In Humans

Clinical guidelines have been published for the management of human blastomycosis by the Infectious Diseases Society of America (IDSA) updated in 2008 (Chapman et al. 2008) and of human fungal pneumonias including blastomycosis by the American Thoracic Society (ATS) in 2011 (Limper et al.

2011). In humans, the recommended treatment for mild to moderate pulmonary or extrapulmonary blastomycosis (other than osteoarticular or CNS disease) is itraconazole 200 mg once or twice daily for 6-12 months; treatment of osteoarticular disease should be for 12 months. Moderately severe to severe pulmonary or extrapulmonary disease should be treated preferably with lipid formulation amphotericin B (3-5 mg/kg) or alternatively amphotericin deoxycholate (0.7-1.0 mg/kg) until clinical improvement, followed by de-escalation to a triazole for 6-12 months (Chapman et al. 2008). Central nervous system disease should be treated with a lipid formulation of amphotericin B (3-5 mg/kg) (for 4-6 weeks or until clinical improvement) followed by step-down to a triazole for 12 months (Chapman et al. 2008; Limper et al. 2011). Recent interest in the use of voriconazole for CNS blastomycosis has been driven by improved CSF and brain tissue penetration (Ta et al. 2009); accumulating published clinical experience provides anecdotal support for its use for this indication (Bakleh et al. 2005; Borgia et al. 2006; Bariola et al. 2010; Bush et al. 2013). Therapeutic drug monitoring is recommended for itraconazole and possibly voriconazole to ensure adequate levels are maintained (Chapman et al. 2008; Limper et al. 2011).

Acute respiratory distress syndrome due to blastomycosis occurs in 8-15% of persons with symptomatic blastomycosis (Meyer et al. 1993; Vasquez et al. 1998; Lemos et al. 2001; Azar et al. 2015), but it portends a grave prognosis with case fatality rates of at least 40% (Meyer et al. 1993; Vasquez et al. 1998; Lemos et al. 2001; Azar et al. 2015; Schwartz et al. 2016). Consequently, the roles of adjunctive, rescue therapies for ARDS caused by blastomycosis are an area of great interest, but little data. Some investigators have suggested a role for adjunctive corticosteroids considering the inflammatory cascade involved in the pathogenesis ARDS (Hough 2014). Anecdotal support has come from case reports and series (Lahm et al. 2008; Plamondon et al. 2010; Azar et al. 2015; Schwartz et al. 2016), although sufficiently powered prospective or retrospective studies are unlikely to be forthcoming (Schwartz et al. 2016). Extracorporeal membrane oxygenation (ECMO) is another promising adjunctive rescue therapy for ARDS due to blastomycosis (Dalton et al. 1999; Resch et al. 2009; Bednarczyk et al. 2015; Schwartz et al. 2016) and should be considered in centers where the capacity exists.

8.5.2

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Source: Seyedmousavi S. et al. (eds). Emerging and Epizootic Fungal Infections in Animals. Springer International Publishing,2018. - 406 p. 2018

In Humans

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