American Board of Internal Medicine (ABIM) Certification Practice Exam

What is the appropriate treatment for severe coccidioidal pneumonia or disseminated coccidioidomycosis?

1. Lipid formulation of amphotericin B until improvement, then itraconazole or fluconazole

2. Itraconazole only

3. Fluconazole alone

4. No treatment is required

The correct answer is: Lipid formulation of amphotericin B until improvement, then itraconazole or fluconazole

The appropriate treatment for severe coccidioidal pneumonia or disseminated coccidioidomycosis involves the use of a lipid formulation of amphotericin B as an initial therapy, especially in severe cases. This injectable antifungal is favored because it is effective in quickly reducing the burden of the fungal infection, providing a rapid response in critically ill patients. After initial improvement has been noted with amphotericin B, transitioning to an oral azole such as itraconazole or fluconazole is recommended for ongoing management. This step-down approach allows for continued control of the infection while minimizing the potential side effects associated with prolonged use of amphotericin B. Other options, such as itraconazole or fluconazole alone, may be suitable for less severe infections or as maintenance therapy, but they are not sufficient as initial treatment in severe cases. Additionally, the option suggesting that no treatment is required does not align with clinical guidelines, as severe forms of coccidioidomycosis necessitate intervention to prevent complications and deterioration of the patient’s condition. Therefore, the comprehensive strategy of starting with amphotericin B, followed by an oral azole, addresses both the acute and chronic management needs of the disease effectively.