Guidelines for the treatment of
blastomycosis are presented; these guidelines are the consensus opinion of an expert panel representing the National Institute of Allergy and Infectious Diseases
Mycoses Study Group and the
Infectious Diseases Society of America. The clinical spectrum of
blastomycosis is varied, including
asymptomatic infection, acute or chronic
pneumonia, and extrapulmonary disease. Most patients with
blastomycosis will require
therapy. Spontaneous cures may occur in some immunocompetent individuals with acute pulmonary
blastomycosis. Thus, in a case of disease limited to the lungs, cure may have occurred before the diagnosis is made and without treatment; such a patient should be followed up closely for evidence of
disease progression or dissemination. In contrast, all patients who are immunocompromised, have progressive
pulmonary disease, or have extrapulmonary disease must be treated. Treatment options include
amphotericin B,
ketoconazole,
itraconazole, and
fluconazole.
Amphotericin B is the treatment of choice for patients who are immunocompromised, have life-threatening or central nervous system (
CNS) disease, or for whom
azole treatment has failed. In addition,
amphotericin B is the only
drug approved for treating
blastomycosis in pregnant women. The
azoles are an equally effective and less toxic alternative to
amphotericin B for treating immunocompetent patients with mild to moderate pulmonary or extrapulmonary disease, excluding
CNS disease. Although there are no comparative trials,
itraconazole appears more efficacious than either
ketoconazole or
fluconazole. Thus,
itraconazole is the initial treatment of choice for nonlife-threatening non-CNS
blastomycosis.