American Board of Internal Medicine (ABIM) Certification Practice Exam

In the treatment of pulmonary histoplasmosis, what is preferred for severe cases?

1. Itraconazole

2. Lipid formulation of amphotericin B followed by itraconazole

3. Fluconazole only

4. Conventional amphotericin B only

The correct answer is: Lipid formulation of amphotericin B followed by itraconazole

In the treatment of severe pulmonary histoplasmosis, the preferred approach is to use a lipid formulation of amphotericin B followed by itraconazole. This strategy addresses the immediate need for effective antifungal therapy in cases of severe infection, where rapid clinical improvement is crucial. The lipid formulation of amphotericin B is favored because it has a lower risk of toxicity compared to the conventional formulation, allowing for higher doses to be administered safely. This is particularly important in severe cases where rapid fungal load reduction is necessary to prevent serious complications. After the initial treatment phase with the lipid formulation, transitioning to itraconazole serves to provide continued therapy against Histoplasma capsulatum, the causative agent, and helps in achieving long-term resolution of the infection. Itraconazole is effective for chronic forms and is less toxic for maintenance therapy, making it a suitable choice once the immediate danger is managed. The other options, while they may have their uses in different contexts of fungal infections or less severe cases, do not provide the same combination of rapid action and lower toxicity that is vital for managing severe pulmonary histoplasmosis effectively. Therefore, the approach of using a lipid formulation of amphotericin B followed by itraconazole is considered the best treatment strategy in