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Treatment recommendations for pulmonary manifestations of histoplasmosis in adults

Treatment recommendations for pulmonary manifestations of histoplasmosis in adults
Syndrome Recommendation
Acute pulmonary: moderately severe to severe Liposomal AmB 3 mg/kg/day IV or AmB lipid complex 5 mg/kg/day IV or AmB deoxycholate* 0.7 to 1 mg/kg/day IV for one to two weeks followed by itraconazole load then 200 mg PO twice daily for a total of 12 weeks
Methylprednisolone, 0.5 to 1 mg/kg/day IV for one to two weeks for respiratory complications (eg, hypoxemia or respiratory distress)
Acute pulmonary: mild to moderate Symptoms <4 weeks: none
Symptoms >4 weeks: itraconazole load then 200 mg once or twice daily for 6 to 12 weeks
Chronic cavitary pulmonary Itraconazole load then 200 mg once or twice daily for at least 12 monthsΔ◊
Mediastinal granuloma Asymptomatic: none
Symptomatic: itraconazole load then 200 mg once or twice daily for 6 to 12 weeks
Mediastinal fibrosis Antifungal treatment not recommendedΔ
Stenting of obstructed vessels can be useful
Broncholithiasis None
Bronchoscopic or surgical removal of the broncholith is recommended
Pulmonary nodule None
AmB: amphotericin B; IV: intravenously; PO: orally.
* The deoxycholate formulation of amphotericin B 0.7 to 1 mg/kg/day is an alternative to a lipid formulation in patients who are at low risk for nephrotoxicity.
¶ Itraconazole should be given as a loading dose of 200 mg every eight hours for the first three days.
Δ If unable to differentiate mediastinal fibrosis from mediastinal granuloma: Itra 200 mg once or twice daily for 6 to 12 weeks.
◊ Concentrations of itraconazole in serum should be monitored in patients being treated for chronic pulmonary histoplasmosis; a random serum concentration >1 mcg/mL should be sought. Drug monitoring is infrequently needed for patients receiving shorter courses of therapy for acute pulmonary histoplasmosis and its complications.
Reproduced with permission from: Wheat LJ, Freifeld AG, Kleiman MB, et al. Clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the Infectious Diseases Society of America. Clin Infect Dis 2007; 45:807. Copyright © 2007 University of Chicago Press.
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