• 9
    May
  • Fluconazole in the Treatment of Persistent Coccidioidomycosis: RESULTS

Clinical response was favorable initially in 12 of 14 patients. The clinical scores of each patient at the beginning and end of treatment are listed in Table 1. The mean score before treatment for the 12 responders was 2.8 ±7; their mean score after treatment was 0.08 ±0.3. Resolution of visible lesions was relatively prompt. These 12 patients took fluconazole for from 5 to 23 months (mean, 13 ± 7).

Two patients had failure of treatment. Patient 6 presented with a four-month course of pneumonia followed by multiple disseminated lesions of the skin, soft tissue, and bones. She was given 50 mg/day for two weeks and then advanced to 100 mg/day. Despite treatment for ten weeks, old lesions continued to enlarge, and she developed new cutaneous lesions.

Patient 14 had chronic synovitis of the knee. He received 50 mg/day for four weeks and was then advanced to 100 mg/day. Despite treatment for three months, he remained symptomatic. Analysis of the synovial fluid showed persistent inflammatory changes, and С immitis continued to be found in the aspirated fluid. generic cialis 20 mg

In general, the drug was well tolerated. Compliance was excellent. Two patients complained of possible drug-related side effects, headaches in one and mem­ory loss in another. In no case was the drug stopped because of intolerance. The only abnormality encoun­tered in the monthly laboratory tests was minimal elevation of the gamma-glutamyl transferase level in seven patients before treatment, which became more abnormal with fluconazole therapy. In no case did the level rise above twice normal, and it usually declined to baseline after a few months of therapy. One patient had persistently elevated SGOT and SGPT concentra­tions.

Table 1—Data on Patients

Complement

Months of

Clinical

Fixation

Treatment

Score


С

immitis*

Titert

Site of

Case

Infection

50
mg

100
mg

Total

Start

End

Start

End

Start

End

Follow-Up, mo$

1

Pulmonary cavity

9

10

19

3

0

POS

NEG

0

0

18;
free of disease

2

Pulmonary cavity

17

0

17

2

0

POS

NEG

16

8

15;
free of disease

3

Fibro­cavitary

20

0

20

4

0

POS

NEG

16

16

6;
reactivation

4

Fibro­cavitary

12

0

12

3

0

POS

NEG

4

4

9
days; reactivation

5

Pulmonary
infiltrate; hilar adenop­athy; dis­seminated disease

5

0

5

4

0

POS

Not done

0

0

4.5;
recurrence with meningitis

6

Skin; soft tissue;
mediastinal adenopathy

0.5

1.5

2

8

12

POS

POS

1,024

256

NA; failed

7

Epididymis;
cervical lymph node; azygous lymph nodes

10

11

21

3

0

POS

Not done

64

16

3;
reactivation

8

Skin

12

0

12

2

0

POS

NEG

8

2

Died, MI; free of
disease

9

Epididymis

3

20

23

3

1

POS

Not done

128

32

13;
free of disease

10

Soft tissue

12

0

12

2

0

POS

Not done

32

16

4;
reactivation

11

Abscess after
nephrectomy

6

16

22

3

0

POS

Not done

128

0

22;
reactivation on drug

12

Skin;
peri­tonitis

6

3

9

3

0

H-POS

Not done

256

64

15;
reactivation of cutaneous lesion

13

Peritonitis;
lymph nodes

4

1

5

2

0

H-POS

Not done

4,096

32

10;
free of disease

14

Synovitis of knee

1

3

4

2

2

POS

POS

512

512

NA, failed

Coccidioides immitis was identified histologically or by culture in all patients at the start of treatment. Follow-up cultures were positive in the two patients with failure of treatment and were negative in five of the 12 responders. In seven patients, follow-up cultures were not done because rebiopsy was not clinically indicated, and there was no noninvasive way to obtain material for culture.

Serologic response to coccidioidin was monitored monthly using the complement fixation assay. Titers before treatment were high; after treatment, titers were significantly lower. In two of the ten responders who had elevated titers initially, there was a sevenfold drop in titer; in four, there was a twofold drop during treatment (Table 1).
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Roentgenograms were made as clinically indicated to assess the response to treatment. Serial roentgen­ograms were read systematically by a chest radiologist (P.F.) and were scored using our radiographic criteria. The patient with infiltrative disease had clearing of most of his infiltrates. The radiographic score at the start of treatment was 5; at the end of treatment, it was 2. The radiographic score on the four patients with cavitary or fibrocavitary disease did not change; however, we did observe minimal improvement, in­cluding clearing of intracavitary fluid, clearing of pericavitary infiltrates, and reduction in the thickness of cavity walls. The improvements noted in cavitary lesions were always minimal and incomplete and of uncertain significance, since these changes can occur spontaneously.

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