title: Treatment of refractory coccidioidomycosis with voriconazole or posaconazole.
abstract: BACKGROUND
  Coccidioidomycosis is a fungal infection of the desert southwestern United States. It may be self-limited or may require antifungal therapy. Currently used triazoles (eg, fluconazole and itraconazole) have largely supplanted amphotericin B, which is fraught with adverse effects. Limited case reports and small open-label trials show that voriconazole and posaconazole benefit patients with coccidioidomycosis refractory to first-line agents.
  
  
  METHODS
  We conducted a retrospective review of patients prescribed voriconazole or posaconazole for coccidioidomycosis at our institution between 1 January 2006 and 1 August 2010. Outcomes were assessed with both a retrospectively applied Mycosis Study Group score (ie, a composite score for symptoms, serology, and radiographic findings) and the documented impressions of treating medical practitioners.
  
  
  RESULTS
  Twenty-one patients who received voriconazole and 16 who received posaconazole met study criteria. After a median duration of 6 months of voriconazole treatment, 14 of 21 patients (67%) were improved in overall status, 5 were unchanged, and 2 were unresponsive to voriconazole. After a median of 17 months of posaconazole treatment, 12 of 16 patients (75%) showed improvement, 1 was unchanged, and 3 were unresponsive due to medication intolerance or relapsed infection.
  
  
  CONCLUSIONS
  Voriconazole and posaconazole are reasonable but not infallible options for salvage treatment of refractory coccidioidomycosis. Prospective comparative trials are required to provide further insights into their efficacy and utility.
authors: Division of Infectious Diseases, Mayo Clinic, Scottsdale, Arizona, USA.
authors: Michelle M
authors: MM
authors: Kim
authors: Holenarasipur R
authors: HR
authors: Vikram
authors: Shimon
authors: S
authors: Kusne
authors: Maria Teresa
authors: MT
authors: Seville
authors: Janis E
authors: JE
authors: Blair
mesh_terms: D000328:Adult; D000368:Aged; D000935:Antifungal Agents / Q000008:administration & dosage*; D003047:Coccidioidomycosis / Q000188:drug therapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011743:Pyrimidines / Q000008:administration & dosage*; D012189:Retrospective Studies; D016879:Salvage Therapy / Q000379:methods; D015206:Southwestern United States; D016896:Treatment Outcome; D014230:Triazoles / Q000008:administration & dosage*; D065819:Voriconazole
chemical_list: D000935:Antifungal Agents; D011743:Pyrimidines; D014230:Triazoles; C101425:posaconazole; D065819:Voriconazole