Factors and outcomes associated with the decision to treat primary pulmonary coccidioidomycosis

Background. Studies that assess the value of initiating oral antifungal therapy to treat primary pulmonary coccidioidomycosis have not been published previously. Methods. Prospectively collected observational data were analyzed from patients with primary pulmonary coccidioidomycosis who attended a single clinic devoted to the management of coccidioidomycosis that is located in a region of coccidioidal endemicity. Results. Fifty-four of 105 patients with primary pulmonary coccidioidomycosis were prescribed antifungal therapy, whereas 51 were not. No statistically significant differences were found between the 2 groups with regard to age, ethnicity, sex, or the presence or type of underlying diseases (for all, P > .100). Treated patients had a higher total clinical score (P = .001), had a higher symptom score (P = .049), and were more likely to have a culture of sputum that was positive for Coccidioides species (P = .048), compared with patients who were not prescribed therapy. There was prospective in-clinic follow-up for 43 patients, for a median duration of 286 days (range, 35-1124 days). The health of all 16 patients who were not treated improved after a median of 217 days, and no patients developed complications during follow-up. However, 2 of 20 patients who were treated but whose therapy was subsequently stopped developed disseminated disease. The rate of clinical improvement was similar in treated and untreated patients (P = .899). A retrospective follow-up of 58 of the remaining 62 patients identified 6 additional patients with complications, all from the group that was initially treated but whose therapy was subsequently discontinued. Conclusions. Approximately one-half of patients with primary pulmonary coccidioidomycosis were prescribed antifungal therapy on the basis of clinical severity. Complications were seen only among patients in the group that was prescribed therapy but whose treatment was discontinued.