Documente Academic
Documente Profesional
Documente Cultură
David C. Slagle
DRUG LIST
Fungal infections are usually more difficult to treat seated or disseminated fungal infections caused by di-
than bacterial infections, because fungal organisms grow morphic fungi, the yeasts Cryptococcus neoformans, and
slowly and because fungal infections often occur in tis- various Candida spp. respond to a limited number of
sues that are poorly penetrated by antimicrobial agents systemic agents: amphotericin B desoxycholate (a poly-
(e.g., devitalized or avascular tissues). Therapy of fungal ene), amphotericin B liposomal preparations, flucyto-
infections usually requires prolonged treatment. Poten- sine (a pyrimidine antimetabolite), the newer azoles, in-
tially life-threatening infections caused by dimorphic cluding ketoconazole, fluconazole, itraconazole and
fungi are becoming more common because increasing voriconazole, and capsofungin (an echinocandin).
numbers of immunocompromised patients are seen in
clinical practice; AIDS, organ and bone marrow trans-
plantation, and illnesses associated with neutropenia all AMPHOTERICIN B
predispose individuals to invasive fungal infection.
Superficial fungal infections involve cutaneous sur-
faces, such as the skin, nails, and hair, and mucous mem-
Chemistry and Mechanism of Action
brane surfaces, such as the oropharynx and vagina. A Amphotericin B (Fungizone), a polyene antifungal drug
growing number of topical and systemic agents are produced by the actinomycete Streptomyces nodosus,
available for the treatment of these infections. Deep- consists of a large ring structure with both hydrophilic
596
52 Antifungal Drugs 597
and lipophilic regions. Polyene antifungal drugs bind to are not elevated in renal or hepatic failure, and the drug
the fungal cell membrane component ergosterol, lead- is not removed by hemodialysis.
ing to increased fungal cell membrane permeability and
the loss of intracellular constituents. Amphotericin has
Clinical Uses
a lesser affinity for the mammalian cell membrane com-
ponent cholesterol, but this interaction does account for Amphotericin B is most commonly used to treat serious
most adverse toxic effects associated with this drug. disseminated yeast and dimorphic fungal infections in
immunocompromised hospitalized patients. As addi-
tional experience has been gained in the treatment of
Antifungal Spectrum fungal infections with the newer azoles, the use of am-
Amphotericin B is used to treat systemic disseminated photericin B has diminished; if azole drugs have equiv-
fungal infections caused by Candida spp., Cryptococcus alent efficacy, they are preferred to amphotericin B be-
neoformans, and the invasive dimorphic fungi (Asper- cause of their reduced toxicity profile and ease of
gillus spp., Histoplasma capsulatum, Coccidioides immi- administration. For the unstable neutropenic patient
tis, Blastomyces dermatitidis, and Sporothrix schenckii). with Candida albicans fungemia, amphotericin B is the
Intravenous amphotericin B remains the treatment of drug of choice. For the stable nonneutropenic patient
choice for serious invasive fungal infections unrespon- with C. albicans fungemia, fluconazole appears to be an
sive to other agents. acceptable alternative. For the AIDS patient with mod-
The development of resistance during amphotericin erate to severe cryptococcal meningitis, amphotericin B
B therapy is rarely clinically significant but has been re- appears to be superior to fluconazole for initial treat-
ported; relative resistance expressed through alter- ment; once infection is controlled, fluconazole in a daily
ations in membrane ergosterols has resulted in fungal oral dose is superior to and more convenient than
isolates with reduced growth rates and reduced viru- weekly intravenous amphotericin B in the prevention of
lence. Infections with organisms intrinsically resistant clinical relapses. For the AIDS patient with dissemi-
to amphotericin B, such as Candidia lusitaniae and nated histoplasmosis, the treatment is similar; ampho-
Pseudallescheria boydii, are uncommon but may be in- tericin B is preferred for the initiation of treatment, but
creasing in frequency. once infection is controlled, daily oral itraconazole is
preferred to intermittently dosed amphotericin B for
suppression of chronic infection. Most forms of blasto-
Absorption, Distribution, Metabolism,
mycosis and sporotrichosis in normal hosts no longer
and Excretion
require amphotericin B treatment.
Amphotericin B is primarily an intravenous drug; ab- Amphotericin B remains the drug of choice in the
sorption from the intestinal tract is minimal. After infu- treatment of invasive aspergillosis, locally invasive mu-
sion the drug is rapidly taken up by the liver and other cormycosis, and many disseminated fungal infections
organs and is then slowly released back into the circula- occurring in immunocompromised hosts (the patient
tion, where 90% of the drug is bound to protein. Its ini- population most at risk for serious fungal infections).
tial half-life is about 24 hours; the second elimination For example, the febrile neutropenic oncology patient
phase has a half-life of 15 days. The initial phase com- with persistent fever despite empirical antibacterial
prises elimination from both a central intravascular and therapy is best treated with amphotericin B for possible
a rapidly equilibrating extravascular compartment; the Candida spp. sepsis.
second, longer phase represents elimination from stor-
age sites in a slowly equilibrating extravascular com-
partment.
Adverse Effects
Drug concentrations in pleural fluid, peritoneal Fever, chills, and tachypnea commonly occur shortly af-
fluid, synovial fluid, aqueous humor, and vitreous hu- ter the initial intravenous doses of amphotericin B; this
mor approach two-thirds of the serum concentration is not generally an allergic hypersensitivity to the drug,
when local inflammation is present. Meningeal and am- which is extremely rare. Continued administration of
niotic fluid penetration, with or without local inflamma- amphotericin B is accomplished by premedication with
tion, is uniformly poor. Measurement of serum, urine, or acetaminophen, aspirin, and/or diphenhydramine or the
cerebrospinal fluid drug levels has not been used clini- addition of hydrocortisone to the infusion bag.
cally. Nephrotoxicity is the most common and the most se-
The major route of elimination of amphotericin B is rious long-term toxicity of amphotericin B administra-
by metabolism, with little intact drug detected in urine tion. This drug reduces glomerular and renal tubular
or bile. About 5% of amphotericin B is excreted in the blood flow through a vasoconstrictive effect on afferent
urine as active drug, with drug still detectable in the renal arterioles, which can lead to destruction of renal
urine 7 or more weeks after the last dose. Serum levels tubular cells and disruption of the tubular basement
598 VI CHEMOTHERAPY
amphotericin B. Candida krusei isolates may be resist- serum. Drug does not appear in significant quantities in
ant to fluconazole. the urine and cannot be measured in spinal fluid.
Fluconazole may be an acceptable alternative to
amphotericin B in the initial treatment of mild crypto- Clinical Uses
coccal meningitis, and it has been shown to be superior
to amphotericin B in the long-term prevention of re- Itraconazole is most useful in the long-term suppressive
lapsing meningitis (such patients require lifelong treat- treatment of disseminated histoplasmosis in AIDS and
ment.). Coccidioidal meningitis, previously treated with in the oral treatment of nonmeningeal, nonlife-threat-
both intravenous and intrathecal amphotericin B, ap- ening blastomycosis. It appears to be the drug of choice
pears to respond at least as well to prolonged oral flu- for all forms of sporotrichosis except meningitis and
conazole therapy. Aspergillosis, mucormycosis, and may have a lower relapse rate in the treatment of dis-
pseudallescheriasis do not respond to fluconazole treat- seminated coccidioidomycosis than does fluconazole.
ment. Sporotrichosis, histoplasmosis, and blastomycosis Itraconazole has replaced ketoconazole as the drug
appear to be better treated with itraconazole, although of choice in the treatment of paracoccidioidomycosis
fluconazole does appear to have significant activity and chromomycosis, based on its lower toxicity profile.
against these dimorphic fungi. Efficacy has also been reported in the treatment of in-
A significant decrease in mortality from deep-seated vasive aspergillosis.
mycoses was noted among bone marrow transplant re- Despite negligible cerebrospinal fluid concentra-
cipients treated prophylactically with fluconazole, but tions, itraconazole shows promise in the treatment of
similar benefits have not been seen in leukemia patients cryptococcal and coccidioidal meningitis. Additional
receiving prophylactic fluconazole. Fluconazole taken uses for itraconazole include treatment of vaginal can-
prophylactically by end-stage AIDS patients can reduce didiasis, tinea versicolor, dermatophyte infections, and
the incidence of cryptococcal meningitis, esophageal onychomycosis. Fungal nail infections account for most
candidiasis, and superficial fungal infections. use of this drug in the outpatient setting.
Adverse Effects
Adverse Effects
Itraconazole is usually well tolerated but can be associ-
Fluconazole is well tolerated. Nausea, vomiting, abdom-
ated with nausea and epigastric distress. Dizziness and
inal pain, diarrhea, and skin rash have been reported in
headache also have been reported. High doses may cause
fewer than 3% of patients. Asymptomatic liver enzyme
hypokalemia, hypertension, and edema. Itraconazole, un-
elevation has been described, and several cases of drug-
like ketoconazole, is not associated with hormonal sup-
associated hepatic necrosis have been reported. Alo-
pression. Hepatotoxicity occurs in fewer than 5% of
pecia has been reported as a common adverse event in
cases and is usually manifested by reversible liver en-
patients receiving prolonged high-dose therapy. Coad-
zyme elevations.
ministration of fluconazole with phenytoin results in in-
creased serum phenytoin levels.
Drug Interactions
Itraconazole has significant interactions with a number
ITRACONAZOLE of commonly prescribed drugs, such as rifampin, phe-
nytoin, and carbamazepine. Itraconazole raises serum
Absorption, Distribution, Metabolism, digoxin and cyclosporine levels and may affect the me-
and Excretion tabolism of oral hypoglycemic agents and coumadin.
Absorption of itraconazole is impaired by antacids, H2
Although itraconazole and fluconazole are both tria- blockers, proton pump inhibitors, and drugs that contain
zoles, they are chemically and pharmacologically dis- buffers, such as the antiretroviral agent didanosine.
tinct. Itraconazole (Sporanox) is lipophilic and water in-
soluble and requires a low gastric pH for absorption.
Oral bioavailability is variable, only 50 to 60% when KETOCONAZOLE
taken with food and 20% or less when the drug is taken
on an empty stomach. Itraconazole is highly protein
Absorption, Distribution, Metabolism,
bound (99%) and is metabolized in the liver and ex-
and Excretion
creted into the bile. With initial dosing, the plasma half-
life is 15 to 20 hours; steady-state serum concentrations Unlike other imidazoles, ketoconazole (Nizoral) can
are reached only after 2 weeks of therapy, when the be absorbed orally, but it requires an acidic gastric
half-life is extended to 30 to 35 hours. In lipophilic tis- environment; patients concurrently treated with H2
sues, drug concentration is 2 to 20 times that found in blockers or who have achlorhydria have minimal drug
600 VI CHEMOTHERAPY
absorption. Serum protein binding exceeds 90%. The Phenytoin serum levels should be monitored closely
drug is metabolized in the liver and excreted in the bile. when ketoconazole is prescribed. Ketoconazole causes in-
The initial half-life of ketoconazole is 2 hours; 8 to 12 creases in serum concentrations of warfarin, cyclosporine,
hours after ingestion, the half-life increases to 9 hours. and sulfonylureas. Because of its ability to increase serum
Reductions in renal and hepatic function do not al- cyclosporine levels, ketoconazole has been given to cy-
ter plasma drug concentrations, and ketoconazole is not closporine-dependent cardiac transplant recipients to re-
removed by hemodialysis or peritoneal dialysis. duce the dose of cyclosporine needed and as a cost-saving
Penetration into cerebrospinal fluid is negligible, so that measure.
ketoconazole is ineffective in the treatment of fungal
meningitis. Since only small amounts of active drug ap-
pear in the urine, ketoconazole is not effective in the MICONAZOLE
treatment of Candida cystitis.
Miconazole (Monistat) is a broad-spectrum imidazole
antifungal agent used in the topical treatment of cuta-
Clinical Uses neous dermatophyte infections and mucous membrane
Ketoconazole remains useful in the treatment of cuta- Candida infections, such as vaginitis. Minimal absorp-
neous and mucous membrane dermatophyte and yeast tion occurs from skin or mucous membrane surfaces.
infections, but it has been replaced by the newer tria- Local irritation to skin and mucous membranes can oc-
zoles in the treatment of most serious Candida infec- cur with topical use; headaches, urticaria, and abdomi-
tions and disseminated mycoses. Ketoconazole is usu- nal cramping have been reported with treatment for
ally effective in the treatment of thrush, but fluconazole vaginitis.
is superior to ketoconazole for refractory thrush.
Widespread dermatophyte infections on skin surfaces
can be treated easily with oral ketoconazole when the CLOTRIMAZOLE
use of topical antifungal agents would be impractical.
Treatment of vulvovaginal candidiasis with topical imi- Clotrimazole (Lotrimin, Gyne-Lotrimin, Mycelex) is a
dazoles is less expensive. broad-spectrum fungistatic imidazole drug used in the
Blastomycosis, histoplasmosis, sporotrichosis, paracoc- topical treatment of oral, skin, and vaginal infections
cidioidomycosis, and chromomycosis are better treated with C. albicans. It is also employed in the treatment of
with itraconazole than ketoconazole, although ketocona- infections with cutaneous dermatophytes.
zole remains an alternative agent. Ketoconazole is inef- Topical use results in therapeutic drug concentra-
fective in the treatment of cryptococcosis, aspergillosis, tions in the epidermis and mucous membranes; less
and mucormycosis. Candidemia is best treated with flu- than 10% of the drug is systemically absorbed. Al-
conazole or amphotericin B. though clotrimazole is generally well tolerated, local ab-
dominal cramping, increased urination, and transient
liver enzyme elevations have been reported.
Adverse Effects
Nausea, vomiting, and anorexia occur commonly with
ketoconazole, especially when high doses are pre- VORICONAZOLE
scribed. Epigastric distress can be reduced by taking ke-
toconazole with food. Pruritis and/or allergic dermatitis Voriconazole (Vfend), a derivative of fluconazole, is a
occurs in 10% of patients. Liver enzyme elevations dur- second-generation triazole that has improved antifun-
ing therapy are not unusual and are usually reversible. gal activity against Aspergillus and Fusarium spp., P.
Severe ketoconazole-associated hepatitis is rare. boydii, Penicillium marneffei, and fluconazole-resistant
At high doses, ketoconazole causes a clinically sig- Candida spp. Like fluconazole, voriconazole has high
nificant reduction in testosterone synthesis and blocks oral bioavailability and good cerebrospinal fluid pene-
the adrenal response to corticotropin. Gynecomastia, tration, but unlike fluconazole, it undergoes extensive
impotence, reduced sperm counts, and diminished li- hepatic metabolism and is highly protein bound. No sig-
bido can occur in men, and prolonged drug use can re- nificant amount of bioactive drug is excreted into the
sult in irregular menses in women. These hormonal ef- urine. Dosage reduction is necessary with severe he-
fects have led to the use of ketoconazole as a potential patic insufficiency but not with renal insufficiency.
adjunctive treatment for prostatic carcinoma. Significant drug interactions include cyclosporins
(increased cyclosporine levels), phenytoin, rifampin,
and rifabutin (decreased voriconazole levels). Because
Drug Interactions of its low toxicity profile, this drug may gain importance
Both rifampin and isoniazid lower plasma ketoconazole in the chronic treatment of infections with invasive di-
levels, and concomitant administration should be avoided. morphic fungi and resistant Candida spp.
52 Antifungal Drugs 601
OTHER IMIDAZOLES considered the drug of choice for these fungal infec-
tions, 5-FC does remain useful as part of combination
A number of topical imidazoles are available for the therapy for systemic candidiasis and cryptococcal
treatment of cutaneous and mucous membrane candidi- meningitis and as an alternative drug for chromomyco-
asis, ringworm, and tinea versicolor. Butoconazole sis. When it is used as monotherapy, resistance and
(Femstat) is an effective topical agent for vaginal can- clinical failure are common. Potential mechanisms for
didiasis; terconazole (Terazol) is effective in the treat- drug resistance include decreased fungal cell mem-
ment of vaginal candidiasis; and econazole (Spectazole) brane permeability and reduced levels of fungal
is useful in the treatment of superficial fungal infections cytosine deaminase. Combination therapy with am-
of the skin, achieving high tissue levels in the stratum photericin B and flucytosine in the treatment of
corneum. Oxiconazole nitrate (Oxistat) and sulconazole cryptococcal meningitis and deep-seated Candida in-
nitrate (Exelderm) are topical imidazole derivatives fections, such as septic arthritis and meningitis, permits
available for the treatment of dermatophyte infections reduced dosing of amphotericin B and prevents the
and pityriasis (tinea versicolor). Tioconazole (Vagistat) emergence of 5-FC resistance. When higher doses of
is available without a prescription for the treatment of amphotericin B are used, combination therapy with
dermatophyte infections and candidiasis. 5-FC confers no additional clinical benefit except in
All of these agents have minimal systemic absorp- the treatment of Candida endophthalmitis, where tis-
tion when applied topically, but occasionally use of sue penetration remains problematic.
these drugs can result in systemic toxicity.
Adverse Effects
FLUCYTOSINE When 5-FC is prescribed alone to patients with normal
renal function, skin rash, epigastric distress, diarrhea,
Chemistry and Mechanism of Action and liver enzyme elevations can occur. When it is pre-
Flucytosine (5-flucytosine, 5-FC; Ancoban) is a fluori- scribed to patients with renal insufficiency or to patients
nated pyrimidine analogue of cytosine that was origi- receiving concurrent amphotericin B therapy, blood lev-
nally synthesized for possible use as an antineoplastic els of 5-FC may rise, and bone marrow toxicity leading
agent. 5-FC is converted to 5-fluorouracil inside the to leukopenia and thrombocytopenia is common. 5-FC
cell by the fungal enzyme cytosine deaminase. Subse- serum levels should be closely monitored in patients
quently, 5-FC metabolites interfere with fungal DNA with renal insufficiency. Because of baseline leukope-
synthesis by inhibiting thymidylate synthetase. Incor- nia, 5-FC is often not tolerated by end-stage HIV-
poration of these metabolites into fungal RNA may in- infected patients with disseminated fungal infection.
hibit protein synthesis.
Study Questions
1. A 65-year-old man with acute leukemia recently un- hyperlipidemia. Three years ago he underwent ca-
derwent induction chemotherapy and subsequently daveric renal transplantation for end-stage kidney
developed neutropenia and fever (with no source of disease secondary to polycystic kidney disease and
fever identified). Fever persisted despite the use of is taking cyclosporin to prevent transplant rejection.
empirical antibacterial therapy, and amphotericin B In prescribing itraconazole for this patient, what ad-
has been prescribed for possible fungal sepsis. justments in his medication regimen do you recom-
Which laboratory test is LEAST helpful in monitor- mend?
ing for toxicities associated with amphotericin B? (A) Discontinue omeprazole and substitute the H2
(A) Liver function tests blocker ranitidine.
(B) Serum potassium (B) Discontinue omeprazole and substitute liquid
(C) Serum magnesium antacids.
(D) Serum blood urea nitrogen and creatinine (C) Discontinue omeprazole.
(E) Hemoglobin and hematocrit (D) Continue lovastatin.
2. A 55-year-old obese woman with adult-onset dia- (E) Increase cyclosporin dosing.
betes mellitus has been receiving amoxicillin for
treatment of an acute exacerbation of chronic bron- ANSWERS
chitis. After a week of therapy, the patient develops 1. A. Nephrotoxicity is the most common and most
dysuria and increased urinary frequency. Urinalysis serious toxicity associated with amphotericin B ad-
shows 10 to 50 white blood cells per high-power ministration. This is manifested by azotemia (ele-
field, and Gram stain of urine shows many budding vated serum blood urea nitrogen and creatinine),
yeasts. Which antifungal agent would be best in and by renal tubular acidosis, which results in the
treating this patient for Candida cystitis? wasting of potassium and magnesium in the urine
(A) Oral ketoconazole (leading to hypokalemia and hypomagnesemia, re-
(B) Oral fluconazole quiring oral or intravenous replacement therapy).
(C) Topical clotrimazole Normochromic normocytic anemia is also seen with
(D) Oral 5-flucytosine long-term amphotericin B administration. Elevation
(E) Oral itraconazole of liver enzymes is not associated with the use of
3. A 43-year-old woman recently underwent allo- amphotericin B.
geneic bone marrow transplantation after chemo- 2. B. Oral fluconazole is well absorbed from the gas-
therapy failed in the treatment of metastatic breast trointestinal tract, and 80% of drug is excreted into
carcinoma. The patient has had a stormy hospital the urinary tract, allowing effective treatment of
course after her transplant, with respiratory failure Candida cystitis. Subtherapeutic concentrations of
requiring mechanical ventilation. A month into her itraconazole and ketoconazole are excreted into the
hospitalization, surveillance sputum cultures reveal urine; these agents are not effective in the treat-
Aspergillus fumigatus, and a new infiltrate appears ment of Candida cystitis. Topical clotrimazole would
on her chest radiograph. Which antifungal agent is be effective in the treatment of Candida vaginitis,
recommended for the treatment of invasive pul- which can cause dysuria, but would not be an effec-
monary aspergillosis in this patient? tive treatment for cystitis. While 90% of 5-flucyto-
(A) Fluconazole sine is excreted unchanged in the urine, this more
(B) Amphotericin B toxic agent is usually used only in combination ther-
(C) Amphotericin B with 5-flucytosine apy with a second antifungal agent (usually ampho-
(D) Capsofungin tericin B) in the treatment of systemic candidiasis
(E) Itraconazole or cryptococcal meningitis.
4. A 57-year-old man with extensive onychomycosis 3. B. Amphotericin B remains the drug of choice in
(fungal toenail infection) asks you for an evalua- the treatment of disseminated or invasive fungal in-
tion. He requests a prescription for itraconazole for fections in immunocompromised hosts; bone mar-
treatment of this problem after seeing a television row transplant recipients are the most heavily im-
advertisement for this drug. He has chronic heart- munocompromised patients encountered in the
burn attributed to gastroesophageal reflux disease hospital setting. 5-Flucytosine has no significant ac-
and is treated with the proton pump inhibitor tivity against Aspergillus spp., and it has bone mar-
omeprazole. He is taking lovastatin for treatment of row toxicity as a common adverse effect; it should
604 VI CHEMOTHERAPY
not be used in this setting. Fluconazole has not been fungal infections. In Remington JS and Swartz MN
shown to be effective in the treatment of aspergillo- (eds.). Current clinical topics in infectious diseases.
sis. Itraconazole has been reported to be effective as Vol. 18. Cambridge, MA: Blackwell Scientific,
salvage treatment in patients with aspergillosis if 1998:1936.
amphotericin B therapy fails; it should not be used Edwards JE. Management of severe candidal infec-
as initial treatment in this setting. Capsofungin, a tions: Integration and review of current guidelines
new echinocandin antifungal agent recently ap- for treatment and prevention. In Remington JS and
proved by the U. S. Food and Drug Administration Swartz MN (eds.). Current clinical topics in infec-
for the treatment of refractory aspergillosis when tious diseases. Vol. 21. Cambridge, MA: Blackwell
standard therapy with amphotericin B fails, should Scientific, 2001:135147.
also not be used to treat invasive aspergillosis until Hatem CJ and Kettyle WM (eds.). Infectious Disease
more data showing efficacy are available. Medicine. In Medical knowledge self-assessment
4. C. Patients receiving multiple medications may program 12. Philadelphia: American College of
have adverse drug reactions when a new medication Physicians, 2000:6171.
is added to the regimen. Itraconazole requires an McEvoy GK (ed.). American hospital formulary ser-
acidic gastric environment for absorption; any drug vice drug information 2001. Bethesda, MD:
reducing gastric acid production (H2 blockers, pro- American Society of Health-System Pharmacists,
ton pump inhibitors) or neutralizing gastric acid 2001.
(antacids) will significantly reduce itraconazole ab- Sabo JA and Abdel-Rahman SM. Voriconazole: A new
sorption. Itraconazole inhibits the metabolism of triazole antifungal. Ann Pharmacotherapy
lovastatin and simvastatin and should not be pre- 2000;34:10321043.
scribed with these -hydroxy--methyglutaryl Stevens DA and Bennett JE. Antifungal agents. In
coenzyme A reductase inhibitors. Itraconazole will Mandell GL, Bennett JE, and Dolin R (eds.).
raise serum cyclosporin levels, resulting in cy- Principles and Practice of Infectious Diseases (5th
closporin toxicity, unless cyclosporin levels are ed.). New York: Churchill Livingston, 2000:448459.
closely monitored with dose reductions as indicated. Walsh TJ et al. Liposomal amphotericin B for empirical
therapy in patients with persistent fever and neu-
SUPPLEMENTAL READING tropenia. N Engl J Med 1999;340:764771.
Abramowitz M (ed.). Capsofungin (Cancidas) for as- Wong-Beringer A, Jacobs RA, and Guglielmo BJ. Lipid
pergillosis. Med Lett 2001;43:5859. formulations of amphotericin B: Clinical efficacy
Andriole VT. Current and future therapy of invasive and toxicities. Clin Infect Dis 1998;27:603618.
stormy course requiring 4 additional weeks of anti- nia. Once neutropenia resolved and the patient
fungal therapy. Eventually the patients liver en- could generate an inflammatory response, fever
zymes returned to normal and follow-up abdominal reappeared and the patient worsened clinically. A
computed tomography showed resolution of hepatic new elevation in serum transaminases provided the
and splenic abscesses. He was discharged home af- clue that led to abdominal imaging and the detec-
ter a 2- month hospitalization. What happened? tion of abscesses in the liver and spleen. The diag-
nosis of chronic disseminated candidiasis is often
ANSWER: Chronic disseminated candidiasis (he-
not confirmed by blood culture; the yield of blood
patosplenic candidiasis) occurs in patients with pro-
cultures in the detection of candidemia is poor, with
found neutropenia. This patient was appropriately
up to 50% of blood cultures falsely negative in this
treated for possible fungal sepsis when antibacterial
setting. Chronic disseminated candidiasis in neu-
therapy failed to resolve fever in the setting of neu-
tropenic leukemia patients is a life-threatening in-
tropenia. Despite therapy, however, the patient did
fection with significant morbidity and mortality.
have disseminated candidiasis, which persisted in a
subclinical state during the long period of neutrope-