consenso histoplasmose
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consenso histoplasmose


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generally decrease with recovery, in-
sufficient data are available to support measurement of anti-
body levels for assessment of response to treatment.
IDSA Guidelines for Management of Histoplasmosis \u2022 CID 2007:45 (1 October) \u2022 815
WHAT IS THE TREATMENT FOR THE
COMPLICATIONS FROM PULMONARY
HISTOPLASMOSIS (E.G., PERICARDITIS,
ARTHRITIS/ERYTHEMA NODOSUM,
MEDIASTINAL LYMPHADENITIS, MEDIASTINAL
GRANULOMA, MEDIASTINAL FIBROSIS,
BRONCHOLITHIASIS, AND PULMONARY
NODULE)?
Pericarditis
Recommendations
7. Nonsteroidal anti-inflammatory therapy is recom-
mended in mild cases (B-III).
8. Prednisone (0.5\u20131.0 mg/kg daily [maximum, 80 mg
daily] in tapering doses over 1\u20132 weeks) is recommended for
patients with evidence of hemodynamic compromise or un-
remitting symptoms after several days of therapy with non-
steroidal anti-inflammatory therapy (B-III).
9. Pericardial fluid removal is indicated for patients with
hemodynamic compromise (A-III).
10. Itraconazole (200 mg 3 times daily for 3 days and then
once or twice daily for 6\u201312 weeks) is recommended if corti-
costeroids are administered (B-III).
Evidence summary. Pericarditis occurs as a complication of
inflammation in adjacent mediastinal lymph nodes in patients
with acute pulmonary histoplasmosis. It represents an inflam-
matory condition rather than infection of the pericardium.
Pericardial infection is a very rare complication of disseminated
disease. Patients respond to nonsteroidal anti-inflammatory
agents without antifungal therapy, often improving after only
a few days of therapy [58, 59]. Large pericardial effusions may
impair cardiac output, however, and thus require drainage [59].
Pericardial constriction is rare and is not a basis for prophylactic
therapy or surgical removal of the pericardium. If corticoste-
roids are used, concurrent itraconazole treatment is recom-
mended to reduce the risk of progressive infection. If the patient
has symptomatic acute pulmonary histoplasmosis with features
for which treatment is recommended, in addition to pericar-
ditis, itraconazole therapy is appropriate
Rheumatologic Syndromes
Recommendations
11. Nonsteroidal anti-inflammatory therapy is recom-
mended in mild cases (B-III).
12. Prednisone (0.5\u20131.0 mg/kg daily [maximum, 80 mg
daily] in tapering doses over 1\u20132 weeks) is recommended in
severe cases (B-III).
13. Itraconazole (200 mg 3 times daily for 3 days and then
once or twice daily for 6\u201312 weeks) is recommended only if
corticosteroids are administered (B-III).
Evidence summary. Arthritis or arthralgia with erythema no-
dosum occurs in 5%\u201310% of cases as a systemic inflammatory
response to acute pulmonary histoplasmosis [60, 61]. These
manifestations do not represent infection, and they respond to
nonsteroidal anti-inflammatory agents without antifungal ther-
apy. In some cases, the manifestations are moderately severe,
requiring treatment with corticosteroids [60]. If corticosteroids
are used, concurrent itraconazole treatment is recommended
to reduce the risk of progressive infection. Bone or joint in-
volvement is very rare in progressive disseminated histoplas-
mosis, but it should not be overlooked.
Mediastinal Lymphadenitis
Recommendations
14. Treatment is usually unnecessary (A-III).
15. Itraconazole (200 mg 3 times daily for 3 days and then
200 mg once or twice daily for 6\u201312 weeks) is recommended
in patients who have symptoms that warrant treatment with
corticosteroids and in those who continue to have symptoms
for 11 month (B-III).
16. Prednisone (0.5\u20131.0 mg/kg daily [maximum, 80 mg
daily] in tapering doses over 1\u20132 weeks) is recommended in
severe cases with obstruction or compression of contiguous
structures (B-III).
Evidence summary. Antifungal treatment is unnecessary in
most patients with symptoms due to mediastinal lymphadenitis.
The symptoms that occur most frequently are chest pain, cough
and/or atelectasis due to bronchial compression, or dysphagia
resulting from esophageal compression. Children are more
likely than adults to present with airway obstruction. In patients
with symptoms of compression of the airways or esophagus,
administration of prednisone in tapering doses over 1\u20132 weeks
may result in prompt relief by reducing the size of the inflamed
lymph nodes [62]. Itraconazole is recommended for 6\u201312 weeks
to reduce the risk of progressive disseminated disease caused
by corticosteroid-induced immunosuppression in patients who
are given corticosteroids and in patients whose symptoms last
longer than 1 month.
Mediastinal Granuloma
Recommendations
17. Treatment is usually unnecessary (A-III)
18. Itraconazole (200 mg 3 times daily for 3 days and then
once or twice daily for 6\u201312 weeks) is recommended for symp-
tomatic cases (B-III).
Evidence summary. The term mediastinal granuloma de-
scribes a large (3\u201310 cm in adults but smaller in children),
mostly caseous mass of mediastinal lymph nodes that coalesce
into a single encapsulated lesion, which is usually located in
816
Table 3. Recommendations for the treatment of histoplasmosis.
Manifestation Treatment Class Comments
Acute pulmonary histoplasmosis
Moderately severe or severe Lipid AmBa (3.0\u20135.0 mg/kg daily) or deoxycholate AmB (0.7\u20131.0
mg/kg daily) for 1\u20132 weeks, followed by Itrab (200 mg twice
daily for a total of 12 weeks)
A-III Usually follows easily identifiable heavy exposure and is accompa-
nied by diffuse infiltrates and hypoxemia
Methylprednisolone (0.5\u20131.0 mg/kg daily intravenously for 1\u20132
weeks)
B-III Effectiveness is not well documented
Mild to moderate For symptoms of !4 weeks, none
For symptoms of 14 weeks, Itra (200 mg once or twice daily for
6\u201312 weeks)
A-III
B-III
Whether treatment shortens the duration of illness is unknown
Chronic cavitary pulmonary histoplasmosis Itrab (200 mg once or twice daily for at least 12 months) A-II Relapse occurs in \u223c15% of cases
Pericarditis
Moderately severe to severe Itra (200 mg once or twice daily for 6\u201312 weeks) only if predni-
sone used
Prednisone (0.5\u20131.0 mg/kg daily in tapering doses over 1\u20132
weeks)
B-III
B-III
Tamponade requires drainage of pericardial fluid; antifungal therapy
is given to reduce possible dissemination caused by prednisone-
induced immunosuppression
Mild Nonsteroidal anti-inflammatory agents B-III Usually rapidly effective at reducing symptoms and pericardial
effusion
Rheumatologic histoplasmosis Nonsteroidal anti-inflammatory agents B-III Corticosteroids are rarely needed
Mediastinal lymphadenitis Mild symptoms of !4 weeks, none
Symptoms warranting treatment with prednisone, prednisone
(0.5\u20131.0 mg/kg daily in tapering doses over 1\u20132 weeks) and Itra
(200 mg once or twice daily for 6\u201312 weeks)
Symptoms of 14 weeks, Itra (200 mg once or twice daily for 6\u201312
weeks)
A-III
B-III
B-III
Nonsteroidal anti-inflammatory agents may be given, but the ef-
fectiveness is unknown; corticosteroids are rarely needed but
have been used in severe cases involving airway obstruction
Mediastinal granuloma Asymptomatic, none
Symptomatic, Itra (200 mg once or twice daily for 6\u201312 weeks)
B-III
B-III
Surgery may be required to relieve obstruction
Mediastinal fibrosis Antifungal treatment not indicated A-III Surgery should be avoided
Stenting of obstructed vessels can be useful B-III Surgery should be avoided
Itra (200 mg once or twice daily for 6\u201312 weeks) C-III Treatment given only if clinical findings cannot differentiate medi-
astinal fibrosis from mediastinal granuloma
817
Broncholithiasis None A-III Removal of stones by bronchoscopy or surgery may be indicated
Pulmonary nodule None A-III Must be differentiated from malignancy
Progressive disseminated histoplasmosis
Moderately severe to severe Liposomal AmBa (3.0 mg/kg daily), AmB lipid complexa (5.0 mg/kg
daily), or deoxycholate AmBa (0.7\u20131.0 mg/kg daily) for 1\u20132
weeks, followed by Itraa (200 mg twice daily for at least 12
months)
A-I Longer treatment may be required in patients with persistent
immunodeficiencyc