph on coccidioidomycosis, the use of the first effective agent for the therapy of coccidioidomycosis, amphotericin B, was reported. This was followed by descriptions of its appropriate clinical use by William Winn and by Hans Einstein, among others. The development of the much less toxic azole antifungal agents greatly simplified therapy in many cases, but much of the management of patients with coccidioidomycosis still relies more on art than science. The search for the "Holy Grail" - a vaccine capable of preventing this disease-continues.

Topics: Amphotericin B; Antifungal Agents; Coccidioides; Coccidioidomycosis; History, 19th Century; History, 20th Century; Humans

This article summarizes the diagnosis and treatment of coccidioidal meningitis (CM) and its complications. An overview of current and prospective pharmacologic treatment options and monitoring parameters is provided. A consensus has not been reached regarding universally accepted therapeutic serum levels for azoles because of insufficient evidence. We describe the preferred therapeutic drug level ranges that our institution uses to monitor azole therapy.. Ho et al. described the preparation and administration of intrathecally delivered amphotericin B deoxycholate. Thompson et al. described possible benefits of controversial adjuvant corticosteroid therapy for secondary prevention of vasculitic infarction secondary to CM. CM was universally fatal until the advent of intrathecal amphotericin B deoxycholate therapy, the introduction of which changed the natural history of the disease in much the same way as penicillin changed the natural history of bacterial meningitis. Although there was still significant morbidity, survival rates drastically increased to approximately 70%. The introduction of azole therapy has decreased the side effects and burden of treatment but without a significant change in CM-related mortality and morbidity compared with the use of intrathecal amphotericin B deoxycholate therapy.

Topics: Amphotericin B; Antifungal Agents; Coccidioides; Coccidioidomycosis; Cognitive Dysfunction; Deoxycholic Acid; Disease Management; Drug Combinations; Humans; Hydrocephalus; Injections, Spinal; Meningitis; Prospective Studies; Treatment Outcome

Coccidioidal meningitis (CM) is a devastating complication of coccidioidomycosis. Since the late 1950s, intrathecal (IT) amphotericin B deoxycholate (AmBd) has been successfully used to treat and often cure this disease, reducing mortality rates from 100% to approximately 30%. The introduction of azoles further revolutionized the treatment of coccidioidal infections. However, IT AmBd remains the only known curative option in the management of CM. While the use of IT AmBd is well described in many articles, few discuss the actual methods behind preparation, titration, and dosing strategies utilized. The practitioners at Kern Medical (Bakersfield, California) have >60 years of experience in the utilization of IT AmBd and the treatment of CM. This article describes the practice experience in the treatment of CM, preparation of IT AmBd, and the different dosing strategies used in regard to route of administration (ie, cisternal, lumbar, ventricular).

Topics: Amphotericin B; Antifungal Agents; Coccidioidomycosis; Humans; Injections, Spinal; Meningitis

Granulomatous diseases are caused by multiple infectious and noninfectious causes. Deep fungal infections can present in the skin or extracutaneously, most commonly with lung manifestations. An Azole or amphotericin B is the universal treatment. Blastomycosis-like pyoderma is a clinically similar condition, which is caused by a combination of hypersensitivity and immunosuppression. Successful treatment has been reported with antibiotics and, more recently, the vitamin A analog, acitretin. Granuloma inguinale and lymphogranuloma venereum cause ulcerative genital lesions with a granulomatous appearance on histology. The Centers for Disease Control and Prevention recommens treatment of these genital infections with doxycycline.

Topics: Acitretin; Amphotericin B; Anti-Bacterial Agents; Antifungal Agents; Azoles; Blastomycosis; Coccidioidomycosis; Cryptococcosis; Dermatomycoses; Doxycycline; Granuloma Inguinale; Histoplasmosis; Humans; Keratolytic Agents; Lymphogranuloma Venereum; Mycoses; Pyoderma; Sexually Transmitted Diseases; Sporotrichosis

We report a case of Coccidioidomycosis of the cranium that presented as a cystlike structure with adjoining bone destruction in a 40-year-old patient with underlying rheumatoid arthritis that was treated with a combination of lipid amphotericin B and longterm fluconazole. We also discuss the common risk factors and presentations of this unusual extra-pulmonary form of Coccidioidomycosis.

Topics: Adult; Amphotericin B; Antifungal Agents; Arthritis, Rheumatoid; Coccidioides; Coccidioidomycosis; Drug Therapy, Combination; Female; Fluconazole; Humans; Osteomyelitis; Radiography; Risk Factors; Skull

Topics: Adolescent; Adult; Amphotericin B; Antifungal Agents; Child; Child, Preschool; Coccidioides; Coccidioidomycosis; Colon; Cryptococcosis; Cryptococcus; Duodenal Ulcer; Endemic Diseases; Female; Histoplasma; Histoplasmosis; Humans; Itraconazole; Job Syndrome; Male; Middle Aged; Mutation; STAT3 Transcription Factor; Treatment Outcome; Triazoles; United States

We describe a possible imported case of osteo-articular coccidioidomycosis in India. Culture of the computed tomography-guided aspirate revealed the growth of Coccidioides spp., which was identified as Coccidioides posadasii by sequencing of the internal transcribed spacer (ITS) region of rDNA. He was successfully treated with amphotericin B followed by itraconazole. All the previous published reports of coccidioidomycosis cases diagnosed in India are also reviewed in order to increase the awareness of this disease in non-endemic areas.

Topics: Adult; Amphotericin B; Antifungal Agents; Biopsy, Fine-Needle; Coccidioides; Coccidioidomycosis; Diagnosis, Differential; Humans; India; Itraconazole; Male; Tomography, X-Ray Computed; Treatment Outcome; Tuberculosis

Topics: Amphotericin B; Antifungal Agents; Back Pain; Coccidioidomycosis; Diagnosis, Differential; Female; Follow-Up Studies; Fungemia; Humans; Itraconazole; Magnetic Resonance Imaging; Middle Aged; Osteomyelitis; Physical Examination; Severity of Illness Index; Spinal Diseases; Thoracic Vertebrae; Treatment Outcome

The perceptions of coccidioidomycosis as a medical problem has undergone sequential and dramatic metamorphoses since its first description more than a century ago. First thought to be rare and lethal, coccidioidomycosis was subsequently found to be common and often mild. During World War II, its overall impact upon large populations came sharply into focus and the consequences for public health became clearer. Early treatments had significant limitations and toxicities, and therefore treatment of coccidioidomycosis was reserved for only the sickest patients. Since then, safer oral therapies have become commonplace. Despite their availability, there has been no investigation of their use in the less severe and much more common early infections. Even newer drugs such as nikkomycin Z, which might actually cure infections, until very recently have had trouble finding a sponsor to move it through clinical trials. Perceptions once formed by the understanding of coccidioidomycosis as a medical problem now appear to hinder the future study of newer therapeutic opportunities. It is suggested in this review that it is time to revisit and possibly change these perceptions if we are to improve our care of patients.

Topics: Administration, Oral; Aminoglycosides; Amphotericin B; Antifungal Agents; Attitude to Health; Coccidioidomycosis; Granuloma; Humans; Miconazole; Perception; Public Health

Coccidioidomycosis is a recognized opportunistic infection in those with HIV-1 infection. The major risk factor is immunodeficiency, particularly when the peripheral blood CD4 T lymphocyte count is below 250/muL. There are many manifestations of coccidioidomycosis during HIV-1 infection, including diffuse, reticulonodular pneumonia, focal primary pneumonia, and disease disseminated beyond the thoracic cavity. Diagnosis is based on serology, culture and histopathologic identification. Two therapeutic modalities are currently available, the polyene antifungal amphotericin B and the triazole antifungals. Of the latter, the most experience is with the triazoles fluconazole and itraconazole. There are increasing data regarding drug interactions between triazoles and antiretroviral agents. The duration of treatment of coccidioidomycosis in those with HIV-1 infection is not established and in many patients it is either prolonged or life-long. Adherence to antiretroviral therapy is important in preventing recurrence.

Topics: Amphotericin B; Antifungal Agents; CD4-Positive T-Lymphocytes; Coccidioidomycosis; HIV Infections; HIV-1; Humans; Patient Compliance; Recurrence; Triazoles

Coccidioidal meningitis affects between 200 to 300 persons annually within the endemic area of the United States, with much larger numbers expected in epidemic years. Because this represents a chronic disease for survivors, several thousand patients may be under treatment at any given time. Epidemiology, background, and diagnosis are reviewed. Azole therapy has replaced intrathecal amphotericin B for induction and maintenance therapy for this disease, given its ease of administration and equivalent efficacy in controlling infection even at the cost of losing the opportunity for cure. Both itraconazole and fluconazole have demonstrated efficacy, but have not been compared in randomized human studies. One of the uses of intrathecal amphotericin B is as "add on" therapy in failing azole regimens without evidence of antagonism. Details of therapeutic approach are reviewed. Approach to diagnosis and management of the two principal potentially life threatening complications, hydrocephalus and vasculitis, is also discussed.

Topics: Amphotericin B; Antifungal Agents; Coccidioidomycosis; Comorbidity; Fluconazole; Humans; Hydrocephalus; Itraconazole; Meningitis, Fungal; Treatment Outcome; Vasculitis

Prior to the 1950s no effective therapy for coccidioidomycosis existed. The advent of amphotericin B ushered in the therapeutic era for coccidioidomycosis. Until this time amphotericin B and its lipid congeners have been regarded as the "gold standard" of therapy for severe pulmonary and disseminated coccidioidomycosis. The availability of azoles and later triazoles for the past three decades have relegated the amphotericins into a rescue mode, used mainly in widely disseminated cases, azole intolerance, or when there are contraindications to Azoles, such as pregnancy. In meningitis the intrathecal use of amphotericin B is still used frequently by some clinicians alone or with a triazole. The newer lipid preparations, while more expensive, have significantly reduced toxicity, particularly nephropathy.

Topics: Amphotericin B; Antifungal Agents; Coccidioides; Coccidioidomycosis; Deoxycholic Acid; Drug Combinations; Female; Humans; Kidney Diseases; Lipids; Meningitis; Pregnancy; Treatment Outcome; Triazoles

Coccidioidomycosis is an uncommon fungal infection during pregnancy. We report a case and review the literature on coccidioidomycosis in pregnancy.. We searched MEDLINE (1966-2005), PubMed (1950-2005), Embase (1974-2005), the Cochrane Library, and the Index-Catalogue of the Library of the Surgeon-General's Office United States Army (1880-1961) for cases of coccidioidomycosis occurring during pregnancy. We describe a woman with disseminated coccidioidomycosis during the last trimester of pregnancy with fungemia, respiratory failure, a miliary pattern on chest radiograph, and skin and bony involvement.. We identified 80 additional cases of coccidioidomycosis occurring with pregnancy in the literature. The mean age of patients was 26 years (range 16-38 years). Disseminated disease was strongly associated with the trimester of pregnancy; 40% of the cases diagnosed before pregnancy, 50% of the cases diagnosed in the first trimester, 62% of the cases diagnosed in the second trimester, and 96% of the cases diagnosed in the third trimester had dissemination (P<.001). In addition, African American women had a 13-fold increased risk of dissemination compared with white women (P=.007).. Mortality rates have improved over time in association with the timely administration of antifungal therapy. Disseminated coccidioidomycosis may occur during pregnancy, especially during the third trimester. Improved maternal and fetal survival is associated with early disease recognition and administration of amphotericin B.

Topics: Adolescent; Adult; Amphotericin B; Antifungal Agents; Black or African American; Coccidioides; Coccidioidomycosis; Female; Fungemia; Humans; Male; Pregnancy; Pregnancy Complications, Infectious; Pregnancy Outcome; Pregnancy Trimesters; Severity of Illness Index; Treatment Outcome; United States; White People

Coccidioidal meningitis is lethal in the absence of treatment. The advent of the azoles has not led to cure, causing many clinicians to revert to intra-cerebrospinal fluid (CSF) amphotericin as part of the treatment regimen, desiring the influence of the latter regimen's ability to clear infection more completely and rapidly. Intra-CSF amphotericin therapy is, however, far more toxic than oral azoles and requires much more clinical management to achieve success and avoid toxicity. This management task increasingly, for insurance reasons or geographic reasons, falls on clinicians unfamiliar with the disease. We delineate our experience in the medical and surgical management of this form of therapy, including procedural details that we have found useful, for the benefit of our colleagues who may wish to use them. As ours is a teaching institution, we have found this material also useful for physicians in training, who are learning about the treatment of these patients.

Topics: Amphotericin B; Antifungal Agents; Coccidioidomycosis; Humans; Injections, Spinal; Instillation, Drug; Meningitis, Fungal

Endemic mycoses remain a major public health problem in several countries and they are becoming increasingly frequent with the spread of HIV infection. Amphotericin B remains the drug of choice during the acute stage of life-threatening endemic mycoses occurring in both immunocompetent and immunocompromised hosts. Ketoconazole is effective in non-AIDS patients with non-life-threatening histoplasmosis, blastomycosis, or paracoccidioidomycosis. Itraconazole is the treatment of choice for non-life-threatening Histoplasma capsulatum or Blastomyces dermatitidis infections occurring in immunocompetent individuals and is the most efficient secondary prophylaxis of histoplasmosis in AIDS patients. Itraconazole is also effective in lymphocutaneous and visceral sporotrichosis, in paracoccidioidomycosis, for Penicillum marneffei infection, and is an alternative to amphotericin B for Histoplasma duboisii infection. Coccidioidomycosis may be effectively treated with prolonged and sometimes life-long itraconazole or fluconazole therapy. Fluconazole has relatively poor efficacy against histoplasmosis, blastomycosis and sporotrichosis. New antifungal agents have been tested in vitro or in animal models and may soon be evaluated in clinical trials.

Topics: AIDS-Related Opportunistic Infections; Amphotericin B; Blastomycosis; Coccidioidomycosis; Histoplasmosis; Humans; Mycoses; Paracoccidioidomycosis; Sporotrichosis

The so-called exotic pulmonary mycoses are imported diseases in France. They are infrequent or exceptional and for this reason can be underdiagnosed or recognized with delay. Nevertheless, they are easily treatable infections with available antifungal agents. As a rule, the site of primary infection is the lung with ensuing clearance or chronic local infection and/or dissemination. Immunocompromised hosts are more prone to develop severe forms or reactivation of the disease.

Topics: AIDS-Related Opportunistic Infections; Amphotericin B; Anti-Infective Agents; Antifungal Agents; Blastomycosis; Coccidioidomycosis; Diagnosis, Differential; Histoplasmosis; Humans; Itraconazole; Ketoconazole; Lung Diseases, Fungal; Paracoccidioidomycosis; Penicillium; Sporotrichosis; Sulfadiazine; Travel; Trimethoprim, Sulfamethoxazole Drug Combination

Sixteen patients with spinal infection from Coccidioides immitis were treated. Lesion location was cervical in two, thoracic in four, lumbar in six, sacroiliac joint in one, and disseminated spinal in three. The neurological status was intact in 11 patients. One patient had incomplete quadriplegia, three patients had incomplete paraplegia, and a fifth patient had a lumbar root lesion. Treatment was medical only in 4 patients (one of whom required surgery 2 years later) and combined medical and surgical in 13 patients. All patients received amphotericin B intravenously. Follow-up averaged 24 months in 15 patients (range, 12-42 months). The outcome in four patients treated medically alone was one death, one remission, one relapse with disease progression, and one without follow-up. The outcome in the combined medical and surgical group was nine fusions, one pseudarthrosis, and three lesional excisions, all with remission. Successful treatment outcome is disease arrest, as opposed to "cure."

Topics: Adult; Aged; Amphotericin B; Antifungal Agents; California; Cervical Vertebrae; Coccidioidomycosis; Combined Modality Therapy; Debridement; Discitis; Disease Outbreaks; Female; Follow-Up Studies; Humans; Internal Fixators; Lumbar Vertebrae; Lung Diseases, Fungal; Male; Middle Aged; Nerve Compression Syndromes; Paraplegia; Postoperative Complications; Prisoners; Quadriplegia; Remission Induction; Ribs; Sacroiliac Joint; Spinal Fusion; Spinal Nerve Roots; Spondylitis; Thoracic Vertebrae; Treatment Outcome

Topics: Amphotericin B; Aspergillosis; Candidiasis; Child; Coccidioidomycosis; Cytokines; Diagnosis, Differential; Fluconazole; Histoplasmosis; Humans; Itraconazole; Mucormycosis; Mycoses; Prognosis

Amphotericin B (AmB), the drug of choice for the treatment of most systemic fungal infections, is marketed under the trademark Fungizone, as an AmB-deoxycholate complex suitable for intravenous administration. The association between AmB and deoxycholate is relatively weak; therefore, dissociation occurs in the blood. The drug itself interacts with both mammalian and fungal cell membranes to damage cells, but the greater susceptibility of fungal cells to its effects forms the basis for its clinical usefulness. The ability of the drug to form stable complexes with lipids has allowed the development of new formulations of AmB based on this property. Several lipid-based formulations of the drug which are more selective in damaging fungal or parasitic cells than mammalian cells and some of which also have a better therapeutic index than Fungizone have been developed. In vitro investigations have led to the conclusion that the increase in selectivity observed is due to the selective transfer of AmB from lipid complexes to fungal cells or to the higher thermodynamic stability of lipid formulations. Association with lipids modulates AmB binding to lipoproteins in vivo, thus influencing tissue distribution and toxicity. For example, lipid complexes of AmB can be internalized by macrophages, and the macrophages then serve as a reservoir for the drug. Furthermore, stable AmB-lipid complexes are much less toxic to the host than Fungizone and can therefore be administered in higher doses. Experimentally, the efficacy of AmB-lipid formulations compared with Fungizone depends on the animal model used. Improved therapeutic indices for AmB-lipid formations have been demonstrated in clinical trials, but the definitive trials leading to the selection of an optimal formulation and therapeutic regimen have not been done.

Topics: Amphotericin B; Animals; Aspergillosis; Blastomycosis; Candidiasis; Cell Death; Cell Membrane; Clinical Trials as Topic; Coccidioidomycosis; Cryptococcosis; Detergents; Drug Carriers; Drug Delivery Systems; Drug Industry; Histoplasmosis; Immunity, Active; Leishmania; Leishmaniasis, Visceral; Lipoproteins; Mice; Molecular Structure; Phospholipids; Rabbits

Topics: Amphotericin B; Antifungal Agents; Aspergillosis; Blastomycosis; Candidiasis; Clinical Trials as Topic; Coccidioidomycosis; Cryptococcosis; Fluconazole; Flucytosine; Hematologic Diseases; Histoplasmosis; Humans; Itraconazole; Ketoconazole; Kidney; Mycoses; Thrombophlebitis

In patients with AIDS with cryptococcosis, prompt diagnosis is essential. Poor results with conventional therapy (amphotericin-5FC) have led to exploration of the azoles. Both fluconazole and itraconazole have given good short-term results with less toxicity. However, cure is achieved far less often than in other compromised hosts. Fluconazole is also useful to prevent relapse after successful initial amphotericin therapy, particularly from genitourinary foci. In both histoplasmosis and aspergillosis, itraconazole has produced impressive therapeutic results, and in histoplasmosis, secondary prophylaxis as well. In coccidioidomycosis results thus far have not been better than conventional amphotericin therapy, especially in initial treatment.

Topics: Acquired Immunodeficiency Syndrome; Amphotericin B; Coccidioidomycosis; Cryptococcosis; Drug Therapy, Combination; Fluconazole; Histoplasmosis; Humans; Itraconazole; Meningitis, Cryptococcal

This review has traced chemotherapy of coccidioidomycosis from its unsuccessful beginnings through the present time. Although in vitro susceptibilities give initial impressions of activity of many drugs, and although animal studies identify the diseases targeted for initial trials, ultimately it is the patient in whom the benefits and risks of a new agent must be weighed. For this reason, considerations have been limited to clinical studies, with no review of animal data or immunologic forms of therapy such as transfer factor. In this review, amphotericin B has been found to be the first active antifungal agent in coccidioidomycosis. Although responses clearly occurred, even in meningitis, the vagaries of disease and investigators prevented a really hard assessment of how many patients really were "cured" versus how many relapsed again and again. Responses were given in broad ranges and the term "remission" came to be considered a more accurate definition for this illness than "cure." The azole antifungals, though fungistatic, gave us, for the first time, the ability to treat a patient indefinitely with an oral preparation; the advantages of this cannot be overstated. Although all of these drugs act by similar mechanisms, the differences in potency, pharmacokinetics and toxicities have brought fluconazole and itraconazole to the fore. Which of the two is superior (if either is) cannot be defined with the limited data available. The role of SCH39304 is, at present, unclear. Other agents such as nikkomycin and modified polyenes may enter a role in clinical evaluation of coccidioidomycosis, but for the next five years the drugs described in the preceding pages, or combinations, are likely to constitute the pharmaceutical arsenal against C. immitis. While we now have much more to offer the heirs of Domingo Escurra and Jose Furtado-Silveira than gentian violet and carbolic acid, we still have response rates of less than 75% for extrameningeal disease and we have not yet identified a drug that will guarantee a cure without later relapse. There is still a way to go.

Topics: Acute Disease; AIDS-Related Opportunistic Infections; Amphotericin B; Antifungal Agents; Chronic Disease; Coccidioidomycosis; Humans; Ketoconazole; Lung Diseases, Fungal

Coccidioidomycosis is usually acquired by inhalation of Coccidioides immitis in certain areas of the Western Hemisphere. However, the disease may occur far away in individuals who have visited or lived in, then departed from, the endemic areas. The disease which can affect normal and immunocompromised individuals, has many manifestations resembling those of many diseases. The diagnosis is usually not difficult and can be accomplished by histopathological, cultural, and serological methods. Therapy can be surgical and/or medical. The latter can make use of parenteral amphotericin B and its lipid-complex, or the azoles ketoconazole, fluconazole, and itraconazole. However coccidioidal meningitis, coccidioidal arthritis, and acute coccidioidal respiratory insufficiency pose significant challenges to the available therapy.

Topics: Acquired Immunodeficiency Syndrome; Amphotericin B; Antifungal Agents; Coccidioidomycosis; Dermatomycoses; Drug Interactions; Drug Therapy, Combination; Humans; Surgical Procedures, Operative

Pregnant women with respiratory symptoms of pleuritic pain and productive cough should undergo evaluation for coccidioidomycosis. This should include a history of travel or residency in endemic areas and careful assessment for toxic erythema, erythema nodosum, or erythema multiforme. To confirm a diagnosis of this disease, a sputum culture, wet mount, and serological tests should be performed. The risk of dissemination, which is highest in the second and third trimesters, can be estimated by a complement-fixation titer. In disseminated cases aggressive treatment with amphotericin B has improved the previously reported high maternal and neonatal mortality rate. Fortunately, case reports do not indicate that transplacental spread occurs. Reactivation or exacerbation of a chronic low-grade infection during pregnancy may occur in patients treated for prior disseminated disease (32, 34). Interestingly, both of the reported cases of reactivation or exacerbation occurred in insulin-dependent diabetics.

Topics: Adult; Amphotericin B; Coccidioidomycosis; Diabetes Mellitus, Type 1; Erythema Multiforme; Erythema Nodosum; Female; Fetal Death; Humans; Insulin Infusion Systems; Opportunistic Infections; Pregnancy; Pregnancy Complications, Infectious; Pregnancy in Diabetics; Pregnancy Trimester, Second

Topics: Amphotericin B; Argentina; Azoles; Central America; Coccidioidomycosis; Disease Outbreaks; Humans; Risk Factors; Southwestern United States

Topics: Amphotericin B; Antifungal Agents; Cell Wall; Coccidioidomycosis; Fungi; Histoplasmosis; Humans; Meningitis, Cryptococcal; Mycoses

Topics: Amphotericin B; Antifungal Agents; Aspergillosis; Aspergillosis, Allergic Bronchopulmonary; Blastomycosis; Coccidioidomycosis; Cryptococcosis; Fluconazole; Flucytosine; Histoplasmosis; Humans; Itraconazole; Ketoconazole; Lung Diseases, Fungal

Coccidioidomycosis is a largely self-limited fungal respiratory illness. However, the infrequent case of progressive or disseminated disease can be devastating. As international travel to and from endemic areas increases, physicians unfamiliar with the disease may be called upon to recognize and treat serious coccidioidal infections. The major risk factors for dissemination are race and immunosuppression. The most common sites of dissemination are the skin, lymph nodes, bone and meninges. Diagnosis is aided by investigation of the patient's clinical history, delayed-type hypersensitivity skin test reaction, serologic testing, and recovery of organisms from infected tissue or secretions for direct examination and culture. Fungicidal agents are not available, fortunately, fungistatic therapy allows many patients to recover. The availability of both intravenous/intrathecal and oral agents now allows more therapeutic flexibility in the treatment of this disease.

Topics: Amphotericin B; Coccidioides; Coccidioidomycosis; Humans; Immune Tolerance; Ketoconazole; Lung Diseases, Fungal; Risk Factors

Although rapid population growth in the Southwestern United States and travel to and through the area are increasing the potential for exposure to Coccidioides immitis, prevalence rates have declined in some endemic areas, probably because of environmental factors. With the iatrogenic immunosuppression of organ transplantation and the immunosuppression inherent in AIDS, more opportunistic infections with this organism are to be expected. The variety of cutaneous manifestations continues to challenge the dermatologist's acumen. Spherule-derived coccidioidin is an improved epidemiologic tool, and serodiagnostic techniques are easier to perform and are useful in the management of dissemination. While amphotericin B remains the standard, ketoconazole has found a definite role in the treatment of this disease in many patients. Itraconazole, now under investigation, appears very promising. Morbidity and mortality from disseminated disease appear to be declining. With current diagnostic and therapeutic methods, the prognosis for survival in immunocompetent patients is excellent.

Topics: Adult; Age Factors; Amphotericin B; Arizona; Biopsy; Child; Child, Preschool; Coccidioidomycosis; Dermatomycoses; Female; Humans; Immune Tolerance; Ketoconazole; Male; Pregnancy; Serologic Tests; Sex Factors; Skin Tests

Coccidioidomycosis is a highly variable disease. Initial respiratory tract infection can lead to self-limited pneumonia, pulmonary complications, and extrapulmonary disease. The early infection requires no therapy, except in immunosuppressed patients and other selected patients. Treatment for pulmonary complications may include surgery for cavities or pyopneumothorax (resulting from rupture of a cavity) and antifungal therapy for chronic pneumonia. The majority of extrapulmonary disease occurs in the skin, bones and joints, or meninges and is an indication for treatment with antifungal agents and sometimes adjunctive surgery. Meningitis is a particularly serious consequence of dissemination and currently is best treated with intrathecal instillation of antifungal agents. Antifungal agents useful in the treatment of coccidioidomycosis are amphotericin B, which is administered intravenously and is relatively toxic, and ketoconazole, which is administered orally and whose toxicities are less serious and reversible. Because studies to compare the efficacy of these two drugs have not been performed, selecting between them for use in individual patients is most rationally based on the pharmacologic differences, which lend themselves to different clinical settings. In future years, new antifungal agents will likely be available, some of which will offer significant advantages over present therapies. Itraconazole is an imidazole related to ketoconazole, which appears to be effective and possibly less toxic than ketoconazole. Fluconazole, another imidazole, has broad antifungal activity, a long serum half-life, and excellent penetration into the cerebrospinal fluid. Thus, the pharmacology of this agent would appear ideal for use in treating coccidioidal meningitis. In addition, other compounds with different modes of action are now under investigation in preclinical studies. It is therefore likely that continued improvements will occur in the coming years in the treatment of this disease.

Topics: Amphotericin B; Coccidioidomycosis; Humans; Ketoconazole; Lung Diseases, Fungal; Meningitis

Topics: Amphotericin B; Antifungal Agents; Coccidioidomycosis; Humans; Ketoconazole

Topics: Age Factors; Aged; Amphotericin B; Blastomycosis; Coccidioidomycosis; Histoplasmosis; Humans; Ketoconazole; Recurrence; Sporotrichosis; United States

Symptomatic involvement of the genitourinary tract as a manifestation of disseminated Coccidioides immitis infection is uncommon. We report a case of a colovesical fistula secondary to Coccidioides immitis infection and review the pertinent medical literature.

Topics: Adult; Amphotericin B; Coccidioidomycosis; Genital Diseases, Male; Humans; Hydronephrosis; Intestinal Fistula; Ketoconazole; Male; Prostatic Diseases; Sigmoid Diseases; Urinary Bladder Diseases; Urinary Bladder Fistula

Genitourinary fungal infections have become increasingly common in clinical practice. We review the literature on such infections, emphasizing recognition of fungal disease, predisposing factors, pathogenesis, and approaches to therapy.

Topics: Amphotericin B; Aspergillosis; Blastomycosis; Candidiasis; Coccidioidomycosis; Cryptococcosis; Female; Genital Diseases, Female; Genital Diseases, Male; Histoplasmosis; Humans; Infant, Newborn; Male; Mycoses; Urinary Tract Infections

The deep mycoses are increasing in importance both as opportunistic infections and from exposure in geographically defined areas. Diagnosis may be difficult in both groups. Mucosal involvement may be non-specific (e.g., in disseminated candidiasis) or highly predictive of disseminated disease (e.g., histoplasmosis, blastomycosis and paracoccidioidomycosis). Skin involvement is generally uncommon in disseminated aspergillosis, mucormycosis and cryptococcosis but is more common in candidemia and coccidioidomycosis. Manifestations of mucosal and cutaneous lesions of the deep mycoses are reviewed and the need for an aggressive diagnostic approach stressed. Culture is more specific than histopathologic examination alone but the latter may have to suffice in some cases. Control of underlying disease and administration of amphotericin B remain the mainstays of therapy. Ketoconazole is being evaluated as an alternative in therapy of some deep mycoses.

Topics: Amphotericin B; Aspergillosis; Blastomycosis; Candidiasis; Candidiasis, Cutaneous; Coccidioidomycosis; Cryptococcosis; Dermatomycoses; Flucytosine; Histoplasmosis; Humans; Immunosuppression Therapy; Ketoconazole; Miconazole; Mouth Diseases; Mouth Mucosa; Mucormycosis; Mycoses; Paracoccidioidomycosis; Sporotrichosis; Travel

Mycotic pneumonias are common problems seen in small companion animals because of the wide environmental distribution of fungi and their use of airborne spores for reproduction. This article outlines the important clinical features and pathogenesis of mycotic pneumonias and includes a detailed discussion of the therapeutic approach to patients with these infections.

Topics: Amphotericin B; Animals; Aspergillosis; Blastomycosis; Cat Diseases; Cats; Coccidioidomycosis; Cryptococcosis; Dog Diseases; Dogs; Histoplasmosis; Ketoconazole; Lung Diseases, Fungal; Pneumonia

In the past 20 years, there has been a marked increase in the number of reported cases of meningitis and brain abscess due to fungi and yeasts. This increase is due in part to better diagnostic techniques and greater awareness of the possibility of fungal invasion of the nervous system; but the increase can also be attributed to a growing pool of severely compromised hosts, many of whom are undergoing treatment with adrenal glucocorticoids or immunosuppressive agents. The diagnosis and treatment of aspergillosis, blastomycosis, candidiasis, coccidioidomycosis, cryptococcosis, infections caused by dematiaceous fungi, histoplasmosis, paracoccidioidomycosis, petriellidosis, and sporotrichosis, as well as relatively rare infections of the central nervous system caused by other fungi, are discussed. The efficacy of amphotericin B and 5-fluorocytosine in the treatment of CNS fungal and yeast infections is also evaluated.

Topics: Adult; Amphotericin B; Antifungal Agents; Aspergillosis; Blastomycosis; Candidiasis; Central Nervous System Diseases; Chromoblastomycosis; Cladosporium; Coccidioidomycosis; Cryptococcosis; Female; Fungi; Histoplasmosis; Humans; Male; Meningitis; Meningoencephalitis; Middle Aged; Mucormycosis; Mycoses; Paracoccidioidomycosis; Phialophora; Sporotrichosis

Topics: Amphotericin B; Antifungal Agents; Aspergillosis; Blastomycosis; Candidiasis; Chromoblastomycosis; Coccidioidomycosis; Cryptococcosis; Flucytosine; Histoplasmosis; Humans; Imidazoles; Ketoconazole; Lung Diseases, Fungal; Miconazole; Mycoses; Nausea; Piperazines; Vomiting

Disseminated coccidioidomycosis should be considered as a diagnostic possibility whenever a patient has visited or resides in an endemic coccidioidal area and has a history of fever, skin rash, persistent pulmonary symptoms, bone pain, headache, or confusion. Imaging of this multisystem disease, especially of the lung, bone, and central nervous system, shows various protean manifestations that can simulate many infectious entities. The radiographic, scintigraphic, computed tomographic, or sonographic findings of this disease may be helpful in diagnosis, prognosis, and treatment follow-up in patients with disseminated coccidioidomycosis.

Topics: Amphotericin B; Angiography; Cerebral Ventriculography; Coccidioidomycosis; Ependymoma; Humans; Hydrocephalus; Knee; Lung Diseases, Fungal; Meningitis; Myelography; Radionuclide Imaging; Tomography, X-Ray Computed

Topics: Amphotericin B; Coccidioides; Coccidioidomycosis; Female; Humans; Lung; Lung Diseases, Fungal; Pneumonia; Prognosis; Radiography; Serologic Tests; Syndrome

Topics: Amphotericin B; Coccidioidomycosis; Humans; Lung Diseases, Fungal

Topics: Adult; Amphotericin B; Coccidioidomycosis; Female; Humans; Male; Miconazole; Skin; United States

Topics: Amphotericin B; Arthritis, Infectious; Coccidioidomycosis; Eosinophilia; Erythema; Erythema Multiforme; Erythema Nodosum; Ethnicity; Female; Humans; Liver Diseases; Lung Diseases, Fungal; Meningitis; Miconazole; Osteomyelitis; Pregnancy; Pregnancy Complications, Infectious; Skin Diseases, Infectious; Tenosynovitis; Transfer Factor; United States

Topics: Amphotericin B; Aspergillosis; Blastomycosis; Candidiasis; Coccidioidomycosis; Complement Fixation Tests; Cryptococcosis; Fluorouracil; Histoplasmosis; Humans; Lung Diseases, Fungal; Skin Tests; Stilbamidines

Topics: Amphotericin B; Animals; Antifungal Agents; Aspergillosis; Blastomycosis; Candicidin; Candidiasis; Coccidioidomycosis; Colistin; Cryptococcosis; Dermatomycoses; Drug Resistance, Microbial; Emetine; Flucytosine; Griseofulvin; Histoplasmosis; Humans; Imidazoles; Minocycline; Natamycin; Nystatin; Polyenes; Tolnaftate

Topics: Adult; Amphotericin B; Coccidioidomycosis; Diabetes Complications; Female; Humans; Lung Diseases, Fungal; Male; Methods; Middle Aged; Recurrence

Topics: Amphotericin B; Brain Diseases; Candidiasis; Coccidioidomycosis; Cryptococcosis; Herpes Zoster; Humans; Immunity, Cellular; Immunity, Maternally-Acquired; Leprosy; Lymphocyte Activation; Lymphokines; Male; Meningitis; Middle Aged; Subacute Sclerosing Panencephalitis; T-Lymphocytes; Tuberculosis; Wiskott-Aldrich Syndrome

Topics: Actinomycosis; Amphotericin B; Antifungal Agents; Aspergillosis; Blastomycosis; Candidiasis; Coccidioidomycosis; Cryptococcosis; Flucytosine; Histoplasmosis; Humans; Mucormycosis; Mycoses; Nocardia Infections; Sporotrichosis

Topics: Amphotericin B; Child; Coccidioidomycosis; Crohn Disease; Diagnosis, Differential; Female; Gastrointestinal Diseases; Histoplasma; Histoplasmosis; Humans; Male; Radiography; Skin Tests

Topics: Amphotericin B; Coccidioidomycosis; Female; Humans; Injections, Intravenous; Injections, Spinal; Meningitis; Methods; Mycoses

Topics: Amphotericin B; Aspergillosis; Candida; Candidiasis; Child; Child, Preschool; Coccidioidomycosis; Coccidiosis; Cryptococcosis; Endocarditis; Granuloma; Histoplasmosis; Humans; Infant; Kidney; Kidney Function Tests; Meningitis; Mycoses; Pneumonia

Topics: Actinomycosis; Adolescent; Adult; Amphotericin B; Animals; Aspergillosis; Basidiomycota; Blastomycosis; Candidiasis; Cephalosporins; Child; Chromoblastomycosis; Coccidioidomycosis; Conjunctiva; Cryptococcosis; Drug Synergism; Eye Diseases; Female; Fungi; Geotrichosis; Guinea Pigs; Histoplasmosis; Humans; Male; Mucor; Mycetoma; Mycoses; Natamycin; Nystatin; Penicillium; Pityriasis; Rabbits; Rhinosporidiosis; Sporotrichosis; Tinea

Topics: Actinomycosis; Amphotericin B; Anti-Bacterial Agents; Aspergillosis; Blastomycosis; Candidiasis; Coccidioidomycosis; Cryptococcosis; Griseofulvin; Histoplasmosis; Humans; Iodides; Mucormycosis; Mycoses; Nocardia Infections; Nystatin; Penicillins; Sporotrichosis; Stilbamidines; Sulfadiazine; Surgical Procedures, Operative; Toxicology

Topics: Adult; Amphotericin B; Animals; Cats; Clinical Trials as Topic; Coccidioidomycosis; Dermatomycoses; Dogs; Drug Evaluation; Drug Evaluation, Preclinical; Drug Resistance, Microbial; Humans; Imidazoles; Lung Diseases, Fungal; Male; Miconazole; Middle Aged; Mycoses

Topics: Adult; Amphotericin B; Blastomycosis; Clinical Trials as Topic; Coccidioidomycosis; Cryptococcosis; Female; Histoplasmosis; Humans; Male; Middle Aged; Sporotrichosis

Coccidioidal meningitis remains difficult to treat. The newer triazole, isavuconazole, has demonstrated efficacy in invasive fungal disease with less side effects than other azoles. We describe a case of refractory pediatric coccidioidal meningitis with disease stabilization and improvement on isavuconazole after failing treatment with other antifungal agents.

Topics: Amphotericin B; Antifungal Agents; Child; Coccidioides; Coccidioidomycosis; Deoxycholic Acid; Drug Combinations; Humans; Meningitis, Fungal; Nitriles; Pyridines; Salvage Therapy; Triazoles; Voriconazole

Coccidioides immitis is a dimorphic fungus endemic to the arid climates of the Southwest United States, Mexico and parts of Central and South America. Human infection occurs through inhalation of spores with less than half of exposures progressing to a symptomatic state that primarily consists of pulmonary manifestations. Disseminated coccidioidomycosis is exceedingly rare, occurring in fewer than 1 % of symptomatic infections. Through hematogenous spread, the fungus can infect most organ systems and may be fatal without systemic antifungal treatment. Individuals with impaired cell-mediated immunity either from primary immunodeficiency disorders or secondary to immunosuppression with medications such as tumor necrosis factor alpha (TNF-α) inhibitors have increased risk of disseminated coccidioidomycosis and previous cases of coccidioidomycosis have been reported with biologic therapy.. We present a case of disseminated coccidioidomycosis in a 16-year-old female with polyarticular juvenile idiopathic arthritis (JIA) being treated with prednisone, methotrexate, and infliximab. The patient presented with symptoms of meningeal irritation, bilateral choroidal lesions, and necrotizing peripheral pneumonia. Her infection was thought to be a reactivation of coccidioidomycosis given her history of resolved pneumonia that occurred after traveling to Arizona, New Mexico, and El Paso one year prior to presentation. Following diagnosis, she improved with discontinuation of her immunosuppressive medications and two weeks of intravenous amphotericin B and fluconazole with plans for lifetime treatment with fluconazole while immunosuppressed. Due to worsening arthritis, she will begin tofacitinib and continue close monitoring of chest x-rays and coccidioides antibody.. Patients undergoing immunosuppressive therapy for rheumatological conditions are at increased risk of disseminated coccidioidomycosis and should be evaluated with high suspicion when presenting with atypical symptoms and history of travel to endemic regions.

Topics: Adolescent; Amphotericin B; Antifungal Agents; Antirheumatic Agents; Arthritis; Arthritis, Juvenile; Choroid Diseases; Coccidioides; Coccidioidomycosis; Disease Progression; Female; Fluconazole; Humans; Immune Tolerance; Infliximab; Meningitis, Fungal; Monitoring, Immunologic; Pneumonia, Necrotizing; Treatment Outcome

Topics: Aged; Amphotericin B; Anti-Bacterial Agents; Antifungal Agents; Aortic Aneurysm, Abdominal; Aortitis; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Clostridium Infections; Coccidioidomycosis; Device Removal; Enterobacter cloacae; Enterobacteriaceae Infections; Fluconazole; Humans; Magnetic Resonance Angiography; Male; Pneumonia, Bacterial; Postoperative Complications; Prosthesis-Related Infections

Topics: Amphotericin B; Antifungal Agents; Coccidioides; Coccidioidin; Coccidioidomycosis; Humans; Hyphae; Itraconazole; Male; Mexico; Middle Aged; Skin Tests; Spores, Fungal

Intrathecal amphotericin B deoxycholate (AmB-d) can be prescribed as an adjunct to systemic therapy for severe or recalcitrant cases coccidioidal meningitis. Recently intravenous (IV) Liposomal amphotericin B (L-AmB) has been recommended as monotherapy therapy for refractory coccidioidal meningitis based on its advantages over (AmB-d), however, its intrathecal use has not been reported. Moreover, there is nothing in the literature quantifying clinical improvement with objective laboratory data in human patients. Consequently, there are no guidelines on how to monitor regularly for improvement of coccidioidal meningitis with treatment of intrathecal L-AmB. The present case addresses both of these. We report intrathecal use of L-AmB for refractory coccidioidal meningitis. Our data demonstrate that there is a correlation between clinical improvement and a decrease in cerebrospinal fluid (CSF) white blood cells (WBC's), protein, and coccidioidal titers with treatment of intrathecal L-AmB with serial collection of CSF studies at the same site, in our case via collection through an external ventricular drain (EVD). As a result, one may postulate that serial CSF collection can be used to monitor the treatment of coccidioidal meningitis; however this case also addresses the risk of developing ventriculitis with sustained EVD placement.

Topics: Adult; Amphotericin B; Antifungal Agents; Coccidioidomycosis; Deoxycholic Acid; Drug Combinations; Humans; Injections, Spinal; Male; Meningitis

Topics: Aged; Amphotericin B; Antifungal Agents; Coccidioidomycosis; Fatal Outcome; Fluconazole; Folliculitis; Humans; Lung Diseases, Fungal; Male

Coccidioidal meningitis remains a difficult clinical problem, and despite life-long therapy with triazole antifungals, relapses of disease and medication intolerance occur necessitating salvage treatment. We report two patients with recurrent coccidioidal meningitis who improved following a 2-week course of liposomal amphotericin B monotherapy and discuss potential advantages of this treatment option.

Topics: Adult; Amphotericin B; Antifungal Agents; Coccidioidomycosis; Humans; Male; Meningitis, Fungal; Middle Aged; Recurrence; Treatment Outcome

Topics: Administration, Oral; Amphotericin B; Antifungal Agents; Coccidioidomycosis; Dermatomycoses; Drug Therapy, Combination; Female; Humans; Infusions, Intravenous; Itraconazole; Lymphadenitis; Neck; Treatment Outcome; Young Adult

To describe a case of Coccidioides endophthalmitis that resulted in a favorable visual outcome after a combined medical and surgical approach.. A 33-year-old previously healthy woman was referred for evaluation of dyspnea and left-sided vision loss, which began 3 months before, after a trip to Nevada. She was found to have a pulmonary cavitary lesion and fluffy white material in the anterior chamber. An aqueous and vitreous paracentesis grew Coccidioides species. She was managed medically with a total of 7 weekly intravitreal injections of amphotericin B and intravenous liposomal amphotericin B followed by transition to oral posaconazole. Seven months after presentation, to ensure ocular sterilization and to clear the visual axis, she underwent temporary keratoprosthesis implantation, anterior segment reconstruction, removal of a cyclitic membrane and the crystalline lens, pars plana vitrectomy, placement of a pars plana Ahmed drainage device, and penetrating keratoplasty.. After surgical intervention and with maintenance posaconazole therapy, the patient had resolution of her dyspnea and improved uncorrected (aphakic) vision with a clear corneal graft, quiet anterior chamber, and normal optic nerve and retina.. A combined medical and surgical approach resulted in a favorable visual outcome and avoided the need for enucleation.

Topics: Adult; Amphotericin B; Antifungal Agents; Aqueous Humor; Coccidioides; Coccidioidomycosis; Combined Modality Therapy; Endophthalmitis; Eye Infections, Fungal; Female; Humans; Intravitreal Injections; Ophthalmologic Surgical Procedures; Treatment Outcome; Triazoles; Vitreous Body

In contrast to adults, coccidioidomycosis is a rare disease in infants and the mechanisms of disease acquisition are not well described in infants. The purpose of this study was to describe the clinical presentation, treatment, and outcome of pulmonary coccidioidomycosis in infants in an endemic area.. We performed a retrospective observational study of all patients less than 12 months of age admitted to a tertiary free standing children's hospital from 2003-2012 diagnosed with coccidioidomycosis.. Thirteen infants were hospitalized during the study period. The majority of the patients presented with upper and/or lower respiratory tract infection. The most common presenting symptoms included fever (77%), cough (61%), and respiratory distress (38%). Disseminated disease, included pericardial effusion, neck abscess, and lesions in the cerebellum, basal ganglia and left temporoparietal skull. Fluconazole was the initial, antifungal agent used. Amphotericin B was reserved for significant lung disease and disseminated cases. Failed response to fluconazole and amphotericin B were treated with a combination of voriconazole and caspofungin. Average length of treatment was 4 years. All patients survived to hospital discharge. The majority of the patients had resolution of chest radiograph and coccidiodal complement fixing antibody titers.. Infant coccidioidomycosis has a non-specific presentation and can mimic common infant respiratory illnesses. In endemic areas, coccidioidomycosis should be considered in the differential diagnosis of infants with pulmonary symptoms unresponsive to conventional treatment. Pediatr Pulmonol. 2016;51:858-862. © 2016 Wiley Periodicals, Inc.

Topics: Amphotericin B; Antifungal Agents; Caspofungin; Coccidioidomycosis; Cough; Diagnosis, Differential; Echinocandins; Endemic Diseases; Female; Fever; Fluconazole; Humans; Infant; Lipopeptides; Lung Diseases, Fungal; Male; Retrospective Studies; Treatment Outcome; Voriconazole

The aim of this report was to present the first known case of coccidioidomycosis involving the temporomandibular joint, review the literature regarding dissemination to the mandible, and to provide treatment recommendations for this challenging condition.. Coccidioidomycosis of the mandibular condyle was identified in a 30-year-old Somali male residing in Arizona. Due to the difficulty of surgical access and the anticipated temporomandibular joint morbidity of radical condylar debridement, primary medical management was performed.. Marked symptomatic improvement was observed after 10 days of IV antifungal therapy. Resolution of the abscess with residual bony destruction was observed on CT scan. Based on the results of this patient and review of the literature, an algorithm is presented to help guide management of coccidioidomycosis dissemination to the mandible.. Prolonged antifungal therapy should be attempted for initial management of a Coccidioides abscess involving the condyle with early surgical intervention reserved for the more easily accessible and less functionally compromising portions of the mandible.

Topics: Abscess; Adult; Amphotericin B; Coccidioidomycosis; Drug Therapy, Combination; Fluconazole; Humans; Infusions, Intravenous; Long-Term Care; Male; Osteomyelitis; Temporomandibular Joint Disorders; Tomography, X-Ray Computed

Topics: Aged; Amphotericin B; Antifungal Agents; Biopsy; Coccidioidomycosis; Female; Humans; Lung; Lung Diseases, Fungal; Lymphocytes; Meningitis, Fungal; Tomography, X-Ray Computed

We present a case of a 32 year old female with a past medical history of hypertension who presented with several years of chronic back pain and was ultimately diagnosed with isolated pelvic coccidioidomycosis. She was initially seen by gynecologic oncology for assessment of possible metastatic cancer by image study, but a cytopathologic diagnosis of coccidioidomycosis lead to a cancellation of the planned surgery and extensive antifungal treatment managed by the infectious disease team. She had no known previous pulmonary disease or immunodeficiency. Pelvic coccidioidomycosis without known pulmonary disease is very rare, and disseminated infection typically only occurs in those who are severely immunocompromised. Our case presented with several years of back pain and a pelvic mass mistaken for possible malignancy by image study.

Topics: Adult; Amphotericin B; Antifungal Agents; Back Pain; Coccidioidomycosis; Female; Humans; Male; Pelvic Infection; Tomography, X-Ray Computed

Coccidioidomycosis is a fungal infection caused by the Coccidioides species, endemic to the southwestern United States. In healthy people, manifestations range mainly from asymptomatic to mild influenza-like signs, whereas in immunosuppressed patients (eg, transplant recipients) this infection is often a severe disseminated disease. We report a case of primary pulmonary coccidioidomycosis in a 61-year-old man with a renal transplant 7 months earlier. The patient had nonspecific symptoms of pulmonary infection, including weakness, anorexia, and weight loss. Both spherules and endospores of Coccidioides immitis were seen histologically after a transbronchial biopsy of a cavitary lesion. The patient was treated with amphotericin B. At the time of this writing (8 months), he remains disease free.

Topics: Amphotericin B; Antifungal Agents; Biopsy; Coccidioides; Coccidioidomycosis; Humans; Kidney Transplantation; Lung Diseases, Fungal; Male; Middle Aged; Time Factors; Tomography, X-Ray Computed; Treatment Outcome; Turkey

Invasive fungal infections are a major cause of morbidity and mortality among solid organ transplant (SOT) and hematopoietic cell transplant (HCT) recipients, but few data have been reported on the epidemiology of endemic fungal infections in these populations.. Fifteen institutions belonging to the Transplant-Associated Infection Surveillance Network prospectively enrolled SOT and HCT recipients with histoplasmosis, blastomycosis, or coccidioidomycosis occurring between March 2001 and March 2006.. A total of 70 patients (64 SOT recipients and 6 HCT recipients) had infection with an endemic mycosis, including 52 with histoplasmosis, 9 with blastomycosis, and 9 with coccidioidomycosis. The 12-month cumulative incidence rate among SOT recipients for histoplasmosis was 0.102%. Occurrence of infection was bimodal; 28 (40%) infections occurred in the first 6 months post transplantation, and 24 (34%) occurred between 2 and 11 years post transplantation. Three patients were documented to have acquired infection from the donor organ. Seven SOT recipients with histoplasmosis and 3 with coccidioidomycosis died (16%); no HCT recipient died.. This 5-year multicenter prospective surveillance study found that endemic mycoses occur uncommonly in SOT and HCT recipients, and that the period at risk extends for years after transplantation.

Topics: Adolescent; Adult; Aged; Amphotericin B; Antifungal Agents; Blastomycosis; Child; Coccidioidomycosis; Coinfection; Comorbidity; Endemic Diseases; Female; Hematopoietic Stem Cell Transplantation; Histoplasmosis; Humans; Incidence; Itraconazole; Male; Middle Aged; Organ Transplantation; Prospective Studies; Respiratory Tract Infections; Time Factors; United States; Young Adult

Coccidioidomycosis infections result from inhalation of the dimorphic fungus Coccidiodes immitis. Coccidioidomycosis typically is benign, but its extremely rare disseminated form can result in significant morbidity and mortality. Dissemination of the fungus to the spine is difficult to control and usually requires an aggressive combination approach (surgical/medical). In this article, we report the case of a 27-year-old Indonesian man with vertebral osteomyelitis caused by disseminated coccidioidomycosis. We outline the case management (includes 30-month follow-up) and review the treatment recommendations. The patient presented with an unstable C5 pathologic fracture caused by C immitis. After corpectomy and stabilization of the cervical spine along with antifungal therapy with amphotericin B and oral fluconazole, he developed multiple complications. This case illustrates some of the potential pitfalls in managing spinal osteomyelitis caused by C immitis and the need for continuous medical therapy after surgical treatment.

Topics: Adult; Amphotericin B; Antifungal Agents; Cervical Vertebrae; Coccidioidomycosis; Fluconazole; Humans; Male; Osteomyelitis; Spinal Fractures; Spinal Fusion; Treatment Outcome

Topics: Administration, Oral; Adult; AIDS-Related Opportunistic Infections; Amphotericin B; Antifungal Agents; Coccidioidomycosis; Fluconazole; Humans; Male; Pelvic Bones; Spine; Treatment Outcome

A 43 year-old diabetic woman, who suffered chronic cough and brown expectoration, is presented in this clinical problem. X-ray exam and CT thorax scan showed a cavitary lung lesion, located at the upper field of the left lung. This lesion had 5 cm in diameter, with a thick wall and a spherical shadow inside. The diagnosis of chronic cavitary pulmonary coccidioidomycosis was based on the isolation of Coccidioides sp. from cultures of expectoration and bronchoalveolar lavage, and the detection of specific antibodies in immunodiffusion test and counterimmunoelectrophoresis with coccidiodin. Her diabetes was not well controlled. She was treated with intravenous amphotericin B and oral itraconazole, with good clinical response; after four months of treatment the patient abandoned clinical controls. We suppose that the patient presented a coccidioidal fungus ball, inside a chronic cavitary lesion due to pulmonary coccidiodomycosis. She came from an endemic zone of coccidioidomycosis in the Northwest of the Argentine Republic (Catamarca Province).

Topics: Adult; Amphotericin B; Antifungal Agents; Argentina; Bronchoalveolar Lavage Fluid; Coccidioides; Coccidioidin; Coccidioidomycosis; Cough; Diabetes Mellitus, Type 2; Drug Therapy, Combination; Dyspnea; Endemic Diseases; Female; Humans; Itraconazole; Lung Diseases, Fungal; Sputum; Tomography, X-Ray Computed

Topics: Amphotericin B; Antifungal Agents; Coccidioides; Coccidioidomycosis; Diabetes Mellitus, Type 1; Diabetic Nephropathies; Fluconazole; Humans; Kidney Transplantation; Lip Diseases; Male; Middle Aged; Pancreas Transplantation; Ulcer

Coccidioidomycosis is a fungal infection endemic to south-west USA, north Mexico and parts of Central and South America. We report here a case of primary pulmonary coccidioidomycosis in a previously healthy 14-year-old boy in China, which is considered a non-endemic country. The patient had non-specific symptoms of pulmonary infection, including fever, non-productive cough and night sweats. Both spherules and endospores of Coccidioides immitis were seen histologically following transbronchial biopsy of a cavitary lesion. The patient was treated with amphotericin B and fluconazole. Follow up 6 months post discharge found that the patient made a good recovery.

Topics: Adolescent; Amphotericin B; Asian People; Coccidioides; Coccidioidomycosis; Cough; Fluconazole; Humans; Lung Diseases, Fungal; Male; Treatment Outcome

Despite the advent of new antifungal agents, coccidioidal meningitis (CM) remains a difficult-to-treat condition with significant morbidity and mortality. In this study we directly compare the clinical presentation and management of patients with Coccidioides immitis meningitis in the azole era (after 1980) to that of a cohort of patients from the pre-azole era. We reviewed 30 CM cases seen at 3 Los Angeles hospitals between the years 1993 to 2008 ("2008 cohort") and compared them to 31 patients ("1980 cohort") described by Bouza et al in a previous study. The demographics and clinical presentation of patients in the 2008 cohort were similar to those of the 1980 cohort except for a higher incidence of Hispanic patients (2008: 53% vs. 1980: 6%) and a greater percentage of patients with underlying, predisposing clinical conditions (2008: 66% vs. 1980: 32%). Ten patients in the 2008 cohort had human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), a condition not reported in the earlier study. Laboratory findings were similar between the 2 groups except for a lower incidence of peripheral leukocytosis and eosinophilia in the 2008 group.There were marked differences in drug treatment between the 2 eras. In the 2008 cohort, 29 patients received fluconazole therapy: 13 were treated with fluconazole monotherapy, and 16 received a combination of fluconazole and intravenous amphotericin B. Although almost all patients (29/31) in the 1980 cohort received intrathecal amphotericin B, only 3 patients in the 2008 study received amphotericin B via this route. With respect to complications of CM, a similar percentage of patients in each cohort developed complications such as stroke and hydrocephalus. The 2008 cohort (40%) had similar mortality compared to patients in the 1980 study (39%); survivors in both groups experienced significant impairment of activities of daily living. Although recommended as first-line therapy for CM, azole-based therapies are not curative and do not necessarily prevent complications associated with the disease.CM remains a serious illness with a high rate of morbidity and mortality. Immunocompromised individuals, especially those with HIV/AIDS, are at special risk for CM and represent a greater share of the overall population with this condition. Despite the clear advantages of azole treatment in CM, new therapeutic approaches are needed to provide definitive cure and to reduce the need for long-term suppressive therapy.

Topics: Acquired Immunodeficiency Syndrome; Adult; Aged; AIDS-Related Opportunistic Infections; Amphotericin B; Anti-Bacterial Agents; Antifungal Agents; Coccidioides; Coccidioidomycosis; Enzyme-Linked Immunosorbent Assay; Female; Fluconazole; Humans; Hydrocephalus; Male; Meningitis; Middle Aged; Radiography, Thoracic; Young Adult

Topics: Amphotericin B; Antifungal Agents; Coccidioidomycosis; Fluconazole; Humans; Itraconazole; United States

In separate previous studies, we have shown that lipid-complexed amphotericin B (Abelcet [ABLC]) and liposomal amphotericin B (AmBisome [AmBi]) are efficacious against coccidioidal meningitis in rabbits. Here, we compared ABLC and AmBi directly in a coccidioidal meningitis model. Male New Zealand White rabbits were infected with 5 x 10(4) Coccidioides posadasii arthroconidia by direct cisternal puncture. Therapy with intravenous ABLC or AmBi at 7.5 or 15 mg/kg of body weight or sterile 5% dextrose water (D5W) began 5 days later. Clinical assessments were done daily; cerebrospinal fluid and blood samples were obtained on day 15 and upon euthanasia. Survivors to day 25 were euthanatized, the numbers of CFU in their tissues were determined, and histology analyses of the brains and spinal cords were done. Controls showed progressive disease, whereas animals treated with either dose of either drug showed few clinical signs of infection. All ABLC- or AmBi-treated rabbits survived, whereas eight of nine D5W-treated rabbits were euthanatized before day 25 (P < 0.0001). Numbers of CFU in the brains and spinal cords of ABLC- or AmBi-treated animals were 100- to 10,000-fold lower than those in the corresponding tissues of D5W-treated animals (P < 0.0006 to 0.0001). However, only two or fewer given a regimen of ABLC or AmBi were cured of infection in both tissues. Fewer ABLC-treated rabbits (four of eight treated with 7.5 mg/kg and five of eight treated with 15 mg/kg) than controls (nine of nine) had meningitis at any level of severity (P, 0.015 or 0.043 for animals treated with ABLC at 7.5 or 15 mg/kg, respectively). Although groups of rabbits treated with AmBi regimens did not have significantly fewer animals with meningitis than the control group (P > 0.05), ABLC and AmBi were not significantly different. In this model, intravenous ABLC and AmBi were similarly highly effective, with few clinical signs of infection, 100% survival, and significantly reduced fungal burdens among treated animals. There appeared to be little benefit in using the 15-mg/kg dosage of either formulation. There was no significant advantage of one drug over the other for this indication. Further studies are required to determine the lowest effective doses of these formulations.

Topics: Amphotericin B; Animals; Antifungal Agents; Brain; Cerebrospinal Fluid; Coccidioides; Coccidioidomycosis; Disease Models, Animal; Humans; Male; Meningitis, Fungal; Rabbits; Severity of Illness Index; Spinal Cord; Treatment Outcome

Hyperimmunoglobulin E syndrome (HIES) is a rare primary immunodeficiency characterized by recurrent skin and lung infections. We report the first case of Coccidioides immitis meningitis in a patient with HIES. Coccidioides should be included in the differential diagnosis for central nervous system infections in HIES patients.

Topics: Adolescent; Amino Acid Substitution; Amphotericin B; Antibodies, Fungal; Antifungal Agents; Cerebrospinal Fluid; Coccidioides; Coccidioidomycosis; Exons; Female; Humans; Immunoglobulin G; Job Syndrome; Meningitis, Fungal; Mutation, Missense; Sequence Analysis, DNA; STAT3 Transcription Factor

Coccidioidal meningitis is a lethal disease, and current therapy is not curative or is burdened with serious toxicities and logistic difficulties. In a patient with refractory disease, continuous infusion amphotericin B therapy was given via a programmable implanted pump into the cisternal subarachnoid space. The patient progressively responded, evidenced clinically and by laboratory studies. Drug delivery issues were addressed during this course that could guide future use of this modality, which is a promising novel avenue of therapy for chronic meningitis.

Topics: Amphotericin B; Antifungal Agents; Coccidioidomycosis; Humans; Infusion Pumps, Implantable; Injections, Spinal; Male; Meningitis, Fungal; Young Adult

The aim of the present study was to evaluate the in vitro interactions of antituberculous drugs (ATDs) with antifungals against Coccidioides posadasii. Eighteen drug combinations, formed by an ATD (isoniazid, pyrazinamide or ethambutol) plus an antifungal (amphotericin B, ketoconazole, itraconazole, fluconazole, voriconazole or caspofungin), were tested using the checkerboard method. All the antimicrobial combinations inhibited C. posadasii strains and synergistic interactions were observed for 10 combinations. Antagonism between the tested drugs was not observed. Stronger synergistic interactions were seen in the combinations formed by triazoles plus ethambutol as well as itraconazole plus pyrazinamide. Further studies in animal models are needed to confirm the usefulness of these combinations.

Topics: Amphotericin B; Antifungal Agents; Antitubercular Agents; Caspofungin; Coccidioides; Coccidioidomycosis; Drug Synergism; Echinocandins; Ethambutol; Fluconazole; Humans; Isoniazid; Itraconazole; Ketoconazole; Lipopeptides; Microbial Sensitivity Tests; Pyrazinamide; Pyrimidines; Triazoles; Voriconazole

We report a case of a life-threatening, recurrent, and azole-resistant pulmonary coccidioidomycosis in a patient receiving long-term fluconazole therapy for a history of coccidioidal meningitis. Since this diagnosis, the patient has received weekly amphotericin B for more than four years and remains in remission with a stable serum Coccidioides complement fixation antibody titer.

Topics: Amphotericin B; Antifungal Agents; Azoles; Coccidioides; Coccidioidomycosis; Drug Resistance, Fungal; Humans; Lung Diseases; Male; Meningitis, Fungal; Middle Aged; Recurrence

Topics: Adolescent; Amphotericin B; Antifungal Agents; Coccidioidomycosis; Fluconazole; Follow-Up Studies; Humans; Male; Pharyngitis; Retropharyngeal Abscess

The therapeutic efficacy of caspofungin alone and in combination with amphotericin B deoxycholate was evaluated in treatment of murine coccidioidomycosis.. Survival and tissue burdens of the spleens and livers were used as antifungal response markers. In a monotherapy study, caspofungin was injected intraperitoneally at 0.1, 0.2, 0.5, 1 and 5 mg/kg per day on days 2 through 15. Amphotericin B deoxycholate was given at 0.1, 0.2 and 0.5 mg/kg intravenously and 1 and 5 mg/kg intraperitoneally three times per week for 2 weeks. In a combination therapy study, amphotericin B deoxycholate at 0.1 mg/kg was administered intravenously three times per week for 2 weeks, respectively, with and without caspofungin intraperitoneally given at 0.1, 0.5 and 5 mg/kg daily on days 2 through 15 post-infection.. The study shows that caspofungin and amphotericin B deoxycholate at > or =0.5 and > or =0.1 mg/kg, respectively, were significant in both prolongation of survival and reduction of the tissue fungal burdens of mice compared with controls. No sterilization of either organ was observed with caspofungin doses. In combination therapy, any combination of caspofungin (0.1, 0.5 and 5 mg/kg) with amphotericin B deoxycholate (0.1 mg/kg) improved the period of survival and significantly reduced spleen and liver counts compared with controls.. This study indicates that caspofungin has efficacy against systemic coccidioidomycosis in a murine model given in combination with amphotericin B deoxycholate.

Topics: Amphotericin B; Animals; Antifungal Agents; Caspofungin; Coccidioides; Coccidioidomycosis; Deoxycholic Acid; Drug Combinations; Drug Therapy, Combination; Echinocandins; Humans; Lipopeptides; Male; Mice; Mice, Inbred ICR; Treatment Outcome

Coccidioidomycosis is a systemic infection caused by the soil-dwelling dimorphic fungi Coccidioides spp. The disease is endemic in semiarid Northeast Brazil, where it is caused by C. posadasii. The aim of this study was to perform antifungal susceptibility tests of clinical and environmental strains of C. posadasii from Northeast Brazil. The in vitro activities of caspofungin, amphotericin B and azoles against clinical and environment isolates of C. posadasii were determined in accordance with the NCLLS M-38P macrodilution method. The antifungal susceptibility analysis showed that all the strains of C. posadasii (n = 10) were sensitive to caspofungin (16 microg/ml < or = MIC < or = 32 microg/ml), amphotericin B (0.0625 mug/ml < or = MIC < or = 0.125 microg/ml), ketoconazole (0.039 microg/ml < or = MIC < or = 0.156 microg/ml), itraconazole (0.125 microg/ml < or = MIC < or = 0.5 microg/ml), fluconazole (3.125 microg/ml < or = MIC < or = 6.25 microg/ml), and voriconazole (0.125 microg/ml). This study is the first description of in vitro antifungal susceptibility pattern of Brazilian strains of C. posadasii.

Topics: Amphotericin B; Antifungal Agents; Azoles; Brazil; Caspofungin; Coccidioides; Coccidioidomycosis; Echinocandins; Humans; Lipopeptides; Microbial Sensitivity Tests; Peptides, Cyclic

Coccidioidal meningitis is a highly lethal condition with a high morbidity and relapse rate caused by Coccidioides immitis. This case report highlights the difficulty in diagnosing and treating coccidioidal meningitis, and discusses a novel combination antifungal therapy (voriconazole and liposomal amphotericin B), which was used to treat this patient.

Topics: Adult; Amphotericin B; Antifungal Agents; Coccidioides; Coccidioidomycosis; Diagnosis, Differential; Drug Therapy, Combination; Humans; Male; Meningitis, Fungal; Pyrimidines; Triazoles; Voriconazole

Pulmonary cavitary coccidioidomycosis with a fungus ball was observed in a immunocompetent case. A 32-year-old Japanese man visited Arizona to play golf. After 1 month he consulted a local hospital complaining of a prolonged cough and hematopysis. The laboratory examination revealed eosinophillia and chest radiograph showed 2 cavitary lesions, surrounded by small nodules in the apices of both lungs. Pulmonary tuberculosis was suspected and treated with 4 antituberculosis drugs for 3 months. However, the cavities enlarged and he was admitted to our hospital for further examination and treatment. Transbronchial lung biopsy was performed and serologically, bacteriologically and histologically a diagnosis of chronic coccidioidmycosis was made. It is very rare for fungus ball formation and coexistence of spherules and hyphae of Coccidioides immitis to be seen. Fluconazole was temporarily effective, causing cavities to shrink and eosinophilia to decrease, however Amphotericin B needed to be used later. Eosinophilia was closely related to the severity of the disease gravity.

Topics: Adult; Amphotericin B; Antifungal Agents; Biomarkers; Chronic Disease; Coccidioides; Coccidioidomycosis; Disease Progression; Eosinophilia; Humans; Lung Diseases, Fungal; Male; Serologic Tests; Severity of Illness Index; Tomography, X-Ray Computed; Treatment Outcome

Topics: Adult; Amphotericin B; Animal Husbandry; Animals; Animals, Wild; Antifungal Agents; Argentina; Chrysosporium; Coccidioidomycosis; Diagnosis, Differential; Granuloma; Humans; Lung Diseases, Fungal; Male; Radiography; Respiratory Distress Syndrome; Rodent Diseases

Topics: Adult; Amphotericin B; Antifungal Agents; Bone Marrow Transplantation; Coccidioidomycosis; Female; Fluconazole; Humans; Myelodysplastic Syndromes; Tomography, X-Ray Computed; Transplantation, Homologous

A 10-year-old patient with known coccidioidomycosis relapsed and had dysrrhythmias and a right atrial mass. Histopathology and culture after surgical removal revealed that this was a vegetative mass infected with Coccidioides spp. We believe that this is the first case of coccidioidal endocarditis to be reported.

Topics: Amphotericin B; Cardiac Surgical Procedures; Child; Coccidioides; Coccidioidomycosis; Combined Modality Therapy; Endocarditis; Follow-Up Studies; Fungemia; Heart Atria; Humans; Male; Risk Assessment; Severity of Illness Index; Treatment Outcome; Ultrasonography

A 37-year-old man presented with coccidioidal meningoencephalitis (CM) 1 month after a preceding case of pneumonia. Initially, he could not be definitely diagnosed with CM because of nonspecific features of the clinical, laboratory, and radiological findings. However, we began to suspect CM because the patient had lived in endemic area of coccidioidomycosis, and our subsequent analysis provided evidence of complement-fixing antibodies for Coccidioides immitis in serum and CSF, leading us to a final diagnosis. The CM was intractable, despite intensive administration of fluconazole and amphotericin B. Although the patient's CM gradually and mildly improved, he also suffered from bacterial meningoencephalitis and left putaminal hemorrhage with intraventricular hematoma, which caused persistent right hemiparesis and dementia. The incidence of coccidioidomycosis in Japan is rapidly increasing. The initial clinical manifestation of coccidioidomycosis is usually pneumonia, which in most cases heals spontaneously. Coccidioidomycosis rarely presents with meningoencephalitis, which is thought to be fatal. Immediate and adequate initiation of anti-fugal treatment is necessary to obtain a better prognosis for CM. Careful history-taking after a foreign trip is helpful when there is a suspicion of coccidioidomycosis.

Topics: Adult; Amphotericin B; Antibodies, Fungal; Antifungal Agents; Brain; Coccidioides; Coccidioidomycosis; Fluconazole; Humans; Magnetic Resonance Imaging; Male; Meningoencephalitis; Tomography, X-Ray Computed

Topics: Amphotericin B; Antifungal Agents; Biopsy, Needle; Coccidioidomycosis; Dermatomycoses; Diagnosis, Differential; Female; Follow-Up Studies; Fungemia; Humans; Immunohistochemistry; Middle Aged; Mycosis Fungoides; Risk Assessment; Severity of Illness Index; Skin Neoplasms; Treatment Outcome

We describe a patient who developed dilated cardiomyopathy and clinical congestive heart failure after 2 months of therapy with amphotericin B (AmB) for disseminated coccidioidomycosis. His echocardiographic abnormalities and heart failure resolved after posaconazole was substituted for AmB. It is important to recognize the rare and potentially reversible toxicity of AmB.

Topics: Adult; Amphotericin B; Antifungal Agents; Cardiomyopathy, Dilated; Coccidioidomycosis; Drug Combinations; Echocardiography; Humans; Injections, Intravenous; Male; Phosphatidylcholines; Phosphatidylglycerols

This case emphasizes that aggressive neurosurgical management may benefit patients with disseminated coccidioidomycosis and skull abscesses. Disseminated infection due to Coccidioides immitis, the causative agent of coccidioidomycosis, is difficult to treat and often requires prolonged antifungal therapy in addition to surgical debridement. We present a case of a young woman with disseminated coccidioidomycosis who had multiple skull lesions, two of which penetrated the skull and invaded the subgaleal and epidural spaces. Despite prolonged aggressive medical management, these lesions failed to resolve until they were surgically drained.

Topics: Abscess; Adult; Amphotericin B; Antifungal Agents; Coccidioidomycosis; Combined Modality Therapy; Drug Therapy, Combination; Female; Fluconazole; Humans; Liposomes; Osteomyelitis; Skull

Topics: Amphotericin B; Antifungal Agents; Cheek; Coccidioidomycosis; Diagnosis, Differential; Female; Foot; Hand; Humans; Low Back Pain; Magnetic Resonance Imaging; Middle Aged; Paresthesia; Spinal Cord Compression; Thigh

The therapeutic efficacy of three lipid formulations of amphotericin B was compared with that of conventional amphotericin B in treatment of murine coccidioidomycosis. All treatments prolonged survival compared with the no-treatment group (P < 0.0001). Although conventional amphotericin B was more active than lipid formulations on reducing quantitative fungal load on a milligram-per-kilogram basis (P < 0.003 to 0.0002), the lipid preparations could be administered at higher doses, sterilizing liver and spleen tissues. The efficacies of the lipid preparations were similar in this murine model of coccidioidomycosis.

Topics: Amphotericin B; Animals; Antifungal Agents; Coccidioides; Coccidioidomycosis; Colloids; Colony Count, Microbial; Drug Carriers; Liposomes; Liver; Lung; Mice; Microbial Sensitivity Tests; Spleen; Survival Analysis

Coccidioidal pericarditis, an uncommonly diagnosed entity, may evolve to a constrictive process. Constrictive coccidioidal pericarditis requires pericardiectomy and antifungal therapy. In the elderly, pericardiectomy may be complicated by coagulopathy and septic shock. Despite potential toxicity, use of antifungal therapy early postoperatively offers the best chance for survival.

Topics: Aged; Amphotericin B; Antifungal Agents; Coccidioidomycosis; Humans; Male; Pericardiectomy; Pericarditis

Topics: Amphotericin B; Antifungal Agents; Back Pain; Biopsy; Braces; Coccidioidomycosis; Combined Modality Therapy; Diagnosis, Differential; Disease Progression; Fluconazole; Humans; Magnetic Resonance Imaging; Male; Patient Isolation; Spinal Fusion; Spondylitis; Thoracic Vertebrae; Treatment Outcome

Disseminated fungal infection is an important cause of morbidity and mortality, especially in immunocompromised hosts. Amphotericin B is an important part of the therapy and treatment of invasive and life-threatening mycoses. We present a case of disseminated coccidioidomycosis in a patient who was successfully treated with liposomal amphotericin B (AmBisome) on steroid therapy. It appears that liposomal amphotericin B may offer an alternative and safe option in the treatment of coccidioidomycosis when conventional amphotericin B cannot be used.

Topics: Aged; Amphotericin B; Antifungal Agents; Coccidioidomycosis; Fluconazole; Humans; Liposomes; Male

The efficacy of intravenously administered liposomal amphotericin B (AmBisome [AmBi]) for the treatment of experimental coccidioidal meningitis was compared with those of oral fluconazole (FLC) and intravenously administered conventional amphotericin B (AMB). Male New Zealand White rabbits were infected by intracisternal inoculation of arthroconidia of Coccidioides immitis. Starting 5 days postinfection, animals received one of the following: 5% dextrose water diluent; AMB given at 1 mg/kg of body weight; AmBi given at 7.5, 15, or 22.5 mg/kg intravenously three times per week for 3 weeks; or oral FLC given at 80 mg/kg for 19 days. One week after the cessation of therapy, all survivors were euthanatized, the numbers of CFU remaining in the spinal cord and brain were determined, and histological analyses were performed. All AmBi-, FLC-, or AMB-treated animals survived and had prolonged lengths of survival compared with those for the controls (P < 0.0001). Treated groups had significantly lower numbers of white blood cells and significantly lower protein concentrations in the cerebrospinal fluid compared with those for the controls (P < 0.01 to 0.0005) and had fewer clinical signs of infection (e.g., weight loss, elevated temperature, and neurological abnormalities including motor abnormalities). The mean histological scores for AmBi-treated rabbits were lower than those for FLC-treated and control rabbits (P < 0.016 and 0.0005, respectively); the scores for AMB-treated animals were lower than those for the controls (P < 0.0005) but were similar to those for FLC-treated rabbits. All regimens reduced the numbers of CFU in the brain and spinal cord compared with those for the controls (P < or =0.0005). AmBi-treated animals had 3- to 11-fold lower numbers of CFU than FLC-treated rabbits and 6- to 35-fold lower numbers of CFU than AmB-treated rabbits. Three of eight animals given 15 mg of AmBi per kg had no detectable infection in either tissue, whereas other doses of AmBi or FLC cleared either the brain or the spinal cord of infection in fewer rabbits. In addition, clearance of the infection from both tissues was achieved in none of the rabbits, and neither tissue was cleared of infection in AMB-treated animals. Overall, these data indicate that intravenously administered AmBi is superior to oral FLC or intravenous AMB and that FLC is better than AMB against experimental coccidioidal meningitis. These data indicate that AmBi may offer an improvement in the trea

Topics: Amphotericin B; Animals; Antifungal Agents; Body Temperature; Body Weight; Brain; Cerebrospinal Fluid; Coccidioidomycosis; Leukocyte Count; Male; Meningitis; Motor Activity; Posture; Rabbits; Spinal Cord; Survival Analysis

A retrospective chart review and telephone follow-up was conducted on patients who were treated for disseminated coccidioidomycosis involving bones or joints at the Naval Medical Center, San Diego, California from 1993-1999. Thirteen patients were identified, with average follow-up of 36 months. Six patients underwent surgical debridement and systemic medical therapy, and seven patients were treated medically only. All patients improved symptomatically with decreasing complement fixation titers at last follow-up. Five of the six patients treated with combined therapy are currently quiescent. Of those treated medically, four patients are quiescent; three were lost to follow-up. Coccidioidomycosis osteomyelitis remains a rare but difficult disease to treat, with a lifelong risk of recurrence. A combined medical and surgical approach has been shown to be effective, but medical therapy alone with intravenous amphotericin B followed by suppressive azole therapy may be effective in selected patients.

Topics: Adult; Aged; Amphotericin B; Coccidioides; Coccidioidomycosis; Debridement; Female; Humans; Itraconazole; Knee; Magnetic Resonance Imaging; Male; Middle Aged; Osteomyelitis; Pelvis; Retrospective Studies; Treatment Outcome

We investigated the susceptibilities of hyphal, mixed hyphal, ungerminated arthroconidial, and germinated arthroconidial populations of Coccidioides immitis to lipid formulations of amphotericin B and nystatin and their conventional preparations, utilizing the National Committee for Clinical Laboratory Standards M38-P broth macrodilution method. The differences in effects of the three different growth stages of the saprobic phase of C. immitis on the MIC/minimum lethal concentration (MLC) ratio were not statistically significant for any of the antifungal agents tested. These results suggest that either inocula could be used for in vitro susceptibility studies with C. immitis.

Topics: Amphotericin B; Antifungal Agents; Coccidioides; Coccidioidomycosis; Drug Carriers; Humans; Liposomes; Microbial Sensitivity Tests; Nystatin

Coccidioidomycosis, a fungal infection endemic in the southwestern United States, can cause life-threatening infections in immunosuppressed patients. We report the contrasting cases of two adolescents with lupus nephritis, treated with intravenous pulse cyclophosphamide and daily oral corticosteroids, who developed pulmonary coccidioidomycosis. One patient developed a fatal form of fulminant disseminated coccidioidomycosis, while the other patient developed a solitary pulmonary Coccidioides immitis abscess which was responsive to intravenous liposomal amphotericin and fluconazole therapy. Because serologies and initial X-ray studies can be negative, definitive diagnostic studies including bronchoaveolar lavage and needle aspiration should be performed when there is clinical suspicion of coccidioidomycosis in an immunocompromised patient. Immunosuppressed patients with coccidioidomycosis should receive early intravenous amphotericin therapy and may benefit from long-term suppressive antifungal therapy to prevent relapse.

Topics: Abscess; Administration, Oral; Adolescent; Adrenal Cortex Hormones; Amphotericin B; Child; Coccidioidomycosis; Cyclophosphamide; Drug Therapy, Combination; Fatal Outcome; Female; Fluconazole; Humans; Immunosuppressive Agents; Injections, Intravenous; Liposomes; Lung Diseases; Lupus Nephritis; Radiography, Thoracic; Tomography, X-Ray Computed

Topics: Amphotericin B; Antifungal Agents; Coccidioidomycosis; Erythema Nodosum; Female; Fluconazole; Humans; Ketoconazole; Patient Selection; Pregnancy; Pregnancy Complications, Infectious; Risk Factors

AIDS epidemics and intercontinental travels in endemic areas have increased the incidence of endemic mycoses (histoplasmosis, coccidioidomycosis, blastomycosis, penicilliosis). Environmental dimorphic fungi, through an aerial contamination cause them. Frequent in the HIV patients living in endemic areas, they represent an AIDS definition criterion. Most of primary infections are asymptomatic, they may also present as influenza or pneumonia, that will spontaneously recover. A secondary dissemination may especially occur among immunocompromised hosts involving most often the skin, central nervous system and bones. Lastly, a chronic pulmonary presentation may also occur. Direct examination and histology, cultures and serologies establish diagnosis. In all cases of disseminated or chronic infections, a long-term treatment is necessary, using amphotericin B and azoles. Life-time secondary prophylaxis is recommended in AIDS patients.

Topics: Adult; AIDS-Related Opportunistic Infections; Amphotericin B; Antifungal Agents; Blastomycosis; Coccidioidomycosis; Diagnosis, Differential; Fluconazole; Histoplasmosis; Humans; Itraconazole; Ketoconazole; Travel

This study was conducted to review the presentation and management of patients with coccidioidomycosis involving the spine.. The authors reviewed 23 cases of spinal coccidioidomycosis treated at their institutions. There were 20 males and three females who ranged in age from 9 to 62 years. Non-Caucasian individuals were disproportionately represented. Spinal disease was the first manifestation of disseminated coccidioidomycosis in 10 cases. Thirteen patients with meningitis, soft-tissue involvement, or pulmonary involvement developed new spinal lesions despite undergoing continued systemic therapy with amphotericin and/or fluconazole. In all patients computerized tomography and magnetic resonance imaging studies demonstrated preferential involvement of the disc spaces, vertebral bodies, and pedicles with extensive paravertebral phlegmons and retropharyngeal, mediastinal, or psoas abscesses. Despite the significant imaging findings, only four patients presented with a significant neurological deficit. Local pain or radiculopathy was the most common complaint. Twenty patients underwent invasive therapy. In five patients with prominent psoas abscesses and disc space disease, drainage was performed after inserting a percutaneous catheter. Progressive bone destruction necessitated debridement and fusion in one of these patients, and two others had poor outcomes after receiving antifungal therapy alone. Initially 15 patients underwent debridement and fusion in which instrumentation (10 cases) or bone graft alone was used (five cases). One patient worsened neurologically after surgery, and another patient required reoperation for a failed fusion and to correct progressive kyphosis. Four of the 23 patients died of complications related to fungemia. Most of the 15 surviving patients have required long-term antifungal therapy for spinal and extraspinal foci.. Spinal coccidioidomycosis can be an aggressive disease process. Systemic antifungal therapy fails to prevent de novo spinal involvement and is usually insufficient treatment for established spinal disease.

Topics: Adolescent; Adult; Amphotericin B; Child; Coccidioidomycosis; Debridement; Drainage; Drug Therapy, Combination; Female; Fluconazole; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Postoperative Complications; Psoas Abscess; Reoperation; Spinal Fusion; Spondylitis; Tomography, X-Ray Computed; Treatment Failure

Amphotericin B Hydrosomes (AH; Access Pharmaceuticals Inc) are a novel formulation of hydrophilic, heparin-surfaced nanoparticles (mean diameter 105 nm) containing amphotericin B (AmB) designed to target infected sites by local adhesion. AH are cleared in part by a hepatobiliary mechanism, which results in a reduction of AmB concentration in major organs by about 50% in 24 h. In mice with pulmonary blastomycosis, unlike Fungizone (Bristol-Myers Squibb Inc), a deoxycholate micellar formulation of AmB, AH accumulates 3-fold more in infected lungs than normal lungs, between 3 and 24 h post-injection. Histologically, AH accumulates at the sites of lesions. AH is approximately 7-fold less toxic than Fungizone based on acute lethality and histopathological assessment of renal damage. In vitro, AH and Fungizone were equally active against Blastomyces dermatitidis and in vivo they were equivalent in prolonging mouse survival, when compared with equal dosing of AmB. In reducing infectious burdens in vivo, Fungizone was 3-fold more effective than AH on a mg/kg basis of administered AmB. However, AH at 4.8 mg/kg cured 50 to 60% of mice, whereas Fungizone at a near lethal dose of 1.2 mg/kg cured none. The AH formulation of AmB has an improved therapeutic index, relative renal-site avoidance and selective accumulation in infected tissues, which combine to merit additional studies in appropriate fungal models.

Topics: Amphotericin B; Animals; Antifungal Agents; Aspergillosis; Blastomycosis; Chemistry, Pharmaceutical; Chemokine CCL2; Coccidioidomycosis; Humans; Immunohistochemistry; Mice; Microbial Sensitivity Tests

Miliary coccidioidomycosis indicates hematogenous or lymphatic spread of Coccidioides immitis and is characterized by the development of multiple small granulomas throughout the lungs and other organs. Previous reports have suggested that this disorder occurs almost exclusively in immunocompromised patients, with most patients succumbing to progressive respiratory failure. In this article, we describe the largest series of immunocompetent patients with miliary coccidioidomycosis, define clinical characteristics, and outline important aspects of diagnosis and treatment.. We identified eight patients (five men and three women; age range, 23 to 65 years) with miliary coccidioidomycosis diagnosed at Kern Medical Center (located in an endemic area) from 1990 to 1997. Four of the patients were white, two were African American, and two were Hispanic. A miliary pattern was defined as the presence of discrete 2- to 10-mm lesions diffusely distributed throughout both lung fields, as shown on chest radiograph. Microscopic examination and culture of C immitis from sputum, tissue, or body fluid confirmed diagnosis. Patients with HIV were excluded.. These patients constituted approximately 1% of those admitted to our institution for coccidioidomycosis from 1990 to 1997. Four patients had symptoms for < or = 1 week before admission (acute), and four had symptoms for between 5 and 12 weeks (chronic). Four patients demonstrated a miliary pattern on initial chest radiograph, and two of these patients received an initial diagnosis of miliary coccidioidomycosis. Five patients required mechanical ventilation. Arterial blood gas measurements revealed a mean PO(2) of 54.2 +/- 8. 6 mm Hg and a mean PCO(2) of 32.5 +/- 3.2 mm Hg. Five patients developed ARDS. Five patients had extrapulmonary involvement, with the meninges (n = 4) and skin (n = 4) being the most common sites. All patients were treated with fluconazole and/or amphotericin B. Three patients died; all had chronic involvement and received mechanical ventilation.. We present eight immunocompetent patients with a lower mortality rate and better outcome than previously reported. In our series, miliary coccidioidomycosis manifested as either an acute respiratory illness or an advanced stage of a chronic illness occurring in the context of widespread dissemination. All who died had chronic involvement. Prompt recognition of miliary coccidioidomycosis is crucial, but may be hindered by the large differential diagnosis. Important diagnostic factors include a history of travel through endemic areas, ethnicity, immunologic status, involvement of multiple organ sites, and pronounced hypoxemia not accounted for by the degree of pulmonary involvement seen on chest radiograph.

Topics: Adult; Aged; Amphotericin B; Antifungal Agents; Chronic Disease; Coccidioidomycosis; Diagnosis, Differential; Drug Therapy, Combination; Female; Fluconazole; Humans; Immunocompetence; Lung Diseases, Fungal; Male; Middle Aged; Respiration, Artificial; Survival Rate

To describe the clinical and laboratory parameters of patients with septic shock following infection with Coccidioides immitis, estimate the incidence of septic shock from coccidioidomycosis, and outline clues that may be helpful in early diagnosis of this syndrome.. Retrospective, descriptive case series.. A 250-bed general public hospital in Kern County, CA.. Eight patients diagnosed with septic shock from infection with C. immitis from September 1991 to December 1993. Five were Hispanic, two were Filipino, and one was African-American. The diagnosis of C. immitis was made by microscopic examination and culture of the organism from sputum or other sites. Septic shock was diagnosed using criteria formulated by the American College of Chest Physicians Consensus Conference/Society of Critical Care Medicine.. No patient had traditional immunocompromising conditions. All patients had pulmonary symptoms and were symptomatic for a mean duration of 19.4 +/- 19.8 days before admission. One patient presented with septic shock and the remaining seven developed shock during their hospital course. Serology for coccidioidomycosis was positive in six patients. The mean cardiac index was 5.8 +/- 1.9 (SD) L/min/m2, the mean arterial pressure was 71.0 +/- 16.7 mm Hg, the mean pulmonary artery occlusion pressure was 16.9 +/- 3.5 mm Hg, and the mean systemic volume resistance index was 846.6 +/- 224.1 dyne-sec/cm5xm2. All patients developed acute respiratory distress syndrome. Coccidioidomycosis was recognized or considered in only five of eight patients before they developed septic shock. Despite therapy with amphotericin B, all patients died. One patient died of progressive pulmonary disease, two patients suffered an acute arrest, and five patients developed progressive multiple organ system failure and died with additional organ involvement.. Septic shock following infection with C. immitis is an ominous yet underrecognized condition. Hemodynamic parameters and cytokine concentrations were not significantly different from values seen in gram-negative septic shock. Clinical clues to the diagnosis include duration of illness and conspicuous pulmonary involvement. Patient outcome in this series was poor but may improve with increased recognition of septic shock in infections from C. immitis.

Topics: Adult; Aged; Aged, 80 and over; Amphotericin B; Antibodies, Fungal; Antifungal Agents; Case-Control Studies; Coccidioides; Coccidioidomycosis; Female; Humans; Lung Diseases, Fungal; Male; Middle Aged; Respiratory Distress Syndrome; Retrospective Studies; Shock, Septic; Sputum; Treatment Outcome

Coccidioidomycosis is endemic in regions of the Americas, but this infection may be encountered in travellers who return from an endemic region. A case is reported of a disseminated infection in a Hong Kong Chinese man, who was successfully treated with amphotericin B lipid complex (ABLC) after intolerance and toxicity precluded the use of other antifungal agents. Lipid-based formulations of amphotericin B merit further evaluation in the treatment of coccidioidomycosis and other systemic mycoses.

Topics: Adult; Amphotericin B; Antifungal Agents; Coccidioidomycosis; Drug Combinations; Humans; Male; Phosphatidylcholines; Phosphatidylglycerols; Treatment Outcome

To describe ocular findings in 2 patients with disseminated coccidioidomycosis diagnosed by skin biopsy.. The clinical and histopathologic findings of the 2 patients were reviewed retrospectively.. One patient had a unilateral, granulomatous iridocyclitis with multiple iris nodules and a large vascularized anterior chamber mass, in the setting of pulmonary, cutaneous, and skeletal infection by Coccidioides immitis. The second patient developed papilledema and multifocal chorioretinitis accompanied by pulmonary, cutaneous, and meningeal C immitis infection. In each case, examination of the skin biopsy specimen revealed C immitis spherules. Treatments included local and systemic amphotericin B and oral fluconazole.. Although rare, intraocular involvement can occur in the setting of disseminated coccidioidomycosis. A thorough systemic evaluation and biopsy of suspicious skin lesions can aid in the diagnosis.

Topics: Adult; Amphotericin B; Biopsy; Bone Diseases; Brain Diseases; Chorioretinitis; Coccidioidomycosis; Dermatomycoses; Eye Infections, Fungal; Female; Fluconazole; Humans; Iridocyclitis; Lung Diseases, Fungal; Male; Radiography; Radionuclide Imaging; Retrospective Studies; Skin; Technetium Tc 99m Pyrophosphate

Topics: Adult; Amphotericin B; Anaphylaxis; Antifungal Agents; Coccidioidomycosis; Drug Combinations; Humans; Injections, Intravenous; Injections, Intraventricular; Lipids; Male; Meningitis, Fungal; Phosphatidylcholines; Phosphatidylglycerols

The skin is frequently a site of extrapulmonary dissemination in patients with coccidioidomycosis. Clinical experience in an endemic area suggests an association between facial cutaneous coccidioidomycosis and meningitis. Awareness of this association is important because coccidioidal meningitis is the most ominous site of spread in coccidioidomycosis. In this study, we assess whether cutaneous dissemination involving the face is associated with meningitis to a greater degree than that limited to the body. We retrospectively reviewed the medical records of 201 patients from 1987 to 1996 with disseminated coccidioidomycosis and found 30 patients with cutaneous involvement. Their mean age was 29.5 +/- 11.6 years; 20 patients were male; 14 were African American, 12 were Hispanic, 3 were white, and 1 was Asian. Nineteen patients had facial involvement, and 11 had isolated body involvement. Meningitis developed in 11 patients, 10 with facial involvement and 1 with only body involvement. Patients with facial lesions were more likely to have meningitis (odds ratio, 11.1; 95% confidence interval, 1.1 to 529, P = .023). The identification of a subgroup of patients at significant risk of developing meningitis may allow earlier detection and perhaps improved management of patients with meningeal disease.

Topics: Adult; Amphotericin B; Antifungal Agents; Coccidioidomycosis; Confidence Intervals; Dermatomycoses; Facial Dermatoses; Female; Fluconazole; Humans; Male; Meningitis, Fungal; Odds Ratio; Retrospective Studies

Topics: Amphotericin B; Antifungal Agents; Coccidioidomycosis; Fluconazole; Humans; Immunocompromised Host; Itraconazole; Lung Diseases, Fungal; Pneumonia

Eight (0.59%) of 1,347 patients who underwent liver transplantation at the UCLA Medical Center (Los Angeles) developed coccidioidomycosis. Whereas only one case occurred during the first 8 years and 10 months of the UCLA Liver Transplant Program (February 1984 to December 1992), seven cases occurred within the following 23-month period (December 1992 to November 1994). The median time of onset for infection after transplantation was 8 weeks (range, 4-312 weeks). Clinical presentations of patients with coccidioidomycosis included pneumonia (six cases), pneumonia with meningitis (one case), hepatitis (one case), and monoarticular arthritis (one case). Despite therapy with amphotericin B alone (six cases) or amphotericin B plus fluconazole (two cases), infection was fatal in four of eight cases. As of this writing, the four surviving patients are receiving chronic maintenance therapy with either fluconazole (three patients) or itraconazole (one patient). These experiences show that coccidioidomycosis can be a serious and frequently fatal infection after liver transplantation and that the incidence of this disease appears to be increasing.

Topics: Adult; Aged; Amphotericin B; Coccidioidomycosis; Female; Fluconazole; Humans; Liver Transplantation; Male; Middle Aged

SCH 56592 (SCH) is a new triazole antifungal with a broad spectrum of activity. In vitro susceptibility testing against five strains of Coccidioides immitis revealed MICs from 0.39 to 3.13 microg/ml and minimal fungicidal concentrations from 1.56 to 3.13 microg/ml. A murine model of systemic coccidioidomycosis was established in female CD-1 mice. Groups received either no treatment or oral therapy with fluconazole at 10 or 100 mg/kg of body weight; itraconazole at 10 or 100 mg/kg; SCH at 0.5, 2, 10, or 25 mg/kg; or its methylcellulose diluent alone. Therapy began 2 days postinfection and continued once daily for 19 days. Surviving mice were euthanized 49 days postinfection, and infectious burdens were determined by culture. All drugs were superior to no-treatment or diluent-treatment controls (P < 0.001) in prolonging survival but were not significantly different from one another. Itraconazole at 100 mg/kg was superior to fluconazole in reduction of CFU in the spleen, liver, and lung (P < 0.01 to 0.001). SCH at 0.5 mg/kg was superior to either fluconazole or itraconazole at 10 mg/kg in reduction of CFU in all three organs (P < 0.05 to 0.001). SCH at 2 mg/kg was not significantly different from itraconazole at 100 mg/kg in all three organs. SCH at 10 and 25 mg/kg was superior to either dose of fluconazole or itraconazole in all three organs (P < 0.05 to 0.001). In terms of reduction of CFU, SCH was > or = 200-fold as potent as fluconazole and > or = 50-fold as potent as itraconazole. There was a clear dose-responsive relationship for SCH in each of the organs. It is noteworthy that SCH effected cures (no detectable C. immitis in any organ) in 1 of 9, 6 of 10, or 9 of 9 surviving mice in animals given 2, 10, or 25 mg/kg, respectively. Neither fluconazole nor itraconazole cured any survivor. SCH has potent, fungicidal activity in vivo against C. immitis. It should be considered for clinical trials in patients with coccidioidomycosis.

Topics: Amphotericin B; Animals; Antifungal Agents; Coccidioides; Coccidioidomycosis; Drug Evaluation, Preclinical; Female; Itraconazole; Mice; Mice, Inbred Strains; Microbial Sensitivity Tests; Triazoles

Topics: Amphotericin B; Anorexia; Antifungal Agents; Aspergillosis; Blastomycosis; Candidiasis; Coccidioidomycosis; Cryptococcosis; Cytochrome P-450 CYP3A; Cytochrome P-450 Enzyme Inhibitors; Dose-Response Relationship, Drug; Drug Interactions; Fluconazole; Flucytosine; Gynecomastia; Histoplasmosis; Humans; Itraconazole; Ketoconazole; Kidney Diseases; Liposomes; Male; Mixed Function Oxygenases; Mucormycosis; Nausea; Paracoccidioidomycosis; Sporotrichosis; Teratogens

Topics: Abnormalities, Multiple; Adult; Amphotericin B; Antifungal Agents; Coccidioides; Coccidioidomycosis; Female; Fluconazole; Humans; Infant, Newborn; Male; Meningitis, Fungal; Osteochondrodysplasias; Pregnancy; Pregnancy Complications, Infectious

Relapse after apparently successful treatment of coccidioidomycosis has been a problem with both amphotericin B and the azoles. We conducted a retrospective cohort study of 34 patients who required therapy for coccidioidomycosis between 1973 and 1993; 10 relapsed and 25 (one patient received two courses of therapy) did not relapse during follow-up. The mean time to relapse after completion of therapy was 7.3 months (range, 1-21 months). All 34 patients responded clinically to therapy. A fourfold or greater decrease in titers of antibody, as determined by complement fixation (CF), during therapy was seen in seven (78%) of nine patients who relapsed and 17 (85%) of 20 patients who did not relapse (P = .956). There was no significant difference between relapsers and nonrelapsers in terms of the lowest CF titer during therapy, the CF titer at the end of therapy, or the peak CF titer. The risk of relapse was increased among those with a peak CF titer of > or = 1:256 (relative risk [RR] = 4.7; 95% confidence interval [CI] = 1.4-16.1), as compared with patients who did not mount such a high antibody response. Similarly, the risk of relapse was higher among those with serially negative coccidioidin skin tests (CSTs) than those with serially positive CSTs (RR = 4.8; 95% CI = 1.2-19.5). We conclude that clinical response, lowest CF titer, end-of-therapy CF titer, and decrease in the CF titer of at least fourfold are not predictive of relapse in patients with coccidioidomycosis. Negative serial coccidioidin skin tests and a peak CF antibody titer of > or = 1:256 are independently associated with increased risk of relapse.

Topics: Adolescent; Adult; Amphotericin B; Antifungal Agents; Coccidioidomycosis; Cohort Studies; Female; Fluconazole; Follow-Up Studies; Humans; Ketoconazole; Male; Middle Aged; Predictive Value of Tests; Recurrence; Retrospective Studies

Coccidioides immitis is a dimorphic fungus primarily found in the soil in a limited region of the southwestern United States. When this fungus causes an infection (coccidioidomycosis), it is due to the spores being inhaled and causing an inflammation of the respiratory tract. In most cases, the infection is self-limiting and is controlled by cell-mediated immunity. In HIV-infected patients, it is thought that the infection may be newly acquired, or reactivated, from a former incident. Patients with a CD4 count under 250 are at highest risk for becoming infected, and may present with pneumonia, fever, weight loss, night sweats, cough, and dyspnea. The infection can also become disseminated, and upon autopsy, widespread disease is found in the majority of patients that die of coccidioidomycosis. Chest x-rays show a diffuse reticulonodular infiltrate, then diagnosis is made by culturing the organism. The treatment of choice for disseminated disease is amphotericin B and alternative therapies including itraconazole and fluconazole, with possible lifelong treatment necessary. There is no current evidence that coccidioidomycosis can be prevented by any of these drugs.

Topics: Amphotericin B; Antifungal Agents; Coccidioides; Coccidioidomycosis; Fluconazole; HIV Infections; Humans; Itraconazole; Risk Factors; Southwestern United States

New approaches to the diagnosis, treatment, and prevention of fungal infections were discussed at Focus on Fungal Infections in 1997. This article examines the use of early presumptive treatment for candida fungemia, the cause of and treatment for recurrent vulvovaginal candidiasis, and the treatment and prevention practices for invasive aspergillosis. The efficacy of using amphotericin B lipid complex, amphotericin B in colloidal dispersion, and liposomal amphotericin B in patients with fungal infections is also discussed. Concluding comments address how serious a problem antifungal resistance is in choosing treatment regimens and the new and upcoming strategies for treating coccidioidomycosis in patients who are immunosuppressed.

Topics: AIDS-Related Opportunistic Infections; Amphotericin B; Antifungal Agents; Aspergillosis; Candidiasis; Coccidioidomycosis; Dosage Forms; Drug Carriers; HIV Infections; Humans; Liposomes; Mycoses

A destructive granulomatous lesion of the temporal bone caused by Coccidioides immitis disseminated from a pulmonary lesion was found in a 4-year-old immunocompetent child. To our knowledge, it is the first case of coccidioidomycosis of the temporal bone reported in the world literature. The child presented with pain in her right ear and a 6-month history of intermittent fever, which partially responded to multiple courses of antibiotics. A tender erythematous postauricular swelling consistent with a subperiosteal abscess subsequently developed over 1 month. A mastoidectomy showed granulation tissue with pockets of purulence, and histologic evaluation of the specimen revealed spherules of C immitis, later verified by culture. The patient responded to intravenous amphotericin B therapy, without evidence of disease recurrence. Coccidioides immitis is endemic in regions of the Southwestern United States, with extremely infectious characteristics and relative resistance to medical therapy. Coccidioidomycosis should be considered in the differential diagnosis of a granulomatous lesion of the temporal bone.

Topics: Abscess; Amphotericin B; Antifungal Agents; Chemotherapy, Adjuvant; Child, Preschool; Coccidioidomycosis; Diagnosis, Differential; Female; Humans; Immunocompromised Host; Lung Diseases, Fungal; Periostitis; Temporal Bone

Topics: Adult; Amphotericin B; Antifungal Agents; Biopsy; Cholangiography; Cholangiopancreatography, Endoscopic Retrograde; Choledochostomy; Cholestasis; Coccidioides; Coccidioidomycosis; Eosinophilia; Fluconazole; Humans; Male

A case of bilateral isolated adrenal coccidioidomycosis in a previously healthy and immunocompetent 43-year-old Caucasian male is presented. He had never travelled to a coccidioidomycosis endemic area. Subclinical adrenal dysfunction was found with elevated plasma ACTH and mineralocorticosteroid and androgen pathway abnormalities. The implement of the fungal infection on adrenal function, and the diagnosis and management of adrenal coccidioidomycosis are discussed.

Topics: Adrenal Gland Diseases; Adrenal Glands; Adult; Amphotericin B; Antifungal Agents; Biopsy; Coccidioidomycosis; Cortisone; Fluconazole; Humans; Male; Sweden

Disseminated coccidioidomycosis is a systemic fungal infection that is occurring more commonly and causes high mortality in patients with compromised host defense or debilitated. It is endemic in certain areas of North, Central, and South America. Increasingly, cases are being recognized outside the endemic area, due to travelers who have visited an endemic area. We experienced a case of disseminated coccidioidomycosis, as a reactivation of infection acquired earlier in a patient, who was a former resident of an endemic area.

Topics: Amphotericin B; Coccidioidomycosis; Female; Humans; Middle Aged

Coccidioidomycosis is a fungal infection endemic to the southwestern United States. Musculoskeletal involvement is rare, and there are few reports with clear recommendations regarding treatment. The purpose of this study was to review a series of 25 patients with musculoskeletal coccidioidomycosis and to assess their outcomes with respect to presentation and treatment. There were 36 lesions among the 25 patients, 8 located in the spine, with the remainder distributed throughout the body. Seventeen patients had a delay in diagnosis of more than 1 month. Eight patients had an elevated white blood cell count, and 10 had an elevated sedimentation rate. Only 7 of the patients had an overt pneumonia before the musculoskeletal presentation. Twenty-four patients underwent formal irrigation and debridement and 22 patients had at least 1 course of Amphotericin B. The average followup after the initiation of treatment was 3.5 years, ranging from 2 to 10 years. Seven patients had recurrent lesions that required further surgical intervention, 4 of whom had a delay in diagnosis of more than 1 month. There were 3 deaths. All surviving patients were free of disease at final followup.

Topics: Adolescent; Adult; Amphotericin B; Antifungal Agents; Child; Child, Preschool; Coccidioidomycosis; Debridement; Diagnostic Errors; Fatal Outcome; Female; Follow-Up Studies; Humans; Infant; Male; Middle Aged; Musculoskeletal Diseases; Therapeutic Irrigation; Treatment Outcome

A patient was treated for lobar pneumonia due to coccidioidomycosis. When the pneumonia recurred, the patient was found to have an arteriovenous malformation, which had become infected. Complete resolution was achieved with resection and postoperative amphotericin B therapy.

Topics: Adult; Amphotericin B; Arteriovenous Malformations; Coccidioidomycosis; Female; Humans; Lung; Pneumonia, Pneumococcal; Recurrence

ICR mice were infected intranasally with arthroconidia of Coccicioides immitis. Mice were treated intravenously with amphotericin B deoxycholate (Fungizone) or an amphotericin B-lipid vehicle (AmBisome). Doses ranged from 0.05 to 1.0 mg kg-1. Lung weight, which parallels disease severity and fungal burden in this infection, was used as the index of protection. Both Fungizone and AmBisome were significantly and equally protective at 0.3 and 1.0 mg kg-1 body weight.

Topics: Amphotericin B; Animals; Coccidioidomycosis; Lung Diseases, Fungal; Mice; Mice, Inbred ICR

Topics: Adult; Amphotericin B; Cardiomyopathy, Dilated; Coccidioidomycosis; Humans; Male

Coccidioidomycosis has reached epidemic proportions in the southwest region of the United States. Despite the greater numbers of cases, isolated anterior segment ocular coccidioidomycosis in the absence of systemic infection continues to be rare, although its incidence may be increasing.. Two patients without clinical evidence of systemic disease and one patient with previously treated pulmonary coccidioidomycosis had granulomatous iridocyclitis and iris nodules that were unresponsive to corticosteroid therapy. All three patients underwent iris biopsy, anterior chamber tap, and washout for histopathologic diagnosis of anterior segment disease, and all subsequently received systemic antifungal therapy. Two patients also received multiple intraocular injections of amphotericin B.. Papanicolaou and hematoxylin-eosin-stained preparations of anterior chamber tap and biopsies of the iris in each of these patients showed fibrinopurulent or granulomatous inflammatory exudate with intact and disrupted Coccidioides spherules. Despite aggressive systemic and intraocular therapy, one patient required enucleation for a blind, painful eye. The other two patients continue to have limited visual acuity but with at least partial resolution of the intraocular lesions.. Ocular coccidioidomycosis without clinical evidence of systemic involvement is rare. Isolated anterior segment disease is also uncommon; however, because of the current epidemic in the southwest region of the United States, ocular coccidioidomycosis should be considered in any patient who traveled through or lived in endemic areas and who has a granulomatous iridocyclitis associated with iris mass that is unresponsive to corticosteroid therapy.

Topics: Amphotericin B; Biopsy; Coccidioidomycosis; Eye Infections, Fungal; Female; Humans; Iridocyclitis; Iris; Male; Middle Aged

Intrathecal administration of amphotericin B is the best method of eradicating intracranial fungal infections. The Ommaya reservoir provides an easy and practical method for fungicidal medication administration. Treatment of coccidioidomycosis with amphotericin B may be accomplished via an Ommaya reservoir. Astute nursing care is essential to prevent complications associated with this procedure.

Topics: Amphotericin B; Brain Abscess; Catheters, Indwelling; Cerebral Ventricles; Coccidioidomycosis; Humans; Injections, Spinal; Male; Meningitis; Middle Aged; Patient Care Planning

Topics: Adult; Amphotericin B; Bone Marrow Transplantation; Coccidioidomycosis; Female; Humans; Leukemia, Promyelocytic, Acute; Lung Diseases, Fungal; Male; Middle Aged; Multiple Myeloma; Opportunistic Infections; Precursor Cell Lymphoblastic Leukemia-Lymphoma

A 10-month-old Hispanic male infant with expansile lesions of the third metacarpal and proximal phalanx positively diagnosed as Coccidioides immitis osteomyelitis is presented. Treatment consisted of combined surgical debridement and systemic antifungal therapy and resulted in complete resolution of the lesions. Treatment was guided by clinical response and complement fixation titers. Osteomyelitis is a relatively infrequent manifestation of disseminated coccidioidomycosis. Neonates and infants appear to be more susceptible to the development of dissemination, but less likely to develop toxicity due to systemic therapy. Current therapy consists of concomitant surgical excision of involved lesions and systemic antifungal therapy. Complement fixation titers correlate closely with clinical response to therapy and are useful in detecting subclinical recurrences.

Topics: Amphotericin B; Coccidioidomycosis; Combined Modality Therapy; Curettage; Hand; Humans; Infant; Male; Osteomyelitis

Topics: Adult; AIDS-Related Opportunistic Infections; Amphotericin B; Coccidioidomycosis; Humans; Male; Ontario

Fifteen confirmed cases of equine coccidioidomycosis that originated in California and Arizona were studied retrospectively. Age, breed, and sex varied among affected horses. The most common historical problems were chronic weight loss (53% of cases) and persistent cough (33% of cases). The most frequent physical examination abnormalities were related to the respiratory tract (60% of cases). In 27% of cases, horses had signs of musculoskeletal pain. Horses consistently had hyperproteinemia, hyperfibrinogenemia, leukocytosis, and neutrophilia. An antemortem etiologic diagnosis was made for 11 (73%) horses, all of which had positive serologic tests for coccidioidomycosis. Of the seropositive horses, 5 (46%) also had positive cultures for Coccidioides immitis. One horse died naturally. The other 14 were euthanatized. Prolonged treatment with specific antifungal agents was attempted in 4 horses without apparent benefit. Postmortem abnormalities included pulmonary parenchymal lesions (64% of cases), thoracic lymphadenopathy (57% of cases), hepatic parenchymal involvement (43% of cases), and osteomyelitis (29% of cases). The lesions were granulomatous or pyogranulomatous and C immitis was observed microscopically in 83% of cases.

Topics: Amphotericin B; Animals; Arizona; California; Coccidioidomycosis; Female; Horse Diseases; Horses; Ketoconazole; Male; Retrospective Studies; Treatment Outcome

Coccidioidomycosis is accepted as being noncontagious because the infectious arthroconidial form of Coccidioides immitis is not produced in humans and other mammalian hosts. However, disseminated coccidioidomycosis developed in a veterinarian who autopsied a horse with disseminated disease but without draining lesions or productive cough. We postulate transmission occurred by inhalation of tissue-phase endospores aerosolized in the course of dissection.

Topics: Adult; Amphotericin B; Animals; Autopsy; Coccidioides; Coccidioidomycosis; Horse Diseases; Horses; Humans; Lung Diseases, Fungal; Male; Meningitis, Fungal; Occupational Diseases; Spores, Fungal; Veterinary Medicine

The comparative activities of two preparations of amphotericin B against Coccidioides immitis were investigated. These preparations were a deoxycholate suspension (conventional amphotericin B) and a lipid-based formulation, amphotericin B lipid complex (ABLC). In-vitro susceptibility testing demonstrated that the MICs of ABLC were < or = 0.25 mg/L and of conventional amphotericin B were 0.5 mg/L for C. immitis. However, conventional amphotericin B was at least four-fold more fungicidal, with a minimum fungicidal concentration of 4.0 vs > 16 mg/L for ABLC. The therapeutic efficacies were tested in murine models of acute systemic coccidioidomycosis. Female CD-1 mice were infected iv with C. immitis arthroconidia to establish high (> 50%) or low (< 50%) mortality models. Therapy with conventional amphotericin B or ABLC was given three times per week for two weeks starting three days post-infection. Controls received no therapy or drug-free diluent only. Survival was tallied up to 49 days post-infection and the fungal cfu counts in spleen, liver, and lungs of all survivors were determined. In the low mortality study all treated mice survived and all therapy regimens reduced infection in all organs. All mice given ABLC 6.6 or 13.2 mg/kg/dose and 80% given ABLC 16.5 mg/kg/dose, as well as 90% given conventional amphotericin B 0.66 mg/kg/dose were free of infection; all controls remained infected. In two high mortality studies, all mice given ABLC 0.66-20 mg/kg/dose or conventional amphotericin B 0.22 or 0.66 mg/kg/dose survived compared with 0-20% of controls. Thirty per cent of uninfected mice given ABLC 20 mg/kg/dose and 40% given conventional amphotericin B 2.0 mg/kg/dose died due to drug toxicity. Mice given ABLC or conventional amphotericin B had lower residual cfu counts of C. immitis in all organs than did controls. Sixty to one hundred per cent of mice given ABLC regimens > or = 6.6 mg/kg/dose were cured, whereas all controls and 50-60% of mice receiving the highest non-toxic conventional amphotericin B regimen (0.66 mg/kg/dose) remained infected. At equal non-toxic amphotericin B doses, conventional amphotericin B was more effective than ABLC in reducing cfu in infected organs.(ABSTRACT TRUNCATED AT 400 WORDS)

Topics: Amphotericin B; Animals; Antifungal Agents; Coccidioidomycosis; Deoxycholic Acid; Drug Combinations; Female; Mice; Microbial Sensitivity Tests

To assess the efficacy of amphotericin B lipid complex (ABLC) in the treatment of coccidioidal meningitis, we compared a wide range of doses (0.35-15 mg kg-1, intravenously (IV)) of ABLC with amphotericin B deoxycholate (AmB) (0.3-7 mg kg-1, intraperitoneally (IP)) and (IV) and a new triazole, SCH 39304 (SCH), in an experimental murine model. Survival data showed high dose ABLC to be of equal efficacy to IV and high dose IP AmB and SCH. Quantitative studies confirmed this outcome. No acute toxicity with ABLC, at the doses employed, was found. We conclude that ABLC is effective in the treatment of murine coccidioidal meningitis.

Topics: Amphotericin B; Animals; Antifungal Agents; Coccidioidomycosis; Drug Carriers; Liposomes; Meningitis, Fungal; Mice; Triazoles

Peritoneal coccidioidomycosis is extremely rare. This report describes a patient infected with the human immunodeficiency virus who presented with unexplained ascites and was found to have peritoneal coccidioidomycosis. The ascites had a low serum-ascites albumin gradient, and laparoscopy showed peritoneal implants that grew Coccidioides immitis. This case is unique in several ways; this is the first case in which a patient's acquired immunodeficiency syndrome-defining illness was peritoneal coccidioidomycosis, and the serum-ascites albumin gradient determination as well as laparoscopy provided information critical to the diagnosis. This patient's dramatic response to systemic antifungal therapy, as evidenced by resolution of ascites and constitutional symptoms, underscores the importance of timely diagnosis and prompt therapy. In summary, this report reviews the previous cases of coccidioidal peritonitis and reports the first case in which localized peritoneal coccidioidomycosis was the acquired immunodeficiency syndrome-defining illness in a human immunodeficiency virus-infected patient.

Topics: Adult; Amphotericin B; Ascites; Blood Cell Count; Coccidioidomycosis; Humans; Laparoscopy; Male; Peritoneum; Peritonitis; Serum Albumin

Topics: Adult; Amphotericin B; Coccidioidomycosis; Diabetes Mellitus, Type 1; Humans; Lung Diseases, Fungal; Male; Pleural Effusion

Coccidioidal osteomyelitis is difficult to diagnose. Confirmation depends on culture and histopathological examination. This rare type of fungal osteomyelitis is to be considered in the differential diagnosis of a chronic infection in some areas of the world. Specific treatment with excision and amphotericin-B can be effective.

Topics: Amphotericin B; Coccidioides; Coccidioidomycosis; Debridement; Foot Ulcer; Humans; Male; Metatarsus; Middle Aged; Osteomyelitis

The efficacy of a novel sterol-complexed preparation of amphotericin B, amphotericin B colloidal dispersion, was compared with that of deoxycholate-complexed amphotericin B in an acute murine model of systemic coccidioidomycosis. Mice (CD-1, female) were infected intravenously with 180 or 200 arthroconidia of Coccidioides immitis, and intravenous therapy was begun 3 days later. Six doses in various regimens of either preparation were given over 14 days, and deaths were tallied for an additional 35 days. All regimens that were not acutely lethal prolonged the survival of mice over that of controls (P less than 0.001). Quantitative determination of residual burdens of C. immitis in the spleen, liver, and lungs of survivors revealed that the colloidal dispersion was not as effective as the deoxycholate suspension on a milligram-per-kilogram basis. Deoxycholate suspension at 1.3 mg/kg cleared the organs in all mice, whereas colloidal dispersion at 5.0 mg/kg was the lowest dose that cleared organisms from all animals. Lower doses cleared organisms from fewer animals or cleared only selected organs. Deoxycholate suspension was more efficacious than colloidal dispersion in clearing C. immitis from the liver or lungs (P less than 0.05 to 0.01, dose and organ dependent) at identical doses. No overt toxicity was observed in mice treated with colloidal dispersion at 10 mg/kg. In contrast, deoxycholate suspension at 2.0 mg/kg was acutely toxic; 50% of the treated mice died after treatment. The two complexes were not equivalent on a milligram-per-kilogram basis; the deoxycholate suspension was three to four times more efficacious and also greater than 5- to greater than or equal to 8-fold more toxic. Thus, the therapeutic index of the colloidal dispersion complex is greater than that of the deoxycholate complex. The amount of amphotericin B per dose could also be increased when given as a colloidal dispersion to an optimally level. Amphotericin B colloidal dispersion shows promise for the therapy of disseminated coccidioidomycosis and should be tested in other animal models and in humans.

Topics: Amphotericin B; Animals; Coccidioides; Coccidioidomycosis; Colloids; Deoxycholic Acid; Female; Mice; Suspensions

Fluconazole is a recently licensed antifungal agent that has gained widespread use in the medical community. Despite a lack of controlled trials in invasive fungal infections, this agent is often prescribed because of ease of administration and concern over amphotericin B toxicity. Three cases of systemic fungal infections in which fluconazole use resulted in unambiguous microbiologic and clinical failure are reported.

Topics: Amphotericin B; Candidiasis; Coccidioidomycosis; Fluconazole; Humans; Male; Middle Aged; Tomography, X-Ray Computed; Treatment Outcome

Through a retrospective review, we identified 77 previously unreported cases of coccidioidomycosis during HIV infection. Patients were classified into 1 of 6 categories based on their primary clinical presentation: 20 had focal pulmonary disease (Group 1), 31 had diffuse pulmonary disease (Group 2), 4 had cutaneous coccidioidomycosis (Group 3), 9 had meningitis (Group 4), 7 had extrathoracic lymph node or liver involvement (Group 5), and 6 has positive coccidioidal serology without a clinical focus of infection (Group 6). Coccidioidal serologies were positive on initial testing in 83% of the patients in whom such serologic testing was performed. Sera from 39% of patients were positive for TP antibodies while 74% had CF antibodies. Eleven of 12 seronegative patients had pulmonary disease (Group 1 or 2). Serologic results of other patients sent to a single reference laboratory were similar, with 26% positive for immunodiffusion TP antibodies and 79% positive for immunodiffusion CF antibodies. For the 77 patients in this study, the CD4-lymphocyte count was below 0.250 X 10(9) cells/L in 46 of the 55 patients who had this test performed, and a low CD4 count was significantly associated with mortality (p less than 0.01). At the time of follow-up, 32 of the 77 patients (42%) had died. There were significantly more deaths in those with diffuse pulmonary disease (Group 2) than in other groups (p less than 0.001). Amphotericin B, ketoconazole, fluconazole, and itraconazole were all used as antifungal therapies. Outcome could not be related to the therapy used. Of note, 3 patients developed coccidioidomycosis while receiving ketoconazole for other conditions.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Adult; Amphotericin B; Arizona; California; Coccidioidomycosis; Dermatomycoses; Female; Follow-Up Studies; HIV Infections; Humans; Ketoconazole; Leukocyte Count; Liver Diseases; Lung Diseases, Fungal; Lymphatic Diseases; Male; Meningitis; Retrospective Studies; T-Lymphocytes, Helper-Inducer

Topics: Administration, Oral; Aged; Alberta; Amphotericin B; Arizona; Coccidioides; Coccidioidomycosis; Female; Fluconazole; Humans; Injections, Spinal; Male; Meningitis; Travel

A case of coccidioidal meningitis following an open-head injury is presented. A 6-year-old boy was ejected from a motor vehicle as it was driven over a cliff, resulting in a severe open-skull fracture with grossly contaminated wounds. The accident occurred in an area in which coccidioidomycosis is endemic, and the causative agent, Coccidioides immitis, is found in high concentration in the soil. In addition to fracture reduction, the child received a course of intrathecal and intravenous amphotericin and achieved a satisfactory clinical response.

Topics: Amphotericin B; California; Child; Coccidioidomycosis; Craniocerebral Trauma; Humans; Male; Meningitis; Tomography, X-Ray Computed; Wound Infection

A woman with coccidiodal meningitis had two successive pregnancies and was treated with intrathecal amphotericin B. The outcome was successful.

Topics: Adult; Amphotericin B; Coccidioides; Coccidioidomycosis; Drug Administration Schedule; Female; Humans; Injections, Intravenous; Injections, Spinal; Meningitis; Pregnancy; Pregnancy Complications, Infectious; Recurrence

Fifteen patients with coccidioidal meningitis were treated with high doses of ketoconazole for up to 4 years. Five patients were treated with ketoconazole alone. One clinically failed, one developed hepatotoxicity, and three achieved remission of meningitis. One patient received intrathecal AMB in addition to ketoconazole for only 2 weeks before continuing on ketoconazole alone. He improved, but discontinued ketoconazole because of nausea and vomiting, and suffered a lethal relapse. Nine patients received ketoconazole in combination with prolonged courses of intrathecal AMB. Two patients were failures from nausea and vomiting, and the remaining seven either improved or experienced remission. The clinical responses appeared to be similar in patients receiving high-dose ketoconazole, either alone or combined with AMB, suggesting that there is no clinically significant antagonism of the drugs. Nausea and vomiting are significant limitations of high-dose ketoconazole. Ketoconazole alone is effective in some patients with coccidioidomycotic meningitis.

Topics: Amphotericin B; Coccidioidomycosis; Drug Therapy, Combination; Humans; Ketoconazole; Leukocyte Count; Meningitis

AME appeared to be as effective as AmB in the treatment of mycoses in humans. AME was much less nephrotoxic than AmB, and was better tolerated in terms of rapid onset and reversible adverse reactions. AME may be more ototoxic than AmB. AME, even as AmB and OAME, may cause neurotoxicity and leukoencephalopathy, particularly when high doses are given for long periods.

Topics: Adult; Aged; Amphotericin B; Antifungal Agents; Candidiasis; Coccidioidomycosis; Cryptococcosis; Female; Follow-Up Studies; Humans; Male; Middle Aged; Mycoses

The therapeutic effect of recombinant human interleukin 2 (rH IL-2) was assessed in experimental murine coccidioidomycosis by daily IV injection for 30 days of doses ranging decimally from 2.5 X 10(1) to 2.5 X 10(5) units. The treatment with rH IL-2 had neither adverse nor salutary effects.

Topics: Amphotericin B; Animals; Coccidioidomycosis; Female; Interleukin-2; Liver; Lung; Mice; Recombinant Proteins; Spleen

The mortality related to coccidioidal meningitis (CM) has been reduced since the introduction of amphotericin B therapy, but children with CM continue to suffer significant morbidity. Some of this is related to the toxicity of the drug. We report nine children with CM treated with orally administered ketoconazole and intraventricularly administered miconazole. Four of them had been treated initially with amphotericin B with resultant failure in one and severe toxicity in all four. The other five children were treated only with imidazoles. All nine children had evidence of ventriculitis at the time of diagnosis and had ventriculoperitoneal shunts inserted for control of increased intracranial pressure. There was no relapse or recrudescence of CM in a follow-up period of 32 to 90 months on imidazole therapy. The coccidioidal complement-fixation antibody titers in the cerebrospinal fluid of the lateral ventricle became negative in all children 3 to 51 months after diagnosis (mean, 17 months). The serum antibody titers demonstrated a 16- to 256-fold decrease from their maximal levels. Four children are still receiving intraventricular miconazole whereas the others have not received miconazole for an average of 51 months. Therapy with the imidazoles was well-tolerated. The main morbidity was related to the shunts required for control of increased intracranial pressure. There was no evidence of hepatic toxicity and no clinical evidence of adrenal insufficiency although transient adrenal suppression was demonstrated at 4 but not at 24 hours after ketoconazole administration.

Topics: Administration, Oral; Amphotericin B; Cerebrospinal Fluid Shunts; Child; Child, Preschool; Coccidioidomycosis; Combined Modality Therapy; Female; Humans; Infant; Injections, Intravenous; Injections, Intraventricular; Injections, Spinal; Ketoconazole; Male; Meningitis; Miconazole; Peritoneal Cavity

Topics: Amphotericin B; Coccidioidomycosis; Humans; Injections, Subcutaneous; Meningitis

Two cases of pulmonary eosinophilia associated with coccidioidal infections are reported. Pulmonary eosinophilia in these cases represents a hypersensitivity reaction to the fungus. Histologically, the pulmonary eosinophilia in these cases closely mimicked or appeared identical to idiopathic chronic eosinophilic pneumonia. Coccidioides immitis organisms were rare or absent in the areas of pulmonary eosinophilia. Recognition of this phenomenon is important for proper care of the patient.

Topics: Adolescent; Amphotericin B; Coccidioides; Coccidioidomycosis; Diagnosis, Differential; Female; Humans; Ketoconazole; Lung; Lung Diseases, Fungal; Middle Aged; Pulmonary Eosinophilia

Cohorts of ten mice, uninfected and infected (intratracheal injection of coccidioidal arthroconidia), were treated for 23 days by intravenous injections of either 5% glucose solution, an immunostimulant (forphenicinol), an immunodepressant (cyclosporine), or amphotericin B. All mice were autopsied (survivors at 26 days postinoculation) and suspensions of lungs, livers, and spleens were cultured. All uninfected animals survived and gained weight, whereas, only 20% of the infected controls survived, and all lost weight. Treatment with forphenicinol had no effect on survival or weight. Cyclosporine secured 90% survival at the lowest dose and 60% at the higher doses, with no net loss of weight; however, all cultures of organs yielded heavy growth of Coccidioides immitis. With amphotericin B, all mice survived and gained weight; four mice from each of the two treatment groups yielded modest growth of C. immitis from the lungs, and one mouse of each group yielded sparse growth from liver and spleen. The paradox of no effect from an immunostimulant and therapeutic effect from an immunodepressant correlated with susceptibility testing of C. immitis in vitro.

Topics: Amphotericin B; Animals; Anti-Bacterial Agents; Body Weight; Coccidioides; Coccidioidomycosis; Cyclosporins; Female; Glycine; Liver; Lung; Mice; Spleen

Of 27 patients with the acquired immunodeficiency syndrome (AIDS) in Tucson, Arizona, 7 had concurrent coccidioidomycosis. Early manifestations of infection in 6 patients included diffuse nodular pulmonary infiltrates and Coccidioides immitis in many extrathoracic sites. By comparison, a retrospective review of the cases of 300 patients hospitalized with coccidioidal infection identified only 13 patients without AIDS who had the same extent of infection, and only 3 of these patients had no immunosuppressing conditions. Antibodies for coccidioidal antigens at serum dilutions as high as 1:2048 were detected in 5 of the 7 patients with AIDS. Six had temporary responses to amphotericin B treatment, taken both alone and combined with ketoconazole, but all died within 14 months of their diagnosis of coccidioidomycosis. Because annual rates of coccidioidal infection in the Tucson area are 4% or less, the rate of 27% that we calculated, based on 7 patients having the infection during 26 years of risk for AIDS, suggests frequent reactivation of the infection or enhanced susceptibility to endemic exposure in persons with AIDS.

Topics: Acquired Immunodeficiency Syndrome; Adult; Amphotericin B; Arizona; Coccidioidomycosis; Humans; Ketoconazole; Lung Diseases, Fungal; Male; Middle Aged; Retrospective Studies

Male ICR mice were challenged intracerebrally with endospores of Coccidioides immitis and then treated with water (control), fluconazole, amphotericin B (Fungizone), or ketoconazole (Nizoral). All three drugs markedly prolonged survival, and all three drugs lowered brain colony counts of C. immitis. Survival of mice treated orally with fluconazole at the high dose was longer than in the ketoconazole treated group. Amphotericin B was more efficacious than fluconazole. Further investigations are needed to determine the efficacy of fluconazole in treatment of coccidioidal meningitis.

Topics: Amphotericin B; Animals; Antifungal Agents; Coccidioides; Coccidioidomycosis; Fluconazole; Ketoconazole; Male; Meningitis; Mice; Mice, Inbred ICR; Triazoles

An unusual case of extensive gastrointestinal involvement by the fungus Coccidioides immitis is reported in a 21-yr-old man. This unique case demonstrates the occurrence of this fungus within chylous ascites, the mesentery, and invasion of the entire length of the small bowel. Histological and cultural documentation for gastrointestinal tract involvement by C. immitis other than for the rare occurrence of peritonitis has not been previously reported. The significance of the disseminated gastrointestinal coccidioidomycosis in the setting of chylous ascites and extensive abdominal lymphatic involvement is discussed with respect to its pathogenesis and treatment.

Topics: Adult; Amphotericin B; Chylous Ascites; Coccidioidomycosis; Gastrointestinal Diseases; Humans; Ketoconazole; Male; Recurrence

Eleven patients with coccidioidal meningitis were treated with high individual doses (1.0 to 1.5 mg) of intrathecal amphotericin B mixed with 25 to 50 mg of hydrocortisone in an attempt to reach a dose of 12 mg per month for at least two consecutive months. Patients received a mean intrathecal dose of amphotericin B of 82 mg (range, 40 to 157 mg) and 2.4 g intravenously (range, 1.0 to 3.5 g). No deaths related to disease or treatment occurred, and overall survival was 91% during an average follow-up period of 75 months (range, 30 to 137 months). Comparative analysis with eight well-known series in the literature reveals that our survival rate and follow-up time are significantly greater than the more recent series (1977-1981). Rank correlation and linear regression showed that the mean intrathecal dose of amphotericin B used in all series corresponds well with mean survival time. Our clinical results and analysis of the literature suggest that intrathecal amphotericin B administered at a high dose rate of 0.75 mg (or greater) three times per week promptly reaching 20 mg and a total surpassing 40 mg is associated with significantly enhanced survival rates.

Topics: Adult; Amphotericin B; Coccidioidomycosis; Humans; Injections, Intravenous; Injections, Spinal; Meningitis; Middle Aged

Coccidioides immitis infections of bones and joints pose difficult problems in diagnosis and treatment. To evaluate further the diagnosis and treatment of this disease, a retrospective review was conducted of 24 patients with 44 separate skeletal lesions of C. immitis infection, as determined by positive culture. Patients treated with combined medical and surgical treatment are more likely to have a successful outcome than those treated with medical therapy alone (p less than 0.005). Although immunosuppression did not appear to prevent a satisfactory response to therapy, patients with a high complement fixation titer (greater than or equal to 1:128) were more likely to fail to respond to medical therapy alone (p less than 0.01).

Topics: Adult; Aged; Amphotericin B; Bone Diseases; Child, Preschool; Coccidioidomycosis; Complement Fixation Tests; Female; Humans; Infant; Joint Diseases; Ketoconazole; Male; Middle Aged; Radiography; Retrospective Studies

Topics: Amphotericin B; Coccidioidomycosis; Dermatomycoses; Head; Humans; Lung Diseases, Fungal; Male; Middle Aged; Neck

Acute respiratory failure caused by infection with Coccidioides immitis is a rare, usually fatal, event. We report 2 patients who survived acute respiratory failure caused by primary pulmonary coccidioidomycosis. We attribute the severity of illness to a large inoculum of organisms. Their treatment included antifungal therapy with amphotericin B and diuresis to decrease noncardiogenic pulmonary edema. Coccidioidomycosis causing respiratory failure may be more frequent than currently clinically appreciated and may result from primary pulmonary coccidioidomycosis, miliary pulmonary disease, or as part of the multisystem organ failure seen in fungemic patients.

Topics: Adult; Amphotericin B; Antibodies, Fungal; Coccidioidomycosis; Complement Fixation Tests; Erythema; Furosemide; Humans; Ketoconazole; Lung Diseases, Fungal; Male; Pulmonary Edema; Respiratory Insufficiency

Topics: Adolescent; Amphotericin B; Coccidioides; Coccidioidomycosis; Drug Therapy, Combination; Humans; Ketoconazole; Male; Skin Tests; Transfer Factor

Topics: Adult; Amphotericin B; Blastomycosis; Coccidioides; Coccidioidomycosis; Cryptococcosis; Estradiol; Female; Flucytosine; Humans; Lung Diseases, Fungal; Pregnancy; Pregnancy Complications, Infectious; Risk; Stimulation, Chemical; United States

The effect of amphotericin B on magnesium metabolism was studied in 10 patients (aged 30 to 68 years) with systemic fungal infections. Renal magnesium wasting resulting in mild to moderate hypomagnesemia was demonstrated by the second week of therapy following relatively small cumulative dosages of amphotericin B (208 +/- 40 mg). The lowest serum levels and largest fractional excretions of magnesium were observed by the fourth week of therapy after cumulative dosages of 510 +/- 118 mg. A plateauing of the renal magnesium wasting is suggested, as there were no further increases or reductions in fractional magnesium excretion and serum magnesium level, respectively, despite continued amphotericin B administration. Reversibility of the magnesium wasting is indicated by data in three of the patients approximately one year following discontinuation of amphotericin B therapy, in whom the serum magnesium level and fractional magnesium excretion had returned to pretreatment baseline values. Although the available data do not allow precise localization of this defect, increased urinary excretion of magnesium despite its reduced filtered load suggests a tubular defect in magnesium reabsorption. Therefore, routine monitoring of the serum magnesium level during treatment with amphotericin B is recommended.

Topics: Adult; Aged; Amphotericin B; Aspergillosis; Candidiasis; Coccidioidomycosis; Creatinine; Cryptococcosis; Female; Humans; Magnesium; Male; Middle Aged; Prospective Studies

The clinical and pathologic findings in 32 patients with central nervous system (CNS) coccidioidomycosis were studied. Seventeen patients had received more than 1.5 g of amphotericin B (AMB), chiefly intravenously, during treatment periods of up to eight years. Eight patients had received 246 mg to 1.3 g of AMB, and three patients had received only brief treatment (one to three days; total dose, no more than 100 mg). Fifteen patients had not received AMB. Significant clinical differences between the patients treated with and without AMB were longer survival time following diagnosis of illness (P less than 0.05) and more frequent cranial nerve signs in the treated patients (P = 0.089). The wide spectrum of macroscopic and microscopic lesions in the CNS included meningitis, ventriculitis, hydrocephalus, and cerebritis. Long-standing infections were associated with disseminated discrete foci of gliosis and infarcts in the brain, particularly in the basal ganglia and deep white matter, related to endarteritis obliterans in basilar meninges. In contrast to patients with CNS and systemic mycoses treated with amphotericin B methyl ester (J Infect Dis 146:125, 1982), no diffuse lesions of white matter were found in patients treated with or without AMB. Histopathologic patterns observed in this study included leptomeningitis alone, leptomeningitis with cerebritis, leptomeningitis with cerebritis and infarcts, and the unusual pattern of disseminated miliary granulomas. The frequency and extent of CNS lesions in the groups treated with and without AMB were not significantly different. It is concluded that AMB therapy, while prolonging survival, does not alter the spectrum of pathologic findings in CNS coccidioidomycosis infection.

Topics: Adolescent; Adult; Aged; Amphotericin B; Central Nervous System; Central Nervous System Diseases; Child, Preschool; Coccidioidomycosis; Endarteritis; Female; Humans; Hydrocephalus; Male; Meningitis; Middle Aged

Coccidioidomycosis tenosynovitis is an unusual rheumatological manifestation of Coccidioides immitis infection. We report a case in a 46-year-old man with leukemia. The literature is reviewed and the treatment discussed.

Topics: Amphotericin B; Coccidioidomycosis; Humans; Leukemia, Lymphoid; Male; Middle Aged; Tenosynovitis

Topics: Adult; Amphotericin B; Coccidioidomycosis; Diphosphonates; Gallium Radioisotopes; Humans; Male; Radionuclide Imaging; Sulfur; Technetium; Technetium Tc 99m Medronate; Technetium Tc 99m Sulfur Colloid

Mortality and complication rates remain unacceptably high with conventional intravenous and intrathecal therapy for patients with coccidioidal meningitis and intracerebral fungal lesions. We studied the ventricular and lumbar cerebrospinal fluid penetration of ketoconazole and the responses to therapy in two patients receiving ketoconazole orally, 800 mg daily, and amphotericin B intraventricularly for meningeal and extrameningeal coccidioidomycosis. Five patients received only 1200 mg of ketoconazole: one had uncomplicated coccidioidal meningitis, three had obstructive hydrocephalus due to coccidioidal meningitis, and one had a histoplasmal brain abscess. Ketoconazole concentrations in ventricular and lumbar fluid ranged from 0.05 to 1.65 micrograms/mL 4 and 8 hours after the dose. The mean penetration of ketoconazole (+/- SD) was 1.9% +/- 0.8% for ventricular fluid and 5.4% +/- 2.6% for lumbar fluid. Ketoconazole concentrations in cerebrospinal fluid varied directly with those in serum and with cerebrospinal fluid protein content. The encouraging clinical responses, convenience, safety, and the consistent penetration of ketoconazole into obstructed and nonobstructed cerebrospinal fluid support the use of these regimens as alternatives to conventional therapy.

Topics: Amphotericin B; Antifungal Agents; Central Nervous System Diseases; Coccidioidomycosis; Drug Therapy, Combination; Humans; Imidazoles; Ketoconazole; Piperazines

An unusual case is reported of a patient with spastic paraparesis who was found to have severe spinal arachnoiditis due to Coccidioides immitis. Despite an obstructive hydrocephalus and a spinal subarachnoid block, the patient was treated effectively with surgery (shunting) and antifungal therapy (amphotericin and ketoconazole). He remains asymptomatic 3 years after diagnosis. Aggressive surgical and medical treatment of coccidioidal infection of the central nervous system can be beneficial, even in patients with the worst prognosis.

Topics: Adult; Amphotericin B; Arachnoiditis; Coccidioidomycosis; Humans; Imidazoles; Ketoconazole; Male; Piperazines; Spinal Cord Diseases

We give a thorough report on coccidioidomycosis, a systemic mycosis only occurring in the New World. We present microorganism, geography, epidemiology, diagnostic procedures, and therapy. A pilot study on German soldiers trained in the endemic areas of the USA demonstrated by means of a positive skin test that 3.73% of them had been infected.

Topics: Adrenal Cortex Hormones; Adult; Amphotericin B; Coccidioidin; Coccidioidomycosis; Diagnosis, Differential; Germany, West; Humans; Ketoconazole; Lung; Male; Military Medicine; Sarcoidosis; Skin Tests; Transfer Factor; Tuberculosis, Pulmonary; United States

Topics: Aged; Amphotericin B; Chronic Disease; Coccidioidomycosis; Humans; Male; Meningitis; Pennsylvania

Topics: Amphotericin B; Coccidioidomycosis; Humans; Pneumonia; Skin Tests

In the 25 years since its introduction, amphotericin B has demonstrated clear value in the management of coccidioidomycosis. However, its effectiveness is less certain than in diseases due to other fungal aetiological agents, even when the loci of infection and in vitro drug susceptibilities are identical. The refractoriness of coccidioidomycosis may relate to the unique ability of each Coccidioides immitis spherule to release hundreds of endospores, thus maximally challenging host defence mechanisms. Amphotericin B is most likely to be effective where there is evidence of intact cell-mediated immunity against C. immitis (i.e. positive coccidioidin or spherulin skin test; low titre of complement fixing antibody), and structural damage to tissues. When bones and joints are involved, as is frequently the case, adjunctive surgical management is generally required. Patients with structural lung disease (i.e. cysts and/or cavities) show variable, often minimal, response to treatment. Amphotericin B has transformed coccidioidal meningitis from a routinely fatal disease to one where prolonged survival is possible. However, the drug must be given by the intrathecal route, and for periods of years, before the possibility of cure can be considered. Relapses of bone, joint and meningeal coccidioidomycosis are common and should be anticipated, especially in patients with impaired immunity.

Topics: Amphotericin B; Chronic Disease; Coccidioidomycosis; Dose-Response Relationship, Drug; Humans; Liver; Pneumonia; Tissue Distribution

A rare case of coccidioidomycosis involving the epididymis is described and compared with the 12 clinically diagnosed cases reported in the literature. With 1 exception, the disease appeared to be limited to the genital organs and the adjacent tissue. Surgical excision of the involved tissue appeared to be curative. Bilateral epididymal involvement occurred in 4 cases and it was the cause of the treatment failure in 2 of the 3 cases in which the local disease was treated unsuccessfully by surgery. The efficacy of antifungal chemotherapy remains to be determined.

Topics: Amphotericin B; Coccidioidomycosis; Epididymitis; Humans; Male; Middle Aged

Topics: Adolescent; Amphotericin B; Child; Coccidioidomycosis; Female; Humans; Infant; Male; Meningitis

Topics: Aged; Amphotericin B; Coccidioidomycosis; Diagnosis, Differential; Humans; Male; Prostatic Diseases; Prostatic Hyperplasia

Topics: Amphotericin B; Child; Child, Preschool; Coccidioidomycosis; Granuloma; Humans; Male; Miconazole; Radiography; Tracheal Diseases; Tracheal Stenosis

Topics: Amphotericin B; Chronic Disease; Coccidioides; Coccidioidomycosis; Humans; Lung Diseases, Fungal; Male; Middle Aged; Prognosis; Skin Tests; Sputum

Topics: Amphotericin B; Child, Preschool; Coccidioides; Coccidioidomycosis; Complement Fixation Tests; Female; Humans; Male

A literature review of case histories describing the use of amphotericin B for the treatment of disseminated coccidioidomycosis was performed to detect parameters that were predictive of therapeutic outcome. Several factors were significantly different between patients who were well during prolonged follow-up versus those with active or recurrent disease: 1) mean complement fixation (CF) titer before treatment was lower in patients who were well; 2) well patients had a greater magnitude fall in CF titer during the amphotericin B therapy; 3) mean CF titer after amphotericin B treatment was lower in patients who were well; and 4) patients with a positive coccidioidin skin test before therapy were more likely to be well at 6 months. There was no correlation between total amphotericin B dose or duration of therapy and therapeutic outcome.

Topics: Adolescent; Adult; Aged; Amphotericin B; Antibodies, Fungal; Child; Coccidioides; Coccidioidomycosis; Complement Fixation Tests; Humans; Middle Aged; Prognosis; Time Factors

We present a patient with coccidioidal meningitis whose diagnosis was not confirmed until a skin biopsy was performed. Because he lived in an area where coccidioidomycosis is not endemic, his meningitis was at first attributed to tuberculosis or sarcoidosis. After a verrucous lesion from the face was biopsied and the diagnosis substantiated, the patient responded well to consolidation therapy consisting of intrathecal amphotericin B and oral ketoconazole.

Topics: Adult; Amphotericin B; Coccidioidomycosis; Dermatomycoses; Humans; Male; Meningitis

Clinical and autopsy studies of 14 patients treated with amphotericin B methyl ester (AME) for focal, disseminated, and nervous system mycotic infections revealed a high incidence of progressive neurologic dysfunction (dementia, akinesia, mutism, hyperreflexia, and tremor) and diffuse white matter degeneration. All of seven patients who received greater than 9.8 g of AME intravenously developed severe neurologic and neuropathologic changes. Two of three patients given 5-7.2 g of AME developed less severe neurologic symptoms; all three had mild diffuse white matter gliosis. Four patients given less than 1.5 g of AME had no bran abnormalities except those related to coccidioidal meningitis. Thirty-one control patients who died on untreated or amphotericin B-treated coccidioidal meningitis showed no diffuse white matter abnormalities. These findings indicate that prolonged administration of AME and/or other contaminating polyenes injures human white matter. Long-term animal studies, with particular attention to nervous system histology, must precede human use of other polyene derivatives.

Topics: Adolescent; Adult; Aged; Amphotericin B; Aspergillosis; Astrocytes; Brain; Brain Diseases; Child; Coccidioidomycosis; Demyelinating Diseases; Gliosis; Humans; Lung Diseases, Fungal; Middle Aged; Myelin Sheath

Topics: Amphotericin B; Animals; Brain Diseases; Coccidioidomycosis; Dogs; Humans; Macaca mulatta; Mycoses; Nervous System Diseases

A 26-year-old woman had an enlarging dense macular lesion in the right eye. The funduscopic and angiographic findings were distinctly different from those in macular histoplasmosis. She was found to have a coccidioidomycotic granuloma in the left lung and was treated with amphotericin B. Within a month the macular lesion was cicatricial. This appears to be the first reported case of presumed ocular coccidioidomycosis in Canada.

Topics: Adult; Amphotericin B; Canada; Coccidioidomycosis; Female; Fluorescein Angiography; Humans; Lung Diseases, Fungal; Macula Lutea; Retinal Diseases

In an effort to define the importance of extrapulmonary coccidioidomycosis in the pediatric age group, we have studied 14 cases and reviewed the literature. The available data suggest that children are as susceptible to dissemination as are adults. Most children with disseminated coccidioidomycosis have evidence, either by history or chest radiographs, of preceding or concurrent pulmonary infection. The most common sites of dissemination are skin, subcutaneous tissue, bone, and meninges. Coccidioides immitis may be detected in tissues or body secretions by microscopic examination or by appropriate culture. Serologic tests are also useful in making the diagnosis and in following the course of the infection. Skin tests are often negative. Infection is progressive in 60% without antifungal therapy. Coccidioidomycosis of bone, skin, or subcutaneous tissue can be managed effectively with combined surgical and antifungal therapy. Meningitis is much more difficult to treat and is fatal in 50% of cases even when treated with amphotericin B.

Topics: Adolescent; Amphotericin B; Child; Child, Preschool; Coccidioidomycosis; Female; Humans; Male; Prognosis; Radiography

Topics: Amphotericin B; Coccidioidomycosis; Humans; Lung; Lung Diseases, Fungal; Miconazole; Nausea; Pneumonia; Radiography; Solitary Pulmonary Nodule

Pelvic inflammatory disease due to Coccidioides immitis is rare. However, female patients with disseminated coccidioidomycosis may have unrecognized pelvic involvement as pelvic examinations are frequently not performed. Inappropriate and inadequate therapy of pelvic coccidioidomycosis may very well contribute to the demise of such patients. The diagnosis must also be suspected in patients with pelvic abscesses which do not respond to antibiotic therapy and conventional surgery. Extirpative surgery, in addition to amphotericin B, is frequently necessary to eradicate the disease. A patient is reported whose course illustrates these conclusions.

Topics: Adult; Amphotericin B; Coccidioidomycosis; Female; Humans; Pelvic Inflammatory Disease

Topics: Adult; Amphotericin B; Coccidioidomycosis; Female; Humans; Meningitis; Methylprednisolone

Three patients with endogenous fungal endophthalmitis were treated intravenously with miconazole. Two patients had disseminated coccidioidomycosis, and one patient had disseminated candidiasis. Intraocular mycotic infections developed in one patient undergoing therapy, and progressed in two others also undergoing therapy. All three patients' ocular infections improved after therapy was switched to intravenous amphotericin B administration. Previous experience with miconazole and amphotericin B therapy for fungal endophthalmitis is reviewed. Whereas several failures have been noted with amphotericin B and success with miconazole, our experience suggests systemic administration of amphotericin B may be superior to systemic administration of miconazole for intraocular mycoses, although further clinical data are urgently needed.

Topics: Adult; Amphotericin B; Candidiasis; Coccidioidomycosis; Endophthalmitis; Female; Fluorescein Angiography; Fundus Oculi; Humans; Imidazoles; Injections, Intravenous; Male; Miconazole; Middle Aged

Disseminated coccidioidomycosis is a systemic fungal infection that causes high mortality in the renal transplatn patient. Cell-mediated immunity, which appears to be the relevant host defense mechanism, is impaired by the immunosupressive agents used to prevent allograft rejection. In the case presented, immunosuppressive therapy was stopped as an adjunct to treatment of this infection. The patient has shown evidence of improvement, and his allograft has continued to function nine months after the withdrawal of immunosuppressive therapy and 18 months after the diagnosis. In vitro lymphocyte function studies indicate that the impairment in cell-mediated immunity detected prior to withdrawal of immunosuppressive therapy has persisted, probably accounting for allograft survival. Withdrawal of immunosuppressive therapy may prolong survival in renal transplant patients with disseminated coccidioidomycosis. Additionally, depression in cell-mediated immunity associated with the fungal infection itself may be sufficient to prevent allograft rejection in these patients.

Topics: Adult; Amphotericin B; Azathioprine; Coccidioidomycosis; Graft Rejection; Humans; Immunity, Cellular; Kidney Transplantation; Male; Transplantation, Homologous

Miconazole was injected intravenously in six patients with coccidioidomycosis. Two patients received 101 and 185 g, respectively, without clinical response and with persistence of positive cultures for Coccidioides immitis. In one patient, symptoms were suppressed when amphotericin B was given with miconazole, but new lesions developed with miconazole alone (total dose, 963 g). Three patients received smaller doses: 30.6 g before death from an unrelated complication; 17 and 22.3 g before development of severe allergic reactions. Because of the high rate of initial failures and relapses, miconazole is not recommended as primary therapy for coccidioidomycosis.

Topics: Adult; Amphotericin B; Coccidioidomycosis; Drug Evaluation; Drug Therapy, Combination; Female; Humans; Imidazoles; Injections, Intravenous; Male; Miconazole; Middle Aged; Recurrence

Topics: Adult; Amphotericin B; Coccidioidomycosis; Female; Humans; Pleural Effusion; Pregnancy; Pregnancy Complications, Infectious

Localized laryngeal coccidioidomycosis has been rarely reported and usually is associated with disseminated disease. This paper has described localized subglottic coccidioidomycosis in a 13-month old white boy who presented with persistent stridor. Medical management including intravenous amphotericin B resulted in complete eradication of the subglottic lesion.

Topics: Amphotericin B; Coccidioidomycosis; Glottis; Humans; Infant; Laryngeal Diseases; Male; Respiratory Sounds

The inpatient experience regarding coccidioidomycosis of head and neck was reviewed at the University of California Medical Center, San Francisco and affiliated hospitals. Four cases in which upper airway obstruction required otolaryngological consultation and intervention are reviewed in detail. History, epidemiology and pathophysiology of coccidioidomycosis involving upper airway are discussed. Suggestions for diagnosis and management are outlined.

Topics: Aged; Airway Obstruction; Amphotericin B; Coccidioidomycosis; Female; Humans; Male; Miconazole; Middle Aged; Radiography; Sex Factors; South America; United States

Chronic progressive coccidioidal pneumonitis (CPCP) is an uncommon sequela of acute pulmonary coccidiodomycosis. Six recent patients with CPCP are described, most of whom were previously healthy. The clinical presentation was indolent, resulting in long diagnostic delays. Serial chest roentgenograms showed progressive pulmonary infiltration and sputum cultures were persistently positive for Coccidioides immitis. Serum complement fixation (CF) antibody titers were high, with five of six patients having titers greater than or equal to 1:16. No patients had evidence of extrapulmonary coccidioidal spread at time of diagnosis of CPCP, although hematogenous dissemination occurred later in one patient. Five patients received amphotericin B intravenously (greater than or equal to 30 mg/kg total), resulting in rapid clinical and mycologic cure, decline in CF titers, and roentgenographic improvement or stabilization. However, two of these five patients suffered permanent physiologic impairment. One patient refused therapy and remains clinically symptomatic, with chronic positivity of sputum cultures for C immitis and high CF titers.

Topics: Adult; Amphotericin B; Chronic Disease; Coccidioidomycosis; Female; Humans; Male; Middle Aged; Pneumonia

In two patients with thyroiditis caused by Coccidioides immitis, presented thyroid symptoms and findings were characteristic of subacute thyroiditis. Fine needle aspiration biopsy of the thyroid proved useful in establishing the diagnosis of coccidioidomycosis. This is the first report of coccidioidomycosis presenting as thyroiditis.

Topics: Adult; Amphotericin B; Biopsy, Needle; Coccidioides; Coccidioidomycosis; Female; Humans; Male; Miconazole; Middle Aged; Radionuclide Imaging; Thyroid Gland; Thyroidectomy; Thyroiditis

Eighteen newly diagnosed cases of symptomatic cocidioidomycosis developed two to four weeks following exposure to a severe natural dust storm. The population at risk consisted of 26,000 residents of the San Joaquin Valley with access to health care at the Naval Hospital, Lemoore, Calif. Eight patients were white, and ten were nonwhite. The number of cases per 100,000 was estimated to be 36 for the white group and 254 for the nonwhite group. The disease was disseminated in four patients, and all were from the nonwhite group. One patient with disseminated disease, a black man, died. These data suggest that nonwhites may be relatively more susceptible to acquiring primary disease, in addition to developing disseminated disease. Dust storms of this magnitude must be considered a threat to health for populations living within areas endemic for coccidioidomycosis.

Topics: ABO Blood-Group System; Adolescent; Adult; Air Microbiology; Air Movements; Amphotericin B; California; Coccidioidomycosis; Disease Outbreaks; Dust; Environmental Exposure; Female; Humans; Male; Middle Aged; Racial Groups; Wind

When clinically apparent, coccidioidomycosis usually presents either as an interstitial pulmonary infiltrate or, later in its course, a parenchymal nodule often with cavitation. The present report concerns a young adult woman whose presentation was one of shortness of breath with wheezing and stridor, secondary to a localized endobronchial coccidiodal granuloma producing nearly complete obstruction of the right mainstem bronchus. Such a presentation has not been reported previously in an adult. The possible association of serious fungal disease with previous jejunoileal bypass surgery is discussed.

Topics: Adult; Airway Obstruction; Amphotericin B; Biopsy; Bronchial Diseases; Bronchoscopy; Coccidioidomycosis; Female; Humans; Tomography, X-Ray

A patient with coccidioidal meningitis was treated with intrathecally administered amphotericin B, and an acute toxic delirium with EEG abnormalities developed. Clinical recovery followed discontinuation of therapy and paralleled EEG resolution. This complication was dose related and argues for caution when initiating intrathecal therapy with amphotericin B at doses greater than 0.025 mg.

Topics: Acute Disease; Adult; Amphotericin B; Coccidioidomycosis; Electroencephalography; Humans; Injections, Spinal; Male; Meningitis; Psychoses, Substance-Induced

A patient received a previously unreported combination of intravenous miconazole and intrathecal amphotericin B for the treatment of disseminated coccidioidomycosis with central nervous system involvement. After first having been treated with amphotericin B, followed by a course of miconazole therapy, the patient responded with remarkable clinical and serologic improvement to the combination of intrathecal amphotericin B and intravenous miconazole. The combination should be considered in the treatment of disseminated coccidioidomycosis with central nervous system involvement.

Topics: Adult; Amphotericin B; Chronic Disease; Coccidioidomycosis; Drug Therapy, Combination; Humans; Imidazoles; Injections, Intravenous; Injections, Spinal; Male; Miconazole

A case of disseminated coccidioidomycosis was diagnosed from a prostatic biopsy. Patients with sterile pyuria, prostatic nodules or symptoms of prostatitis who have lived in or traveled through an endemic area need careful evaluation of the lower genitourinary tract. Immunological treatment with a transfer factor currently is under investigation. Miconazole may offer a promise for future treatment of this fungal infection and, particularly, for patients with impaired renal function.

Topics: Amphotericin B; Biopsy; Coccidioidomycosis; Humans; Immunotherapy; Male; Miconazole; Middle Aged; Prostatic Diseases; Transfer Factor

Topics: Amino Acids; Amphotericin B; Apolipoproteins; Coccidioidomycosis; Female; Humans; Lipids; Lipoproteins, HDL; Male; Threonine

Topics: Adult; Amphotericin B; Coccidioidomycosis; Fear; Humans; Lung Abscess; Lung Diseases, Fungal; Male; Patient Care Planning; Pneumothorax; Sick Role

A severe granulomatous iridocyclitis developed in association with a cavitary pulmonary lesion in a 29-year-old man. The initial diagnosis and treatment was for pulmonary tuberculosis with tuberculous uveitis. Although the pulmonary lesion improved with antituberculous therapy, the condition of the eye deteriorated. An anterior-chamber tap was positive for Coccidioides immitis, and the patient was treated with intravenous and two intracameral injections of amphotericin B. The eye was ultimately enucleated three weeks after the initial intracameral injection, and yet was culture-positive for the organism. Histopathologic examination disclosed diffuse involvement of the anterior segment, with multiple spherules present within the iris and limbus.

Topics: Adult; Amphotericin B; Coccidioides; Coccidioidomycosis; Endophthalmitis; Humans; Lung Diseases, Fungal; Male; Uveitis, Anterior

A patient with disseminated coccidioidomycosis initially had pulmonary and skin manifestations and survived for 14 years before dying of meningitis due to Coccidioides immitis. In addition to several courses of amphotericin B therapy the patient received injections of transfer factor derived from appropriate donors and miconazole nitrate therapy. The immunologic defence mechanisms of the patient during the course of his disease were studied and the possibility of a cell-mediated immunologic defect, potentially reversible by transfer factor, was demonstrated.

Topics: Adult; Amphotericin B; Coccidioidomycosis; Dermatomycoses; Humans; Immunity, Cellular; Male; Meningitis; Miconazole; Prognosis; Transfer Factor

A review of twelve cases in which disseminated coccidioidomycosis caused localized infection of the spine showed that eight of the twelve patients were alive and well with no evidence of active infection an average of eleven years after onset (range, two to thirty-five years). One patient who was followed for more than twenty-three years had a slowly developing neurological impairment in the lower extremities as a result of lumbosarcral destruction instability. One patient died early in the course of the disease from fulminating cervical spondylitis and quadriplegia. A second patient had a paraplegia from thoracic spondylitis. On patient had no evidence of active spondylitis five years after the onset of the disease, but then died of coccidioidal meningitis. All patients were treated with intravenous amphotericin at some time in the course of their illness, although its effect was not always dramatic. The three patients with neurological impairment did not undergo spine fusion, but most of the others had that operation. Surgical evacuation of abscesses and debridement of infected bone was also performed in many cases.

Topics: Adult; Amphotericin B; Arthrodesis; Black People; California; Child; Coccidioidomycosis; Complement Fixation Tests; Debridement; Female; Follow-Up Studies; Humans; Male; Middle Aged; Racial Groups; Spinal Fusion; Spondylitis; Therapeutic Irrigation

Fifty-two diabetic patients who underwent pulmonary surgery for coccidioiodmycosis were evaluated by a retrospective study which included classification by stage of disease, status of insulin dependency, and reaction to coccidioidin skin test. The insulin-dependent diabetic patient had a fourfold increase in the incidence of more severe (progressive) disease. Perioperative therapy with amphotericin B may be of value in the adult surgical candidate with progressive disease but is not necessary or desirable in the juvenile diabetic patient. Coccidioidomycosis is a disease of relative immunocompromise, and a negative skin test should herald such compromise and support a decision for surgery. Such surgery in the progressive stages should be totally extirpative. The presence of inadequately resected disease may adversely affect subsequent immunologic resistance of the host.

Topics: Adult; Age Factors; Amphotericin B; Coccidioidomycosis; Diabetes Complications; Diabetes Mellitus, Type 1; Female; Humans; Lung Diseases, Fungal; Male; Middle Aged; Pneumonectomy; Skin Tests

Miconazole at dosages up to 30 mg/kg/day was given intravenously to seven patients with complicated courses of disseminated coccidioidomycosis. Six had received treatment with amphotericin B previously and five of these patients could be evaluated for the efficacy of the treatment. In three patients the condition failed to respond to therapy, another patient required intratracheal administration of amphotericin B later, and the fifth patient had an equivocal response to treatment. Severe phlebitis, pruritus, nausea, vomiting, hyperlipidemia, and thrombocytosis were frequent side effects. These limited unfavorable results indicate that until controlled studies demonstrate its safety and efficacy, therapy with miconazole should be reserved for highly selected patients with disseminated coccidioidomycosis who cannot receive amphotericin B.

Topics: Adult; Amphotericin B; Coccidioidomycosis; Drug Evaluation; Humans; Imidazoles; Infusions, Parenteral; Injections, Intraventricular; Lung Diseases, Fungal; Male; Meningitis; Miconazole; Middle Aged

Primary coccidioidal synovitis of the knee is a rare disorder and controversy exists in the literature over the efficacy of treatment with synovectomy and Amphotericin B therapy. Four cases are presented illustrating features of the natural history, diagnosis, and treatment of the disease.

Topics: Adult; Aged; Amphotericin B; Amputation, Surgical; Biopsy; Coccidioidomycosis; Female; Humans; Knee Joint; Male; Middle Aged; Synovitis

The course and treatment of two patients with otomycosis due to Coccidioides immitis, believed to be the first such cases reported, are described. Both infections appeared due to reactivation of hematogenously disseminated foci. Local and systemic chemotherapy plus surgery resulted in remission, and host immune response also appears to be an important factor. One patient, with systemic lupus erythematosus, required more extensive surgery, more chemotherapy, and reduction in steroid dose to arrest the disease. A combined surgical and chemotherapeutic approach appears necessary when otomycosis is due to invasive fungi such as C immitis.

Topics: Adult; Amphotericin B; Coccidioidomycosis; Debridement; Ear Diseases; Female; Humans; Male

Coccidioidomycotic osteomyelitis developed at the angle of the right side of the mandible in a 5-month-old Papago infant. The disease was successfully treated with a combination of amphotericin B, surgery, and transfer factor with complete immunological, microbiological, and radiological cure. At 4 years of age, the only residual effect is prominence of the right hemimandible with asymmetry of the jaw.

Topics: Amphotericin B; Child, Preschool; Coccidioides; Coccidioidomycosis; Female; Humans; Infant; Mandibular Diseases; Osteomyelitis; Radiography

Two cases of coccidioidomycosis detected in a group of more than 750 renal transplants are presented. The first patient died from unsuspected disseminated coccidioidomycosis 4 1/2 years after primary transplantation and 6 days after retransplantation. In the second patient pulmonary coccidioidomycosis was recognized and treated by lobectomy and amphotericin B before transplantation; subsequent transplantation has provided good renal function without recurrence of infection for 5 years. Experience with six other reported cases of coccidioidomycosis illustrates the high risk of exacerbation and dissemination of preexisting coccidioidal infection in immuno-suppressed transplanted recipients. Nevertheless, this risk can be made acceptable if active coccidioidomycosis is treated vigorously before immunosuppression is started and if the possibility of exacerbation of infection after transplantation is carefully monitored.

Topics: Adult; Amphotericin B; Coccidioidomycosis; Female; Humans; Immunosuppression Therapy; Kidney Transplantation; Lung Diseases, Fungal; Male; Risk

Topics: Amphotericin B; Blastomyces; Blastomycosis; Coccidioides; Coccidioidomycosis; Humans; Serologic Tests

Pulmonary mycetoma due to Coccidioides immitis has been reported on three occasions. The present case is the fourth such report occurring in a patient with widely disseminated disease. Spherules and hyphae were found in the specimen. While the active pulmonary and extra-pulmonary lesions responded well to therapy with amphotericin B, resection was required to eliminate the residual mycetoma and its attendant hemoptysis.

Topics: Adult; Amphotericin B; Coccidioidomycosis; Humans; Lung Diseases, Fungal; Male; Pneumonectomy

Pericarditis with effusion can occur as a complication of disseminated coccidioidomycosis. Information on management of this condition is very scanty in the medical literature. One case is described in detail. Early diagnosis and appropriate therapy with amphotericin B have been emphasized as keys to success in treating this condition.

Topics: Adult; Amphotericin B; Coccidioides; Coccidioidomycosis; Complement Fixation Tests; Echocardiography; Humans; Male; Pericardial Effusion; Radiography

Three patients seen recently at Wilford Hall USAF Medical Center emphasize the point that coccidioidomycosis may resemble lymphoma because of persistence of adenopathy on the chest roentgenogram after the initial infiltrate has resolved. Such a clinical picture strongly indicates dissemination and is probably sufficient reason to initiate therapy.

Topics: Adult; Amphotericin B; Coccidioidomycosis; Diagnosis, Differential; Humans; Lymphatic Diseases; Lymphoma; Male; Middle Aged; Radiography

The susceptibility of 12 strains of Coccidioides immitis to amphotericin B (amB) was studied in vitro and in vivo. The minimal inhibitory concentration (MIC) of the mycelial phase of these strains was 0.078 to 0.16 mug/ml after 3 days of incubation, but by 15 days all strains were inhibited by 2.5 mug/ml. Mice infected intraperitoneally with these strains were sucessfully treated with 0.5 mg of amB per kg per day. These strains included several studied by others and which reportedly varied widely in susceptibility (MIC from 0.24 to 24.01 mug/ml) to amB. Four of these strains representing this putative broad range of susceptibility were used to infect mice intranasally. Regardless of infecting strain, mice were sucessfully treated with 0.38, 0.75, and 1.5 mg/kg, but 0.19 mg/kg was only partially effective. Thus, in vivo as well as in vitro there was a uniform response of C. immitis strains to amB.

Topics: Amphotericin B; Animals; Coccidioides; Coccidioidomycosis; Female; Mice; Species Specificity

Topics: Adolescent; Adult; Amphotericin B; Biopsy; Bone Marrow; Calcitonin; Calcium; Coccidioides; Coccidioidomycosis; Female; Humans; Hypercalcemia; Male; Miconazole; Middle Aged; Ribs

A case of disseminated histoplasmosis followed later by disseminated coccidioidomycosis is described. The clinical illness and immunologic studies suggest subtle defects that may have existed antecedent to infection and, thus, provided an opportunity for widespread dissemination by these normally nonopportunistic organisms. Poor correlation was noted between the clinical course and in vitro tests of cell-mediated immunity.

Topics: Adult; Amphotericin B; Coccidioides; Coccidioidomycosis; Complement Fixation Tests; Histoplasma; Histoplasmosis; Humans; Lymphocyte Activation; Male; Precipitins; Skin Tests

A 17 year old caucasian woman in whom disseminated coccidioidomycosis developed with culture positive meningitis during her third trimester of pregnancy was treated with amphotericin B and subsequently with transfer factor prepared from her father's peripheral lymphocytes. Clinical response and in vivo and in vitro immunologic data indicated that this transfer factor afforded a significant contribution to her survival whereas previous therapy with transfer factor from an unrelated donor provided only transient immunologic reactivity. This experience suggests that transfer factor prepared from a related donor with positive responses to C. immitis may be more efficacious than that prepared from an unrelated donor.

Topics: Adolescent; Amphotericin B; Coccidioidomycosis; Female; Humans; Immunity, Cellular; Lymphocyte Activation; Parents; Pregnancy; Pregnancy Complications, Infectious; Remission, Spontaneous; Transfer Factor

Evidence provided by histopathological study of lesions is a valuable adjunct for evaluating chemotherapeutic efficacy in experimental animal models, In addition, this should be correlated with a measure of disease severity in the same animal. The latter could be obtained by homogenization of infected organs and quantitative enumeration of viable cells of the etiological agent, but this would preclude histopathological studies in the same animal. Progression of disease in pulmonary infection is associated with replacement of air space by fluid, cells, and cellular debris. Therefore, an increase in lung weight should reflect severity of disease. Results with the murine model of coccidioidomycosis demonstrate that increasing lung weight parallels the increasing census of fungus cells in the lungs of both treated and nontreated infected mice. This was supported with evidence obtained from microscopic studies of lesions indicating that specific chemotherapy limited spread of the infection and inhibited multiplication of the fungus in the lung. Therefore, lung weight can be used as a measure of disease severity in the murine model of coccidioidomycosis.

Topics: Amphotericin B; Animals; Bronchopneumonia; Coccidioides; Coccidioidomycosis; Lung; Male; Mice; Mice, Inbred DBA; Neutrophils; Organ Size

The methyl ester of amphotericin B was compared with the parent compound, amphotericin B, in terms of therapeutic efficacy in experimental murine coccidioidomycosis and of toxicity. Infections were established by intraperitoneal or intratracheal inoculation with arthrospores. The mice were given either intraperitoneal or intravenous injections of drug for 30 days, according to several dosage schedules. At low doses, amphotericin B methyl ester was less effective therapeutically than was amphotericin B; however, at higher doses, amphotericin B was directly lethal and/or nephrotoxic, whereas the methyl ester was therapeutically effective and nontoxic. In contrast to amphotericin B, the methyl ester did not cause either azotemia or histopathologic changes in the kidneys.

Topics: Amphotericin B; Animals; Coccidioidomycosis; Disease Models, Animal; Dose-Response Relationship, Drug; Drug Evaluation, Preclinical; Mice

Topics: Amphotericin B; Antifungal Agents; Coccidioidomycosis; Drug Administration Schedule; Drug Resistance, Microbial; Humans; Imidazoles; Male; Miconazole; Middle Aged

Amphotericin B, the principal drug used for treating systemic mycoses, possesses undesirable toxic properties. The ability of this antibiotic to potentiate antifungal activity of other compounds suggests that lower doses of amphotericin B could be used in combination with a second drug without loss of therapeutic efficacy. In vitro tests demonstrated that amphotericin B potentiated rifampin against the mycelial growth phase of Coccidioides immitis but not against the spherule-endospore phase. Therapy for murine coccidioidomycosis with a combined amphotericin B-rifampin regimen was not better than treatment with amphotericin B alone; in fact, combined drugs may have been even less effective. This would have clinical significance for therapy of concurrent infections.

Topics: Amphotericin B; Animals; Coccidioides; Coccidioidomycosis; Disease Models, Animal; Drug Synergism; Drug Therapy, Combination; Male; Mice; Rifampin

Transfer factor is a dialyzable extract of sensitized leukocytes, which transfers reactivity from skin test-positive donors to skin test-negative recipients. Transfer factor supplied by our laboratory has been used therapeutically to induce cellular immunity in 78 patients around the world. Many patients received multiple doses of transfer factor ranging from 1 unit given every 6 months for 3 years to 1 unit every week for 6 months to as much as 8 units per week for a brief period. A total of 299 units of transfer factor have been given. Diseases in which transfer factor appeared to cause improvement include the Wiskott-Aldrich syndrome, severe combined immunodeficiency disease, mucocutaneous candidiasis, chronic active hepatitis, coccidioidmycosis, dysgammaglobulinemia, Behcet disease, aphthous stomatitis, linear morphea, familial keratoacanthoma and malignancy.

Topics: Amphotericin B; Behcet Syndrome; Binding Sites, Antibody; Candidiasis, Cutaneous; Coccidioidomycosis; Dysgammaglobulinemia; Hepatitis; Humans; Immunity, Cellular; Immunologic Deficiency Syndromes; Immunotherapy; Keratoacanthoma; Macrophage Migration-Inhibitory Factors; Monocytes; Neoplasms; Scleroderma, Localized; Stomatitis, Aphthous; Transfer Factor; Wiskott-Aldrich Syndrome

Toxicity and failure of treatment with amphotericin B are stimuli for researchers to evaluate alternative antifungal antimicrobics. Also, data from susceptibility tests of Coccidioides immitis are sparse. With use of a defined, synthetic culture medium, C. immitis (25 strains). Candida albicans (21 strains), and Cryptococcus neoformans (21 strains) were tested against flucytosine, clotrimazole, and amphotericin B. Molecule for molecule, the sequency of activity was: clotrimazole greater than amphotericin B greater than flucytosine (totally inactive) C. immitis; and clotrimazole greater than amphotericin B greater than flucytosine with C. albicans and C. neoformans. With four strains of C. immitis, the minimal inhibitory concentration (of amphotericin B) was the same when inocula of arthrospores were tested as when corresponding spherules/endospores were tested simultaneously and identically. The clinical outcome of coccidioidomycosis in 17 patients treated with amphotericin B correlated best with minimal inhibitory concentration after incubation of cultures for 48 hr; a favorable response was associated with minimal inhibitory concentrations of less than or equal 1.0 mug/ml. Because clinical isolates of fungi appear to vary in susceptibility, in vitro tests may have clinical utility.

Topics: Adult; Aged; Amphotericin B; Candida albicans; Child; Child, Preschool; Clotrimazole; Coccidioides; Coccidioidomycosis; Cryptococcus; Cryptococcus neoformans; Cytosine; Drug Resistance, Microbial; Female; Flucytosine; Humans; Imidazoles; Lung Diseases; Male; Microbial Sensitivity Tests; Middle Aged; Pregnancy; Pregnancy Complications, Infectious; Spores, Fungal

Topics: Actinomycosis; Amphotericin B; Blastomycosis; Candida albicans; Candidiasis, Cutaneous; Chromoblastomycosis; Coccidioidomycosis; Cryptococcosis; Dermatomycoses; Flucytosine; Griseofulvin; Histoplasmosis; Mucormycosis; Mycetoma; Sporotrichosis; Tinea Capitis; Tinea Pedis; Tinea Versicolor

Three cases of coccidioidomycosis of the female genital tract are reviewed. The diagnosis was made by laparotomy in 2 patients who presented with tender adnexal masses, and by endometrical curettage in a third patient with disseminated coccidioidomycosis. Hysterectomies were performed in all 3 patients; 1 had a bilateral salpingo-oophorectomy and the others a bilteral salpingectomy and unilateral oophorectomy. Two patients received chemotherapy with amphotericin B. One patient died 4 years after her operation from disseminated and meningeal coccidioidomycosis. In a female patient who has resided in an endemic region and who presents with pelvic pain of obscure origin, unexplained infertility, a menstrual disorder, or a chronic, refractory pelvic inflammatory disease, genital coccidioidomycosis should be considered in the differential diagnosis.

Topics: Adolescent; Adult; Amphotericin B; Coccidioidomycosis; Curettage; Diabetes Complications; Fallopian Tubes; Female; Genital Diseases, Female; Genitalia, Female; Humans; Hysterectomy; Laparotomy; Ovary

A 29-year-old man with coccidioidomycosis of the tarsal bones and toxic reactions to intravenous Amphotericin B was treated by surgical curettage and local suction-irrigation system of Amphotericin B. The patient responded to treatment and was free of disease 2 years later. Local suction-irrigation with Amphotericin B may be a valuable adjunct in the treatment of coccidioidomycosis infection of bone.

Topics: Adult; Amphotericin B; Bone Diseases; Coccidioides; Coccidioidomycosis; Drainage; Foot; Humans; Male; Radiography; Tarsal Bones; Therapeutic Irrigation

Topics: Amphotericin B; Child, Preschool; Coccidioidomycosis; Humans; Injections, Intravenous; Injections, Spinal; Male; Meningitis; Spinal Puncture

Topics: Amphotericin B; Child; Coccidioidomycosis; Humans; Male; Remission, Spontaneous

The clinical course of disseminated coccidioidomycosis is highly variable. Neither spontaneous cure nor spontaneous ankylosis has ever been demonstrated in an adult with the disease in one or more disseminated articular foci. Coccidioidomycotic arthritis may fluctuate in activity, and may be compatible with years of limited function and moderate morbidity. Amputation as well as arthrodesis accompanied by adequate excision of diseased tissue are generally reliable methods of treatment of infected joints, but the decision whether or not to "cover" such patients with systemic doses of amphotericin is still difficult, and the roles of synovectomy and topical amphotericin remain to be determined.

Topics: Adult; Aged; Amphotericin B; Arthritis, Infectious; Arthrodesis; Coccidioidomycosis; Elbow Joint; Female; Humans; Male; Middle Aged; Synovectomy; Thoracic Vertebrae; Wrist Joint

Topics: Amphotericin B; Antifungal Agents; Antigens, Fungal; Aspergillosis; Biopsy; Blastomycosis; Candidiasis; Coccidioidomycosis; Complement Fixation Tests; Cryptococcosis; Fluorescent Antibody Technique; Fungi; Histoplasmin; Histoplasmosis; Humans; Immunity, Maternally-Acquired; Immunodiffusion; Immunosuppression Therapy; Lung; Methods; Mycoses; Precipitin Tests; Silver; Skin Tests; Sporotrichosis; Staining and Labeling; Stilbamidines

Topics: Amphotericin B; Animals; Arachnoiditis; Cervical Vertebrae; Cisterna Magna; Coccidioidomycosis; Cryptococcosis; Glucose; Haplorhini; Injections, Spinal; Lumbar Vertebrae; Macaca; Meningitis; Methods; Models, Biological; Posture; Serum Albumin, Radio-Iodinated; Solutions; Specific Gravity; Thoracic Vertebrae; Water

Topics: Aged; Amphotericin B; Blood Urea Nitrogen; Coccidioidomycosis; Complement Fixation Tests; Epididymitis; Heart Diseases; Humans; Hypocalcemia; Immunity; Kidney; Male; Potassium; Potassium Chloride; Skin Diseases

Topics: Adrenal Cortex Hormones; Amphotericin B; Coccidioidomycosis; Drug Combinations; Humans; Hydrocephalus; Immunity, Maternally-Acquired; Meningitis; Prognosis

Topics: Amphotericin B; Antibodies, Fungal; Antigens, Fungal; Arthrodermataceae; Candida; Coccidioides; Coccidioidomycosis; Complement Fixation Tests; Female; Humans; Hypersensitivity, Delayed; Immunity, Maternally-Acquired; Immunization, Passive; Immunotherapy; Leukocytes; Lung Diseases; Lymphocyte Activation; Lymphocytes; Middle Aged; Precipitin Tests; Skin Tests; Streptodornase and Streptokinase; Tissue Extracts

Although amphotericin B is the principal antibiotic for treating systemic mycoses, its clinical use is restricted, primarily because of the toxicity associated with the required prolonged therapy. Other investigators have reported results from in vitro experiments demonstrating that amphotericin B can potentiate antifungal activity of other antibiotics which are ineffective when used alone. In the present study, amphotericin B was used in combination with tetracycline for treating experimental coccidioidomycosis in mice. The results show that the combination of antibiotics is effective with a dosage of amphotericin B reduced 2.5 to 4 times of that required for effective chemotherapy with amphotericin B alone.

Topics: Amphotericin B; Animals; Coccidioidomycosis; Drug Therapy, Combination; Male; Mice; Mice, Inbred DBA; Tetracycline

Topics: Adult; Amphotericin B; Antifungal Agents; Autopsy; Benzyl Compounds; Brain; Coccidioides; Coccidioidomycosis; Drug Evaluation; Drug Resistance, Microbial; Ethers; Humans; Imidazoles; Injections, Intravenous; Male; Meningitis

Topics: Abscess; Adult; Amphotericin B; Coccidioidomycosis; Dermatomycoses; Humans; Lung Diseases, Fungal; Male; Thoracic Diseases

Topics: Adult; Amphotericin B; Arthritis, Infectious; Coccidioidomycosis; Humans; Immunity, Maternally-Acquired; Immunotherapy; Male; Osteomyelitis

Topics: Amphotericin B; Arizona; Coccidioides; Coccidioidomycosis; Humans; Indians, North American; Infant, Newborn; Infant, Newborn, Diseases; Male; Prognosis; Sputum

Topics: Amphotericin B; Antifungal Agents; Blastomycosis; Coccidioidomycosis; Cryptococcosis; Flucytosine; Histoplasmosis; Humans; Meningitis; Mycoses; Natamycin; Nocardia Infections; Penicillin G; Potassium Iodide; Sporotrichosis; Stilbamidines; Sulfonamides

Topics: Adult; Amphotericin B; Biopsy; Cheek; Coccidioidomycosis; Dermatomycoses; Facial Dermatoses; Female; Granuloma; Humans; Nose Diseases; Pregnancy; Pregnancy Complications, Infectious

Topics: Amphotericin B; Coccidioidomycosis; Cryptococcosis; Female; Fetus; Humans; Pregnancy; Pregnancy Complications, Infectious

Topics: Amphotericin B; Asthma; Coccidioidomycosis; Complement Fixation Tests; Female; Glucocorticoids; Histoplasmosis; Humans; Male; Middle Aged; Mycoses; Nocardia Infections; Prednisone; Sulfadiazine

Topics: Adult; Amphotericin B; Coccidioidomycosis; Hand; Histiocytes; Humans; Immunosuppressive Agents; Male; Synovectomy; Tenosynovitis

Topics: Adult; Amphotericin B; Biopsy; Coccidioides; Coccidioidomycosis; Complement Fixation Tests; Humans; Male; Methods; Skin Tests; Spores, Fungal

Topics: Amphotericin B; Antifungal Agents; Aspergillosis; Blastomycosis; Candidiasis; Coccidioidomycosis; Cryptococcosis; Flucytosine; Histoplasmosis; Humans; Iodides; Mycoses; Nystatin; Sporotrichosis

Topics: Amphotericin B; Bacterial Infections; Catheterization; Cerebral Ventricles; Cerebrospinal Fluid; Cerebrospinal Fluid Shunts; Chronic Disease; Coccidioidomycosis; Cryptococcosis; Humans; Hydrocephalus; Injections, Spinal; Meningitis; Methods; Time Factors; Wound Infection

Topics: Adolescent; Amphotericin B; Arachnoiditis; Coccidioidomycosis; Female; Humans; Injections, Spinal; Male; Meningitis; Staphylococcal Infections; Sterilization

Of two patients who had acute neurologic damage from cisternal punctures, one died 17 hours following a tap which produced major subarachnoid hemorrhage, the other patient recovered from probable brain stem infarction associated with cisterna magna amphotericin injection. Subarachnoid hemorrhage is the commonest major complication of cisternal puncture, with at least 30 reported fatalities. Other serious complications result from direct puncture of brain substance.Cisternal puncture is not an appropriate alternative to a difficult lumbar puncture, and indications for its use are limited. The occasional required cisternal tap should be performed only by persons carefully trained in the technique, preferably utilizing fluoroscopic guidance, and only where neurosurgical assistance is readily available.Post-puncture subarachnoid hemorrhage accompanied by progressive obtundation requires emergency evaluation and consideration of posterior fossa decompression.

Topics: Adult; Amphotericin B; Brain Stem; Cisterna Magna; Coccidioidomycosis; Female; Humans; Infarction; Injections, Spinal; Male; Meningitis; Middle Aged; Punctures; Subarachnoid Hemorrhage

Topics: Amphotericin B; California; Coccidioides; Coccidioidomycosis; Disease Outbreaks; Humans; Injections, Spinal; Meningitis; Occupational Diseases; Soil Microbiology

The localization of coccidioidal meningitis in the basilar regions, with resultant hydrocephalus and uniformly fatal outcome, has necessitated intrathecal injection of amphotericin B via cisternal puncture or subcutaneous ventricular reservoir for successful therapy. A simpler form of treatment is described here, whereby amphotericin B diluted in 10 percent glucose solution is injected via lumbar puncture, and delivered to the base of the skull by tilting the patient to a head-down position. A simultaneously performed hyperbaric cisternogram with (131)I-serum albumin has demonstrated satisfactory migration of the injected bolus to the occiput. This method of administration resulted in successful suppressive treatment of one patient, including two years of follow-up without serious sequelae or relapse.

Topics: Aged; Amphotericin B; Coccidioidomycosis; Humans; Injections, Spinal; Male; Meningitis; Methods

Topics: Amphotericin B; Coccidioidomycosis; Diagnosis, Differential; Humans

Topics: Adult; Aircraft; Amphotericin B; Arizona; Coccidioidomycosis; Complement Fixation Tests; Diagnosis, Differential; Germany, West; Humans; Lung Diseases, Fungal; Lymph Nodes; Male; Radiography; Skin Tests; Tuberculosis, Pulmonary

Topics: Abscess; Amphotericin B; Child; Coccidioides; Coccidioidomycosis; Complement Fixation Tests; Environmental Exposure; Humans; Male; Skin Diseases, Infectious; Time Factors

Topics: Aerosols; Aged; Amphotericin B; Coccidioidomycosis; Humans

Topics: Amphotericin B; Blood Urea Nitrogen; Coccidioidomycosis; Fever; Histoplasmosis; Humans; Injections, Intramuscular; Injections, Intravenous; Methods; Nausea; Pain; Procaine; Sporotrichosis; Stimulation, Chemical; Vomiting

Topics: Amphotericin B; Animals; Aspergillosis; Blastomycosis; Candidiasis; Cat Diseases; Cats; Coccidioidomycosis; Cryptococcosis; Dog Diseases; Dogs; Histoplasmosis; Mycoses; Sporotrichosis

Topics: Adult; Amphotericin B; Canada; Cerebral Ventriculography; Chronic Disease; Coccidioidomycosis; Humans; Hydrocephalus; Male; Meningitis; Microscopy, Electron; South America; Time Factors; United States

Topics: Adolescent; Adult; Aged; Amphotericin B; Chronic Disease; Coccidioides; Coccidioidomycosis; Complement Fixation Tests; Diagnosis, Differential; Female; Histoplasmosis; Humans; Lung Diseases, Fungal; Male; Middle Aged; Radiography; Skin Tests; Sputum; Tuberculosis, Pulmonary

Topics: Adult; Amphotericin B; Coccidioidomycosis; Diagnosis, Differential; Humans; Lung Diseases, Fungal; Male; Radiography; Skin Tests; Texas; Time Factors; Tuberculosis, Pulmonary

Topics: Adult; Amphotericin B; Coccidioidomycosis; Female; Humans; Nephrosis; Pregnancy; Pregnancy Complications, Infectious

Topics: Adolescent; Adult; Amphotericin B; Coccidioides; Coccidioidomycosis; Complement Fixation Tests; Female; Humans; Male; Meningitis; Neurologic Manifestations; Skin Tests

Topics: Adult; Aged; Aminohippuric Acids; Amphotericin B; Biological Transport, Active; Blood Urea Nitrogen; Coccidioidomycosis; Cryptococcosis; Glomerular Filtration Rate; Histoplasmosis; Humans; Inulin; Kidney Concentrating Ability; Kidney Function Tests; Kidney Tubules; Male; Middle Aged; Mycoses; Natriuresis; Potassium; Urea

Topics: Adolescent; Amphotericin B; Animals; Biopsy; Child; Child, Preschool; Coccidioides; Coccidioidomycosis; Complement Fixation Tests; Disease Outbreaks; Dog Diseases; Dogs; Ecology; Female; Humans; Lung; Lung Diseases, Fungal; Male; Radiography; Skin Tests; Soil Microbiology; Sputum; Texas

Topics: Amphotericin B; Animals; Antigens; Coccidioides; Coccidioidomycosis; Drug Synergism; Fungal Vaccines; Immunization; Mice; Polysaccharides; Stimulation, Chemical; Time Factors

Topics: Amphotericin B; California; Coccidioidomycosis; Female; Humans; Maternal Mortality; Maternal-Fetal Exchange; Pregnancy; Pregnancy Complications, Infectious

Topics: Actinomycosis; Africa; Amphotericin B; Aspergillosis; Blastomycosis; Candidiasis; Coccidioidomycosis; Farmer's Lung; France; Histoplasmosis; Humans; Hypersensitivity; Lung Diseases, Fungal; Nystatin; Sputum; United States

Topics: Amphotericin B; Biliary Tract Diseases; Child; Coccidioidomycosis; Complement Fixation Tests; Dust; Humans; Jaundice; Lymph Nodes; Male; Radiography; Soil Microbiology

Topics: Adult; Amphotericin B; Coccidioidomycosis; Female; Humans; Osteosclerosis; Radiography; Spinal Diseases

Topics: Actinomycosis; Amphotericin B; Antifungal Agents; Blastomycosis; Candidiasis; Coccidioidomycosis; Cryptococcosis; Histoplasmosis; Mucormycosis; Mycoses; Nocardia Infections; Sporotrichosis

Topics: Actinomycosis; Adult; Amphotericin B; Biopsy; Blastomycosis; Coccidioidomycosis; Cryptococcosis; Diagnosis, Differential; Female; Histoplasmosis; Humans; Male; Middle Aged; Mycoses; Nystatin; Respiratory Tract Infections; Skin; Skin Diseases; Skin Ulcer; South America; Sputum

Topics: Adult; Amphotericin B; Coccidioidomycosis; Humans; Lung Diseases, Fungal; Male; Michigan

Topics: Adult; Aged; Amphotericin B; Coccidioidomycosis; Cryptococcosis; Female; Histoplasmosis; Humans; Male; Middle Aged; Mononuclear Phagocyte System; Mycoses; Phagocytosis; Serum Albumin, Radio-Iodinated

Topics: Adult; Amphotericin B; Chronic Disease; Coccidioides; Coccidioidomycosis; Humans; Male; Middle Aged; Time Factors

Topics: Adrenocorticotropic Hormone; Adult; Amphotericin B; Chloroquine; Coccidioidomycosis; Cortisone; Female; Humans; Lupus Erythematosus, Systemic; Methoxsalen; Methylprednisolone; Prednisolone; Tetracycline

Topics: Adolescent; Adult; Amphotericin B; Brain Abscess; Brain Neoplasms; Cerebral Ventriculography; Chronic Disease; Coccidioidomycosis; Complement Fixation Tests; Diagnosis, Differential; Female; Humans; Male; Meningitis; Skin Tests

Topics: Adult; Amphotericin B; Coccidioidomycosis; Epididymitis; Humans; Male; Prostatitis

Topics: Adolescent; Adult; Age Factors; Amphotericin B; California; Child; Coccidioides; Coccidioidomycosis; Female; Humans; Lung; Lung Abscess; Lung Diseases, Fungal; Male; Middle Aged; Pneumoperitoneum, Artificial; Pneumothorax, Artificial; Racial Groups; Radiography; Sex Factors; Skin Tests; Tuberculin Test

Topics: Amphotericin B; Coccidioidomycosis; Diagnosis, Differential; Female; Humans; Male; Pneumonectomy; Postoperative Complications; Radiography; Tuberculosis, Pulmonary

Topics: Adolescent; Amphotericin B; Antifungal Agents; Coccidioidomycosis; Diagnosis, Differential; Female; Humans; Lung; Lung Diseases, Fungal; Nystatin; Radiography; Tuberculosis, Pulmonary

Topics: Adult; Amphotericin B; Coccidioides; Coccidioidomycosis; Complement Fixation Tests; Granuloma; Humans; Injections, Intra-Articular; Knee Joint; Male; Synovitis

Topics: Alkenes; Amphotericin B; Animals; Antifungal Agents; Blastomycosis; Coccidioidomycosis; Cryptococcosis; Female; Histoplasmosis; Mice

Topics: Amphotericin B; Coccidioidomycosis; Humans; Male; Middle Aged; Retinitis

Topics: Adolescent; Adult; Aged; Amphotericin B; Child; Child, Preschool; Coccidioidomycosis; Female; Humans; Infant; Lung Diseases, Fungal; Male; Middle Aged; Postoperative Complications; Radiography, Thoracic

Topics: Adolescent; Adult; Amphotericin B; Black or African American; California; Child; Child, Preschool; Coccidioides; Coccidioidomycosis; Dermabrasion; Female; Head; Humans; Infant; Male; Middle Aged; Neck; Skin Diseases

Topics: Adolescent; Adult; Aged; Amphotericin B; Aspergillosis; Biopsy; Coccidioidomycosis; Cryptococcosis; Female; Histoplasmosis; Humans; Lung Diseases, Fungal; Male; Middle Aged; Nocardia Infections; Radiography

Topics: Adult; Alanine Transaminase; Amphotericin B; Aspartate Aminotransferases; Coccidioidomycosis; Eye Manifestations; Female; Humans; Injections, Intravenous; Liver; Pregnancy; Pregnancy Complications, Infectious

Topics: Actinomycosis; Amphotericin B; Anti-Bacterial Agents; Blastomycosis; Coccidioidomycosis; Humans; Penicillins; Sulfonamides

Topics: Adult; Amphotericin B; Coccidioides; Coccidioidomycosis; Female; Granuloma; Humans; Knee; Male; Middle Aged; Radiography; Synovial Membrane; Synovitis

Topics: Adult; Amphotericin B; Biopsy; Coccidioidomycosis; Eye Diseases; Female; Humans; Liver; Liver Diseases; Radiography, Thoracic

Topics: Adult; Amphotericin B; Coccidioidomycosis; Facial Dermatoses; Humans; Male

Topics: Adult; Amphotericin B; Coccidioides; Coccidioidomycosis; Female; Humans; Male; Middle Aged; Norway; Radiography, Thoracic

Topics: Amphotericin B; Blastomycosis; Central Nervous System Diseases; Coccidioidomycosis; Cryptococcosis; Histoplasmosis; Humans; Meningitis; Mycoses; Penicillins; Sputum; Sulfonamides

Topics: Amphotericin B; Anemia; Blood Urea Nitrogen; Coccidioidomycosis; Drug Therapy; Fungi; Hypokalemia; Lung Diseases, Fungal; Toxicology; Urea

Topics: Aerosols; Amphotericin B; Animals; Coccidioidomycosis; Dogs; Fungal Vaccines; Injections; Injections, Subcutaneous; Lung; Pathology; Pharmacology; Research; Respiration; Vaccination

Topics: Amphotericin B; Coccidioidomycosis; Drug Therapy; Fungi; Lung Diseases, Fungal; Radiography, Thoracic; Toxicology

Topics: Amphotericin B; Biomedical Research; Blastomycosis; Chlorpromazine; Coccidioidomycosis; Cryptococcosis; Drug Therapy; Fever; Histoplasmosis; Humans; Lactose; Nausea; Pentobarbital; Sporotrichosis; Toxicology; Vomiting

Topics: Amphotericin B; California; Coccidioidomycosis; Drug Therapy; Epidemiology; Fungi; Humans; Lung Diseases, Fungal; Radiography, Thoracic; Skin Manifestations

Topics: Agricultural Workers' Diseases; Agriculture; Amphotericin B; Biopsy; Coccidioidomycosis; Dermatomycoses; Diagnosis; Drug Therapy; Humans; Lymph Nodes; Pathology

Topics: Amphotericin B; Coccidioidomycosis; Dermatomycoses; Diagnosis; Drug Therapy; Foot Diseases; Hand Injuries; Humans; Lymph Nodes; Sepsis; Skin Tests; Wound Infection

Topics: Amphotericin B; Coccidioidomycosis; Drug Therapy; Humans; Laboratory Infection; Lung Diseases, Fungal; Mycoses; Occupational Diseases

The data derived from these three young patients would indicate the need for: (1) Early recognition of the primary cutaneous skin infection as being due to Coccidioides immitis. (2) The prompt use of suppressive intravenous amphotericin B therapy until such time as local tissue resistance and systemic immunity become manifest and sufficient to contain the pathogenic fungus within the initial cutaneous site of infection as manifested by complete healing of this primary lesion and its associated lymphadenopathy. It is apparent that there is a need to reassess present concepts which have been based on insufficient data, and to revise conclusions derived from the study of the eight previously reported instances of primary cutaneous coccidioidomycosis. The traumatic cutaneous inoculation of C immitis into a previously uninfected person, contrary to earlier impressions, can result not only in prolonged illness but in serious dissemination of the disease, and in one reported instance has resulted in coccidioidal meningitis.

Topics: Adolescent; Amphotericin B; Child, Preschool; Coccidioidomycosis; Dermatomycoses; Female; Humans

Topics: Amphotericin B; Coccidioidomycosis; Complement Fixation Tests; Histoplasmosis; Humans; Lung Diseases, Fungal; Male; Middle Aged

Topics: Adult; Amphotericin B; Catheterization; Coccidioidomycosis; Cryptococcosis; Female; Humans; Injections, Intravenous; Injections, Spinal; Injections, Subcutaneous; Male; Meningitis; Middle Aged

Topics: Amphotericin B; Blastomycosis; Coccidioidomycosis; Humans; Lung Diseases, Fungal; Lymph Nodes; Mouth; Mycoses

Topics: Actinomycosis; Amphotericin B; Biomedical Research; Blastomycosis; Candidiasis; Coccidioidomycosis; Cryptococcosis; Cycloserine; Erythromycin; Histoplasmosis; Humans; Mycoses; Nocardia Infections; Penicillins; Pharmacology; Sporotrichosis; Stilbamidines; Sulfamerazine; Tetracycline

Topics: Actinomycosis; Amphotericin B; Anti-Bacterial Agents; Antifungal Agents; Aspergillosis; Blastomycosis; Candidiasis; Coccidioidomycosis; Cryptococcosis; Histoplasmosis; Humans; Iodides; Lung Diseases, Fungal; Nocardia Infections; Penicillin G; Sporotrichosis; Stilbamidines; Sulfonamides; Toxicology

Topics: Amphotericin B; Bone Diseases; Cervical Vertebrae; Coccidioides; Coccidioidomycosis; Humans; Meningitis; Paralysis; Quadriplegia; Radiography; Surgical Procedures, Operative

In a study of 25 patients the usefulness of amphotericin B in the control of meningeal infection produced by Coccidioides immitis was established. Initial treatment must be intensive, consisting of intravenous and intraspinally administered amphotericin B. Serologic evaluation of coccidioidal disease provides the most important single criterion for determining the course of the meningeal infection and for estimating the response of the patient to amphotericin B therapy. Final control of coccidioidal meningitis rests upon the prevention of relapse after completion of initial intensive therapy. This requires continued suppressive fungistasis by regular intracisternal injections of amphotericin B at intervals of three to seven days after the patient returns home. Such suppressive cisternal therapy does not replace the initial intensive use of both intravenously and intraspinally administered amphotericin B. This "local" type of inhibition of C. immitis is without toxic effect upon the kidney, the red blood cells or the serum potassium values which may be associated with the intravenous administration of amphotericin B. Such intraspinal therapy, by lowering the total intravenous dosage required in the initial phase of treatment, results in a proportionate decrease in the degree of nephrotoxicity produced by amphotericin B. The total intravenous dosage given ordinarily should not exceed 5 grams. The long-term therapeutic plan as outlined permits the development of an adequate immune mechanism that appears essential to complete recovery from coccidioidal meningitis. The importance of such immunity in the recovery process has been previously indicated and confirmed by detailed study of a patient who required immunosuppression for successful homotransplantation of a kidney.

Topics: Administration, Intravenous; Adolescent; Amphotericin B; Black People; Cerebrospinal Fluid; Child; Cisterna Magna; Coccidioides; Coccidioidomycosis; Complement Fixation Tests; Dactinomycin; Dosage Forms; Humans; Imidazoles; Immunity; Infusions, Intravenous; Injections; Injections, Intravenous; Injections, Spinal; Kidney Transplantation; Meningitis; Meningitis, Fungal; Purines; Subarachnoid Space; Toxicology; Transplantation Immunology; White People

Topics: Amphotericin B; Blood; Coccidioidomycosis; Humans; Hypokalemia; Kidney Diseases; Muscular Diseases; Paralysis; Pathology; Potassium; Statistics as Topic; Toxicology; Urine

Topics: Amphotericin B; Arizona; Coccidioidomycosis; Humans; Leukemia; Leukemia, Lymphoid; Lung Diseases; Lung Diseases, Fungal; Prednisone; Sarcoidosis; Toxicology

Topics: Amphotericin B; Coccidioidomycosis; Diagnosis, Differential; Drug Therapy; Humans; Infant; Lung Diseases; Lung Diseases, Fungal; Pathology; Prognosis; Radiography, Thoracic; Serologic Tests; Skin Tests; Toxicology; Tuberculosis; Tuberculosis, Miliary

Topics: Amphotericin B; Coccidioidomycosis; Diagnosis, Differential; Drug Therapy; Italy; Pathology; Radiography, Thoracic

Castleberry, Merida W. (U.S. Army Biological Laboratories, Fort Detrick, Frederick, Md.), John L. Converse, and Peter J. Soto, Jr. Antibiotic control of tissue reactions in dogs vaccinated with viable cells of Coccidioides immitis. J. Bacteriol. 87:1216-1220. 1964.-A total of 12 dogs (15 to 25 lb each), vaccinated with viable Coccidioides immitis (subcutaneous injection of 260 viable arthrospores in the medial surface of the hind leg), resisted a respiratory challenge (aerosol) with the same organism (13,000 viable arthrospores) administered (aerosol) 2 months after vaccination. Oral amphotericin B therapy (150 mg of Fungizone per day for 21 days) of 6 of the 12 dogs, initiated immediately after vaccination, eliminated the undesirable side reactions of the viable vaccine (ulcerated vaccination site and inguinal lymphadenopathy exhibited by the 6 untreated dogs) without affecting the immunogenicity of the vaccine. Clinical observation (blood-urea nitrogen levels) during and after therapy and histological examination approximately 3 months after respiratory challenge failed to disclose any evidence of nephrotoxicity or renal damage due to the oral antibiotic therapy (total doses of more than 3 g of amphotericin B).

Topics: Amphotericin B; Animals; Blood Urea Nitrogen; Coccidioides; Coccidioidomycosis; Dogs; Fungal Vaccines; Lung; Virulence

Topics: Amphotericin B; Blastomycosis; Coccidioidomycosis; Histoplasmosis; Humans; Mycoses

Topics: Amphotericin B; Biomedical Research; Biopsy; Coccidioidomycosis; Drug Tolerance; Kidney; Kidney Function Tests; Nephrosclerosis; Pathology; Toxicology

Topics: Amphotericin B; Anuria; Coccidioidomycosis; Humans; Kidney; Kidney Diseases; Kidney Function Tests; Toxicology; Uremia

Topics: Amphotericin B; Coccidioidomycosis; Humans; Kidney Diseases; Kidney Function Tests; Toxicology

Topics: Acute Kidney Injury; Amphotericin B; Coccidioidomycosis; Humans; Kidney Transplantation; Pathology; Renal Insufficiency; Toxicology

Topics: Actinomycosis; Amphotericin B; Aspergillosis; Blastomycosis; Candidiasis; Coccidioidomycosis; Histoplasmosis; Humans; Lung Diseases, Fungal; Nocardia Infections; Nystatin; Sulfadiazine

Topics: Actinomycosis; Amphotericin B; Anti-Bacterial Agents; Blastomycosis; Coccidioidomycosis; Cryptococcosis; Fungi; Histoplasmosis; Humans; Lung Diseases; Lung Diseases, Fungal; Nocardia Infections; Penicillins; Radiography, Thoracic; Sulfadiazine; Thoracic Diseases

Topics: Amphotericin B; Antifungal Agents; Coccidioidomycosis; Fungicides, Industrial; Peptides; Psychotherapy, Multiple

Topics: Amphotericin B; Coccidioidomycosis; Humans; Meningitis

Topics: Amphotericin B; Antifungal Agents; Coccidioidomycosis

Amphotericin B is the first agent to alter favorably the course of coccidioidal meningitis. The morbidity and toxicity of the drug are at present its chief limiting factors. Although no cures were obtained in a series of 11 cases, significant remissions usually followed a course of therapy. Comparison with similar groups showed a significant prolongation of life in adequately treated cases.

Topics: Amphotericin B; Antifungal Agents; Coccidioidomycosis; Fungicides, Industrial; Humans; Life; Meningitis; Meningitis, Fungal

Topics: Amphotericin B; Antifungal Agents; Coccidioidomycosis; Dermatomycoses; Granuloma; Humans; Sepsis

Topics: Amphotericin B; Antifungal Agents; Coccidioidomycosis; Fungicides, Industrial; Lung Diseases

Topics: Amphotericin B; Antifungal Agents; Coccidioidomycosis; Mycoses; Sepsis

Topics: Amphotericin B; Antifungal Agents; Coccidioidomycosis; Humans

Topics: Amphotericin B; Antifungal Agents; Coccidioidomycosis; Fungicides, Industrial; Humans; Meningitis; Meningitis, Fungal

Topics: Amphotericin B; Antifungal Agents; Coccidioidomycosis; Humans

Topics: Amphotericin B; Antifungal Agents; Coccidioidomycosis; Fungicides, Industrial

Topics: Amphotericin B; Antifungal Agents; Coccidioidomycosis; Humans

Topics: Amphotericin B; Antifungal Agents; Coccidioidomycosis; Fungicides, Industrial; Humans

Topics: Amphotericin B; Antifungal Agents; Coccidioidomycosis; Fungicides, Industrial; Humans

Topics: Amphotericin B; Antifungal Agents; Coccidioidomycosis; Fungicides, Industrial; Humans

Topics: Amphotericin B; Anti-Bacterial Agents; Antibiotics, Antitubercular; Antifungal Agents; Coccidioidomycosis; Dermatologic Agents; Fungicides, Industrial; Humans

Topics: Amphotericin B; Animals; Anti-Bacterial Agents; Antifungal Agents; Candida albicans; Candidiasis; Coccidioides; Coccidioidomycosis; Humans; In Vitro Techniques; Male; Mice