Recommendations for the Diagnosis and Treatment of Histoplasmosis | |||
| TYPE OF HISTOPLASMOSIS | DIAGNOSTIC TESTS | TREATMENT RECOMMENDATIONS | COMMENTS |
|---|---|---|---|
| Acute pulmonary, moderate to severe illness with diffuse infiltrates and/or hypoxemia | Histoplasma antigen (BAL fluid, serum, urine) Cytopathology on and fungal culture of BAL fluid | Lipid AmB (3-5 mg/kg per day) ± glucocorticoids for 1-2 weeks; then itraconazole (200 mg bid) for 12 weeks. Monitor renal and hepatic function. | Pts with mild cases usually recover without therapy, but itraconazole should be considered if the pt's condition has not improved after 1 month. |
| Chronic/cavitary pulmonary | Histoplasma serology (immunodiffusion and complement fixation) Fungal culture of sputum or BAL fluid | Itraconazole (200 mg qd or bid) for at least 12 months. Monitor hepatic function. | Continue treatment until radiographic findings show no further improvement. Monitor for relapse after treatment is stopped. |
| Progressive disseminated | Histoplasma antigen (serum, urine) Fungal culture of blood or bone marrow aspirate Cytopathology on biopsy of affected organ | Lipid AmB (3-5 mg/kg per day) for 1-2 weeks; then itraconazole (200 mg bid) for at least 12 months. Monitor renal and hepatic function. | Liposomal AmB is preferred, but the AmB lipid complex may be used because of cost. Chronic maintenance therapy may be necessary if the degree of immunosuppression cannot be reduced. |
| Central nervous system | Histoplasma antigen and serology of CSF Fungal culture of CSF | Liposomal AmB (5 mg/kg per day) for 4-6 weeks; then itraconazole (200 mg bid or tid) for at least 12 months. Monitor renal and hepatic function. | A longer course of lipid AmB is recommended because of the high risk of relapse. Itraconazole should be continued until CSF or CT abnormalities clear. |
Abbreviations: AmB, amphotericin B; BAL, bronchoalveolar lavage; CSF, cerebrospinal fluid.