Practice guidelines for the management of patients with blastomycosis

Guidelines for the treatment of blastomycosis are presented; these guidelin es are the consensus opinion of an expert panel representing the National I nstitute of Allergy and Infectious Diseases Mycoses Study Group and the Inf ectious Diseases Society of America. The clinical spectrum of blastomycosis is varied, including asymptomatic infection, acute or chronic pneumonia, a nd extrapulmonary disease. Most patients with blastomycosis will require th erapy. Spontaneous cures may occur in some immunocompetent individuals with acute pulmonary blastomycosis. Thus, in a case of disease limited to the l ungs, cure may have occurred before the diagnosis is made and without treat ment; such a patient should be followed up closely for evidence of disease progression or dissemination. In contrast, all patients who are immunocompr omised, have progressive pulmonary disease, or have extrapulmonary disease must be treated. Treatment options include amphotericin B, ketoconazole, it raconazole, and fluconazole. Amphotericin B is the treatment of choice for patients who are immunocompromised, have life-threatening or central nervou s system (CNS) disease, or for whom azole treatment has failed. In addition , amphotericin B is the only drug approved for treating blastomycosis in pr egnant women. The azoles are an equally effective and less toxic alternativ e to amphotericin B for treating immunocompetent patients with mild to mode rate pulmonary or extrapulmonary disease, excluding CNS disease. Although t here are no comparative trials, itraconazole appears more efficacious than either ketoconazole or fluconazole. Thus, itraconazole is the initial treat ment of choice for non-life-threatening non-CNS blastomycosis.