Ketoconazole for treatment of disseminated coccidioidomycosis

Of 29 selected patients with disseminated coccidioidomycosis, 27 were treated for at least 6 months with ketoconazole, 200 to 600 mg/d. Two patients had progression of coccidioidal disease shortly after starting ketoconazole, and one developed meningitis. Seven of eight patients with synovitis had prompt improvement in symptoms, but four either had recurrent synovial thickening without recoverable Coccidioides immitis or could not remain free of symptoms off the drug. The response of osteomyelitis to ketoconazole was hard to assess; three of eight cases clearly improved and none progressed. Abscess or sinus formation clearly improved in eight of patients; five remained free of disease after the drug was discontinued. Skin lesions improved in six of nine; three lesions remain healed off the drug. Ketoconazole is absorbed readily after oral ingestion and has little toxicity. In the dosages used, it seems to suppress but not eradicate C. immitis. The drug may be able to stabilize the infection while cell-mediated immunity is restored.