Paracoccidioidomycosis: Next-Line Treatment When IV Amphotericin B or IV Sulfamethoxazole-Trimethoprim Did Not Achieve Clinical Goals
This protocol applies to patients with severe paracoccidioidomycosis (PCM) who meet specific severity criteria and whose initial intravenous therapy failed to reach the expected clinical benchmarks, warranting escalation to a further treatment step.
Severity Criteria — Three or More Must Be Present
- 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, bones)
- Lack of intradermal reaction to paracoccidioidin
Previous Line — Failure Condition That Triggers Escalation
First-line management of severe PCM involved parenteral induction with intravenous amphotericin B or intravenous sulfamethoxazole-trimethoprim, followed by oral maintenance. Escalation to this next-line protocol is indicated when that treatment failed to achieve:
- Resolution of signs and symptoms and involution of active lesions within 1–8 weeks
- Decreased erythrocyte sedimentation rate and normalization of C-reactive protein and alpha1 acid glycoproteins within 4–12 weeks
Next-Line Approach — Partial Overview Only
When the causative organism remains susceptible, an intrathecal route of antifungal delivery may be considered for patients unresponsive to intravenous therapy. A concomitant corticosteroid is included to reduce the risk of arachnoiditis. The complete protocol — drug selection, sequencing, monitoring, and decision criteria — is available via the full regimen.
Dosing, duration, and clinical decision points are not shown here.
References
- 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.
- As low levels are found in CNS, some authors prescribe AmB intrathecally (0.1–10 mg) in patients unresponsive to intravenous therapy when the fungus is susceptible to AmB.
- In this case, hydrocortisone 25–30 mg, or the equivalent dose of dexamethasone, can be administered to avoid arachnoiditis, and could be prescribed to pregnant women as it is not teratogenic.
DOI: 10.1590/S0036-46652015000700007
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