IS IT EVER SAFE TO STOP AZOLE THERAPY FOR COCCIDIOIDES-IMMITIS MENINGITIS

Objective: To determine 1) whether patients with coccidioidal meningit is who had achieved remission with oral azole therapy were cured and 2 ) when oral atole therapy could be discontinued in these patients. Des ign: Data were gathered on patients with coccidioidal meningitis who h ad successfully responded to atole therapy in previous clinical trials . Setting: Referral centers, including university, county, and veteran s' hospitals and clinics. Patients: 18 patients in whom atole therapy for meningitis had been discontinued, usually because of a presumption of cure. Main Outcome Measures: Clinical and cerebrospinal fluid rela pse. Results: 14 of 18 patients (78% [95% CI, 52% to 94%]) had relapse with disseminated disease after discontinuation of therapy, for a tot al of 1 nonmeningeal and 15 meningeal relapses to date. Relapse occurr ed both soon and late (range, 0.5 to 30 months) after therapy was disc ontinued. The characteristics of patients who did not have relapse, in cluding the particular atole used, the duration of therapy, the reason therapy was discontinued, and the cerebrospinal fluid indices before discontinuation, were similar to the characteristics of patients who h ad relapse. Relapse had serious consequences in some patients; 3 patie nts died. Conclusion: Our data suggest 1) that disease is only suppres sed in patients with meningitis who achieve remission while receiving atole therapy and 2) that discontinuing atole therapy is unsafe. The a lternative is lifelong treatment with azoles; this appears to be accep table, because toxicity is uncommon with triazole therapy, even longte rm triazole therapy.