Royce Johnson, M.D., F.A.C.P. Disclosure Information Research Support/Consultant/Speaker

Transcription

1 Royce Johnson, M.D., F.A.C.P. Disclosure Information Research Support/Consultant/Speaker Astellas Enzon Pharmaceuticals Merck & Co, Inc. Ortho-McNeil, Inc. Pfizer, Inc. Sanofi Aventis Schering-Plough

2 The Scourge of the Lower Sonoran Lifezone ROYCE JOHNSON, M.D., F.A.C.P. Professor and Vice Chair Department of Medicine Geffen School of Medicine UCLA Chair Department of Medicine Chief Infectious Disease Kern Medical Center

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17 Basis for Establishing a Diagnosis 1. Skin tests Coccidioidomycosis of Coccidioidomycosis 2. Serologic test (tube precipitins, complement fixation, etc.) 3. Wet mounts of sputum, pus and body fluids 4. Histologic studies of biopsy specimens from skin, lung, etc. 5. Cultures of sputum, pus and body fluids

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22 I. Pulmonary Coccidioidomycosis Primary Pulmonary Coccidioidomycosis Asymptomatic Symptomatic Influenza-like syndrome Pneumonia Pleural Primary Cutaneous Coccidioidomycosis

23 II. Complicated and Residual Pulmonary Coccidioidomycosis Severe and persistent pneumonia Progressive primary coccidioidomycosis Progressive fibrocavitary coccidioidomycosis Cavities Nodules Fibrosis Empyema

24 III. Disseminated Coccidioidomycosis

25 EPIDEMIC: CLINICAL FEATURES SYMPTOM PREVALENCE N= COUGH CHEST PAIN SOB SPUTUM E. NODOSUM RASH HOSPITALIZED NOT HOSP ALL Johnson, Caldwell, Welch, Einstein, Cocci: Proceedings of 5 th International Conference, 1996;

26 EPIDEMIC: CLINICAL FEATURES SYMPTOM PREVALENCE n= FEVER CHILLS NOC SWEATS HEADACHE FATIGUE MYALGIAS HOSPITALIZED NOT HOSP ALL Johnson, Caldwell, Welch, Einstein, Cocci: Proceedings of 5 th International Conference, 1996;

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38 EPIDEMIC: CLINICAL FEATURES FACTORS ASSOCIATED WITH DISSEMINATION FACTOR OR P-value Highest CF titer > 1: AF Am Age > 50 years 1.82 NS Adenopathy CXR 1.96 NS Neg Skin Test Sex- Male Alk Phos > Note: Including patients presenting with dissemination that developed during 1 year follow-up.

39 Johnson, Cocci: Proceedings of 5 th International Conference, 1996;

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52 Indications for Antifungal Treatment 1. ALL disseminated cases 2. Primary Disease A. Rapidly Progressive B. CF Titer (>1:64) C. Slow Resolution (>6 weeks) D. Host Risk Factors Race, Age, Neg Skin Test, Co-morbidity

53 Characteristics of the Ideal Antifungal Drug Broad spectrum of antifungal activity Fungicidal No development of resistance during treatment Available for oral and intravenous administration Penetrates body fluid spaces, especially the spinal fluid No toxicity

54 Treatment Azoles Polyenes New Drugs

55 Therapeutic Agents Polyenes Amphotericin B (Fungizone) Amphotericin B Liposomal (Ambisome) Amphotericin B Colloidal Dispersion (ABCD, Amphotec, Amphocil) Amphotericin B Lipid Complex (ABLC, Abelcet) Azoles Ketoconazole Itraconazole Fluconazole Voriconazole Posaconazole

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59 Table 3. Complications of Cisternal Antifungal Treatment Headache Hypertension Bradycardia Arrthymias Infection Nausea, vomiting Cranial palsy Disequilibrium Gait problems Upper motor neuron disorders Hemorrhage (meningismus, brain stem compression, obstruction of fourth ventricle Brain puncture (cough, vomiting, weakness, electric sensation, respiratory disorders)

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