Combination therapy of disseminated coccidioidomycosis with caspofungin and fluconazole

Abstract

Background: The current recommended therapy for diffuse coccidioidal pneumonia involves initial treatment with amphotericin B deoxycholate or high-dose fluconazole, followed by an azole after clinical improvement. Amphotericin B is more frequently used as initial therapy if the patient's deterioration is rapid.

Case presentation: A 31-year-old Korean male with coccidioidomycosis presented to the hospital with miliary infiltrates on chest X-ray (CXR) and skin rash on the face and trunk. Initially, the patient did not respond to amphotericin B deoxycholate therapy. However, following caspofungin and fluconazole combination therapy, the patient showed favourable radiological, serological, and clinical response.

Conclusion: This appears to be the first case of diffuse coccidioidal pneumonia with skin involvement in an immunocompetent patient who was treated successfully with caspofungin and fluconazole. Combination therapy with caspofungin and fluconazole may, therefore, be an alternative treatment for diffuse coccidioidal pneumonia that does not respond to amphotericin B deoxycholate therapy.

Figure 1

Chest X-ray (CXR) and high-resolution computed tomography (CT) findings on admission, and again at five months following combined treatment. Top (on admission): (A) Posterior-anterior chest radiograph (P-A CXR) shows multiple tiny reticular nodules on both lungs; (B) Tiny centrilobular and subpleural nodules are evident in both lungs on the chest CT. Bottom (five months after combined treatment): (C) A follow-up CXR shows improvement in the multiple reticular nodules; (D) A follow-up CT scan reveals the improvement of the residual nodules.