Richard F. Schillaci

Ketoconazole for treatment of disseminated coccidioidomycosis.

Of 29 selected patients with disseminated coccidioidomycosis, 27 were treated for at least 6 months with ketoconazole, 200 to 600 mg/d. Two patients had progression of coccidioidal disease shortly after starting ketoconazole, and one developed meningitis. Seven of eight patients with synovitis had prompt improvement in symptoms, but four either had recurrent synovial thickening without recoverable Coccidioides immitis or could not remain free of symptoms off the drug. The response of osteomyelitis to ketoconazole was hard to assess; three of eight cases clearly improved and none progressed. Abscess or sinus formation clearly improved in eight of patients; five remained free of disease after the drug was discontinued. Skin lesions improved in six of nine; three lesions remain healed off the drug. Ketoconazole is absorbed readily after oral ingestion and has little toxicity. In the dosages used, it seems to suppress but not eradicate C. immitis. The drug may be able to stabilize the infection while cell-mediated immunity is restored.

Ketoconazole for Treatment of Chronic Pulmonary Coccidioidomycosis

Twenty-one patients with chronic pulmonary coccidioidomycosis were treated with ketoconazole. In 16 patients with chronic cavitary disease, nine improved, four showed no change, and the condition of three deteriorated; three of nine patients had culture conversion. Roentgenograms showed improvement in two patients, no change in 12, and deterioration in two. Serologic improvement was not noted. In five patients with persistent infiltrative disease, the response was more favorable. Radiographic improvement, culture conversion, and serologic improvement were seen in most patients. Ketoconazole-induced side effects were mild and of short duration, ending in the first days of therapy. Ketoconazole seems to be of significant value in infiltrative pulmonary disease, but seems unable, at the doses used, to change finding in the sputum or to change radiographic findings in chronic cavitary disease. Further long-term observation is necessary to evaluate fully the role of this drug in chronic pulmonary coccidioidomycosis.

Treatment of coccidioidomycosis with ketoconazole: An evaluation utilizing a new scoring system

The evaluation of the response of patients with coccidioidomycosis to any therapeutic modality is a major challenge. A numerical scoring system was devised to quantitate separately the severity of disease on clinical presentation, the findings on chest film, bone scan, gallium scan, serology and skin test with coccidioidin and spherulin. The scoring system was used to evaluate the response to treatment with ketoconazole of seven patients with infiltrate pulmonary coccidioidomycosis; 20 patients with chronic cavitary coccidioidomycosis; and 40 patients with disseminated coccidioidomycosis. Dissemination included the soft tissue in 15, bone in 15, synovium in 11 and skin in 18. In all categories clinical severity scores improved dramatically. Radiographic scores showed similar improvement in cases of infiltrative pulmonary coccidioidomycosis but showed no change in cavitary coccidioidomycosis. Serology scores improved significantly (-2 or more) in one of seven infiltrative pulmonary cases, three of twenty chronic cavitary cases and twenty-three of forty disseminated cases. Among those with adequate mycology followup, cultures converted to negative in two of three infiltrative pulmonary coccidioidomycosis; seven of fourteen chronic cavitary coccidioidomycosis; and sixteen of twenty-two with disseminated disease. Unfortunately, when ketoconazole was discontinued or interrupted, symptoms recurred in four of twenty (20 percent) with chronic cavitary and ten of forty (25 percent) of disseminated cases. The disease in two patients progressed while on ketonconazole. One of those developed meningitis.

Cytomegalovirus Infection, Ascending Myelitis, and Pulmonary Embolus

Excerpt To the editor: Bronchoscopy with bronchoalveolar lavage and transbronchial lung biopsy are now readily available for detection of opportunistic lung infections in patients with the acquired...

Focal increased lung perfusion and intrapulmonary veno-arterial shunting in bronchiolo-alveolar cell carcinoma

A patient with bronchiolo-alveolar cell carcinoma presented with a veno-arterial shunt localized to the area of tumor involvement by differential position shunt testing. Perfusion lung scan revealed increased radionucleotide uptake in the area of the tumor, confirmed by pulmonary angiography, and suggested that the primary blood supply to the tumor was originating from the pulmonary circulation. Surgical resection of the tumor resulted in marked reduction of the intrapulmonary shunt.