ATS recommendations for management of histoplasmosis9
| Clinical situation | Management recommendations* |
|---|---|
| Immunocompetent hosts | |
| Asymptomatic pulmonary nodules | Observation alone |
| Asymptomatic broncholithiasis | Observation alone |
| Broncholithiasis causing post-obstructive pneumonia, haemoptysis, fistula or airway compromise | Bronchoscopic evaluation, bronchoscopic removal of broncholith and/or surgical intervention |
| Fibrosing mediastinitis | Itraconazole 200 mg BID for 12 weeks; continue for 12 months if radiographic/physiologic improvement. Consider airway or intravascular stents if tracheobronchial or vascular compromise is present. Anti-fibrotics or steroids controversial. |
| Symptomatic mild pulmonary disease | Observation for 3 weeks |
| Persistently symptomatic mild or moderate pulmonary disease | Itraconazole 200 mg BID for 12 weeks |
| Severe/life-threatening pulmonary disease | Amphotericin B (0.7 mg/kg/day) until clinical improvement or up to a cumulative dose of 2 g. Following improvement, itraconazole 200 mg BID for at least 12 weeks. Systemic steroids (prednisone 40–60 mg daily) are recommended for 1–2 weeks. |
| Immunocompromised hosts | |
| Mild to moderate pulmonary disease or progressive/disseminated disease | Itraconazole 200 mg TID for 3 days, followed by 200 mg BID for 12 months |
| Moderate to severe pulmonary disease or progressive/disseminated disease requiring hospitalisation | Amphotericin B (0.7–1.0 mg/kg/day) or liposomal amphotericin B (3–5 mg/kg/day) until clinical improvement or a cumulative dose of 2 g of amphotericin B. Following improvement, itraconazole 200 mg BID for 12 months. In patients with AIDS, continue itraconazole until CD4+ T-cell count is >200/μL. |
| Chronic pulmonary disease or cavitation | Itraconazole 200 mg BID for 1–2 years |
| Patients with AIDS who remain immunosuppressed, on lifelong maintenance therapy | Monitor urine and serum Histoplasma antigens several times per year |
ATS = American Thoracic Society; BID = two times a day; TID = three times a day.
*In patients unable to tolerate itraconazole, alternatives include fluconazole and ketoconazole.