Coccidioidomycosis

Prevention of Exposure
(1) Although HIV-infected persons living in or visiting areas in which coccidioidomycosis is endemic cannot completely avoid exposure to Coccidioides immitis, they should, when possible, avoid activities associated with increased risk (e.g., those involving extensive exposure to disturbed native soil, for example, at building excavation sites or during dust storms) (CIII).

Prevention of Disease
(2) Routine skin testing with coccidioidin (spherulin) in coccidioidomycosis-endemic areas is not predictive of disease and should not be performed (DII). Within the endemic area, a positive serologic test may indicate an increased risk for active infection; however, routine testing does not appear to be useful and should not be performed (DIII).

(3) Primary prophylaxis for HIV-infected persons who live in coccidioidomycosis-endemic areas is not routinely recommended.

Prevention of Recurrence
(4) Patients who complete initial therapy for coccidioidomycosis should be administered lifelong suppressive therapy (i.e., secondary prophylaxis or chronic maintenance therapy) (AII) using either fluconazole 400 mg po qd or itraconazole 200 mg bid (56). Patients with meningeal disease require consultation with an expert.

Discontinuation of Secondary Prophylaxis (chronic maintenance therapy)
(5) Although patients receiving secondary prophylaxis (chronic maintenance therapy) may be at low risk for recurrence of systemic mycosis when their CD4+ T-lymphocyte counts increase to > 100 cells/uL on HAART, the numbers of patients who have been evaluated are insufficient to warrant a recommendation to discontinue prophylaxis in such patients.

Notes

Pediatric Note
(6) Although no specific data are available regarding coccidioidomycosis in HIV-infected children, it is reasonable to administer lifelong suppressive therapy after an acute episode of the disease (AIII).

Note Regarding Pregnancy
(7) The potential teratogenicity of fluconazole and itraconazole should be considered when assessing the therapeutic options for HIV-infected women receiving maintenance therapy for coccidiodomycosis who become pregnant. In such patients, therapy with amphotericin B may be preferred, especially during the first trimester. Effective birth control should be recommended for all HIV-infected women on azole therapy for coccidioidomycosis (AIII).

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