Treatment of Paracoccidioidomycosis When Three or More Severity Criteria Are Present
This protocol covers the management of Paracoccidioidomycosis in patients meeting three or more markers of severe or moderate acute disease — including significant weight loss, high serological titers, suppurative lymphadenopathy, or multi-organ involvement.
Clinical Scenario
This protocol applies when the patient presents with three or more of the following findings:
- Total body weight loss ≥ 10%
- Counter immunoelectrophoresis (CIE) titers ≥ 1/64
- Tumor-like lesions or suppurative lymph nodes
- Multiple organ involvement (central nervous system, adrenal glands, or bones)
- Lack of intradermal reaction to paracoccidioidin
Treatment Approach
Management begins with a parenteral induction phase during the acute period, followed by a structured transition to oral maintenance therapy.
Full drug selection, dosing sequence, step-down criteria, and maintenance duration are available in the complete protocol.
Treatment Goals
- Resolution of signs and symptoms and involution of active lesions within 1–8 weeks of starting therapy
- Decreased erythrocyte sedimentation rate and normalization of C-reactive protein and alpha1 acid glycoproteins within 4–12 weeks
References
DOI: 10.1590/S0036-46652015000700007
- In severe or moderate acute cases, the patient has three or more of the following criteria: total body weight loss ≥ 10%; counter immunoelectrophoresis (CIE) titers ≥ 1/64; presence of tumor-like lesions or suppurative lymph nodes; multiple organ involvement (central nervous system, adrenal, bones); and lack of intradermal reaction to paracoccidioidin.
- AmB has been recommended since 1958 for the treatment of the most severe PCM cases.
- The starting dose varies from 5-10 mg but in severe cases, the total dose should be rapidly increased to 1 mg/kg/day.
- Severe cases received SMX-TMT intravenously, including those with CNS involvement.
- Once the acute phase is under control, the treatment can be changed to oral drugs (once or twice daily), favoring the adherence to longer treatment regimens.
- For maintenance therapy, slowly excreted sulfa (sulfamethoxypyridazin) could be used twice a day or even SMX-TMT 2-3 times a day.
- Involution of active lesions and resolution of signs and symptoms should occur within 1-8 weeks of starting therapy.
- Acute phase tests: decreased erythrocyte sedimentation rates and normalization of acute phase proteins should occur in the first 4-12 weeks (C-reactive protein and alpha1 acid glycoproteins).
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