In endemic mycoses, spontaneous recovery without treatment usually occurs, especially in patients who are mildly affected and immunocompetent without dissemination; otherwise, administer treatment as outlined in the Table.
If aspergillosis, mucormycosis, and candidiasis occur in an immunocompromised host, reverse the factors affecting the patient's immune status, which is linked to successful recovery from the infection. Attempt the following ancillary events, which may help to promote recovery from the opportunistic infection:
- With the use of growth factors, ensure neutropenia recovery in patients receiving chemotherapy and bone marrow transplants.
- Withdraw or taper immunosuppressive drugs and steroids.
- Remove infected or highly colonized catheters in patients with candidiasis.
Medical Treatment
Histoplasmosis
Acute pulmonary histoplasmosis with hypoxia; prolonged moderate symptoms more than 1 month; disseminated disease; immunosuppressed host
Mortality for untreated disseminated disease 80%; reduced to 25% with treatment
Significant hemoptysis; recurrent pneumonia; repair of bronchopleural fistula
Corticosteroids in severe hypoxia
Anti-inflammatory agents to treat rheumatologic syndromes
Coccidioidomycosis
Disseminated disease; chronic pulmonary disease; acute pulmonary infection with hypoxia or protracted morbidity (more than 1-2 mo); immunosuppressed host (worst outcome, 70% mortality)
Surgical debridement or resection of infective tissue often necessary adjunct to antifungal treatment
Anti-inflammatory agents for rheumatologic syndromes
Blastomycosis
Persistent or recurrent symptoms of acute or chronic pulmonary disease or with pleural involvement; disseminated disease
Cryptococcosis
Patients who immunosuppressed and symptomatic; patients who are immunocompetent with disease progression; any patients with meningitis or disseminated disease
Candidiasis
All patients with invasive disease or dissemination; important to reverse factors affecting immune status
Rapid tapering of immunosuppressive agents and corticosteroids; important to remove indwelling infected intravenous lines or urinary catheters in setting of hematogenous spread
Aspergillosis; mucormycoses
All patients with invasive disease; in patients who are immunosuppressed, early diagnosis and empiric treatment for persistent fever not responding to broad-spectrum antibiotics; high mortality once infiltrates and symptoms appear; prognosis ultimately linked to severity and outcome of underlying disease
Mortality of 50-60% in patients with AIDS; mortality as high as 85% in patients with prior bone marrow transplantation
Aggressive surgical debridement of necrotic tissue important in mucormycosis, especially if confined to lungs
Rapid tapering of immunosuppressive agents and corticosteroids and reversal of neutropenia (if possible)
