Corticosteroids in the Management of Severe Coccidioidomycosis

Abstract

Introduction: There is limited data suggesting that recovery from severe pulmonary infection with Coccidioides may be hastened by the addition of systemic corticosteroids. Methods/Results: We report two patients with persistent and progressive coccidioidomycosis who demonstrated a dramatic response to adjunctive corticosteroid therapy. Both patients had Coccidioides immiitis cultured from respiratory samples. One was a 69 year old man who had been treated with combination fluconazole and liposomal amphotericin for over six weeks, with persistent fever and pneumonia. The other was a 61 year old man treated with fluconazole and then amphotericin for three weeks, with progression to acute respiratory distress syndrome (ARDS) and shock. Both received short courses of intravenous methylprednisolone and recovered to be discharged home. Conclusion: As opposed to associated hypersensitivity, corticosteroid treatment in these cases was directed at modulating the ongoing destructive effects of unchecked inflammation. Rapid improvement was noted in both cases and raises the possibility that the addition of systemic corticosteroids may hasten recovery in patients with severe coccidioidomycosis.

Prevalence of Atopic Disorders Among Pediatric Patients With Pulmonary and Disseminated Coccidioidomycosis

“…However, there is limited data that suggests the addition of systemic glucocorticoid to the standard treatment of fluconazole and liposomal amphotericin can improve recovery from severe pulmonary coccidioidomycosis. 9 Currently, the Infectious Diseases Society of America suggests that the use of glucocorticoids is anecdotal, supported by case reports, and may provide pain relief in patients with neurologic complications. 10 There is no consensus as to the dose and duration of systemic glucocorticoids in severe coccidioidomycosis.…”

December 2020 Pulmonary Case of the Month: Resurrection or Medical Last Rites?

“…After an additional 5 days of treatment, he was saturating well on room air and was able to be discharged to home. There are only a few case reports of corticosteroid therapy being clinically beneficial in severe pulmonary cocci (5,6). The proposed mechanism is similar to that proposed in some other infections (PJP, ?Covid-19) in which an excessive inflammatory response is suppressed.…”

Host–Pathogen Interactions in Coccidioidomycosis: Prognostic Clues and Opportunities for Novel Therapies

“…Improvement has been described in severe acute pulmonary CM, including cases of adult respiratory distress syndrome. 76,77 The indications for this therapy and the duration of therapy have yet to be defined; however, some experts recommend a tapering corticosteroid regimen similar to that used in cases of moderate to severe Pneumocystis jirovecii pneumonia for primary pulmonary CM with adult respiratory distress syndrome. 78 Similarly, corticosteroids have been advocated as an adjunctive therapy during treatment of central nervous system complications of coccidioidal meningitis, including cranial neuropathy, arachnoiditis, vasculitic infarction, encephalitis, and the development of a syrinx, or to ameliorate symptoms.…”