Itraconazole for deep mycoses: preliminary experience in Mexico

Challenges in the therapy of chromoblastomycosis

Chromoblastomycosis (CBM) is an implantation mycosis mainly occurring in tropical and subtropical zones worldwide. If not diagnosed at early stages, patients with CBM require long-term therapy with systemic antifungals flanked by various physical treatment regimens. As in other neglected endemic mycoses, comparative clinical trials have not been performed for this disease; nowadays, therapy is mainly based on a few open trials and on expert opinions. Itraconazole, either as monotherapy or associated with other drugs, or with physical methods, is widely used. Recently, photodynamic therapy has been employed successfully in combination with antifungals in patients presenting with CBM. In the present paper, the most used therapeutic options against CBM are reviewed as well as the several factors that may have impact on the patient's outcome.

Posaconazole treatment of refractory eumycetoma and chromoblastomycosis

Eumycetoma and chromoblastomycosis are chronic, disfiguring fungal infections of the subcutaneous tissue that rarely resolve spontaneously. Most patients do not achieve sustained long-term benefits from available treatments; therefore, new therapeutic options are needed. We evaluated the efficacy of posaconazole, a new extended-spectrum triazole antifungal agent, in 12 patients with eumycetoma or chromoblastomycosis refractory to existing antifungal therapies. Posaconazole 800 mg/d was given in divided doses for a maximum of 34 months. Complete or partial clinical response was considered a success; stable disease or failure was considered a nonsuccess. All 12 patients had proven infections refractory to standard therapy. Clinical success was reported for five of six patients with eumycetoma and five of six patients with chromoblastomycosis. Two patients were reported to have stable disease. As part of a treatment-use extension protocol, two patients with eumycetoma who initially had successful outcome were successfully retreated with posaconazole after a treatment hiatus of > 10 months. Posaconazole was well tolerated during long-term administration (up to 1015 d). Posaconazole therapy resulted in successful outcome in most patients with eumycetoma or chromoblastomycosis refractory to standard therapies, suggesting that posaconazole may be an important treatment option for these diseases.

Chromoblastomycosis: clinical and mycologic experience of 51 cases

This is a study of 51 cases of chromoblastomycosis detected in a 17-year period, all of which were clinically and mycologically proven by direct examinations, cultures and biopsies. The therapeutic results of the various treatments used are reported. Most cases were males (36 of 51; 70%), the mean age was 35 years and farmers predominated (74%); the most frequent lesions were in the lower limbs (54%). Major clinical presentations were nodular (41%) and verrucous (26%). The principal aetiologic agent isolated was Fonsecaea pedrosoi (90%). Overall results of the various treatments were as follows: 31% were cured, 57% improved and 12% failed. The best results were obtained with cryosurgery for small lesions, with itraconazole for large ones, and in some cases the combination of both treatments.

Antifungal agents. Part II. The azoles

Before 1978, amphotericin B and flucytosine were the only drugs available for the treatment of systemic fungal infections. The imidazoles, miconazole and ketoconazole, were introduced during the next 3 years. Intravenously administered miconazole served a limited therapeutic role and is no longer available. Orally administered ketoconazole, an inexpensive, effective, and convenient option for treating mucosal candidiasis, was widely used for a decade because it was the only available oral therapy for systemic fungal infections. During the 1990s, use of ketoconazole diminished because of the release of the triazoles--fluconazole and itraconazole. Fluconazole is less toxic and has several pharmacologic advantages over ketoconazole, including penetration into the cerebrospinal fluid. In addition, it has superior efficacy against systemic candidiasis, cryptococcosis, and coccidioidomycosis. Despite a myriad of drug interactions and less favorable pharmacologic and toxicity profiles in comparison with fluconazole, itraconazole has become a valuable addition to the antifungal armamentarium. It has excellent activity against sporotrichosis and seems promising in the treatment of aspergillosis. Itraconazole has replaced ketoconazole as the therapy of choice for nonmeningeal, non-life-threatening cases of histoplasmosis, blastomycosis, and paracoccidioidomycosis and is effective in patients with cryptococcosis and coccidioidomycosis, including those with meningitis. Further investigation into the development of new antifungal agents is ongoing.

Treatment of tropical mycoses

Several subcutaneous and deep-seated mycoses are either observed more frequently in the tropical areas or are restricted to certain regions within the tropics. These mycoses include sporotichosis, chromoblastomycosis, entomophthoromycosis, eumycetoma, lobomycosis, and paracoccidioidomycosis. In sporotrichosis and paracoccidioidomycosis, therapy often results in either complete resolution or marked improvement. For decades sporotrichosis has been treated successfully with potassium iodide, but recently the triazole compounds, especially itraconazole, have proved effective and free of major side effects. The usual therapy for paracoccidioidomycosis is sulfonamides or amphotericin B; the former requires prolonged treatment, whereas the latter causes a significant degree of toxicity. Various azole derivatives (ketoconazole, fluconazole, saperconazole, and itraconazole) allow shorter treatment courses, can be given orally, and are more effective. Presently, itraconazole is the drug of choice. Chromoblastomycosis is a difficult condition to treat, especially if it is caused by Fonsecaea pedrosoi. Several therapeutic approaches have been used, including heat, surgery, cryotherapy, thiabendazole, amphotericin B combined with flucytosine, and azole derivatives, but their success has been modest. A 65% response rate has been obtained with itraconazole given for periods of 6 to 19 months; in limited trials, saperconazole appears to be more effective and requires shorter treatment courses. Only a few patients with eumycetoma respond to therapy; 70% of patients with Madurella mycetomatis respond to prolonged treatment with ketoconazole. Griseofulvin has been tried in nonresponders with partial success. Limited data in patients with Fusarium species eumycetoma indicate good responses to itraconazole. Eumycetoma caused by Pseudallescheria boydii or Acremonium species has been refractory to therapy. Therapy of entomophthoromycosis is also difficult because the diagnosis is usually established late and not all patients respond to therapy; this situation applies to infection caused by either Basidiobolus haptosporus or Conidiobolus coronatus. Although there is no consensus, African physicians prefer to use potassium iodide or trimethoprim-sulfamethoxazole. Isolated reports indicate that the azole derivatives, including the triazoles, may be effective. As for lobomycosis, all attempts at medical treatment have failed. Surgery is successful only when the lesion is small and can be fully resected; repeated cryotherapy appears to be more successful.

Antifungal agents: an overview. Part II

The recent introduction of a new generation of antifungal drugs promises to alter significantly therapy for both systemic and superficial mycoses, in particular, onychomycosis. This article presents an in-depth review of the azoles (the triazoles itraconazole and fluconazole), the allylamines (naftifine and terbinafine), and the morpholine derivative amorolfine.

Treatment of sporotrichosis with itraconazole. NIAID Mycoses Study Group

PURPOSE

To describe the clinical presentation and outcomes of treatment with itraconazole in patients with sporotrichosis.

METHODS

A culture for Sporothrix schenckii or compatible histopathology was required for inclusion in the study. Patients with both cutaneous and systemic sporotrichosis were treated. Patients received from 100 to 600 mg of itraconazole daily for 3 to 18 months. Patients were classified as responders or nonresponders. Responders were further classified as remaining on treatment, relapsed, or free of disease. Nonresponders included patients who failed to respond or progressed during treatment with itraconazole.

RESULTS

Twenty-seven patients (mean age: 53 years) were treated with 30 courses of itraconazole. Diabetes mellitus and alcoholism were present in eight and seven patients, respectively. Sites of involvement included lymphocutaneous alone in 9 patients, articular/osseous in 15 (multifocal in 3), and lung in 3. Prior therapy was unsuccessful in 11 patients. Among the 30 courses, there were 25 responders and 5 nonresponders. All 5 nonresponders received at least 200 mg daily of itraconazole for durations that ranged from 6 to 18 months. Of the 25 responders, 7 relapsed 1 to 7 months after treatment durations of 6 to 18 months. Of the 7 who relapsed, 2 are responding to a second course. One responder was lost to follow-up after 10 months of treatment with itraconazole. Of the remaining 17 responders, 3 remain on treatment, and 14 are free of disease over follow-up durations of 6 to 42 months (mean: 17.6 months). Itraconazole was well tolerated with few side effects noted.

CONCLUSIONS

These results document the efficacy of itraconazole in the treatment of cutaneous and systemic sporotrichosis.

Subcutaneous phaeohyphomycosis

We report the case of a 13-year-old boy who presented with multiple swellings all over the body. His condition remained undiagnosed for over 3 years. Exophiala spinifera was recovered from pus drained from the swellings. We discuss the difficulties in the initial diagnosis and the ease of correct diagnosis once we had used special fungal stains.

Sporotrichosis presenting as arthritis and subcutaneous nodules

Arthritis is a rare manifestation of systemic sporotrichosis. A patient who had sporotrichal arthritis of both wrists and elbows is described. Predisposing factors included alcoholism, rose gardening, and antecedent trauma. The onset of the arthritis was insidious, and the diagnosis was made 2 1/2 years after his first symptoms were noted. Treatment with surgical debridement and a 23-week course of ketoconazole was unsuccessful. A review of the literature suggests that some combination of intravenous or intraarticular amphotericin B and potassium iodide, ketoconazole, or surgery is necessary for effective treatment.

Successful treatment of sporotrichosis with oral fluconazole: a report of three cases

We report three cases of sporotrichosis successfully treated with oral fluconazole. A verrucous lesion on the toe was cured after 126 days, and a lesion on the left foot resolved after 91 days' treatment. A case of lymphangitic-type sporotrichosis required 174 days of treatment to achieve a cure, and a higher dose (400 mg daily) was necessary in this case. Any side-effects were insignificant. We conclude that this new bis-triazole compound can be successfully used as an alternative treatment for sporotrichosis when conventional drugs must be avoided.

Pulmonary sporotrichosis treated with itraconazole

A 62-year-old woman had chronic cavitary pulmonary sporotrichosis refractory to medical management over an 8-year period. She was treated with oral itraconazole and had an apparent microbiologic and clinical response; however, the patient succumbed to progressive pulmonary hypertension. The early use of oral itraconazole for treatment of pulmonary sporotrichosis is advocated.

Four non-endemic New Zealand cases of chromoblastomycosis

The majority of cases of chromoblastomycosis are reported from tropical to subtropical countries; only one previous case being reported from New Zealand. Four non-endemic cases in Pacific Island patients are described. All of the New Zealand cases were caused by Fonsecaea pedrosoi. In the present report, one patient was successfully treated by excision of the lesion followed by skin grafting. Another was treated with 200 mg ketoconazole daily for 10 weeks with no obvious improvement. No follow-up on the treatment of this case nor of the remaining two patients is available. This disease must be included in the differential diagnosis in patients who present with chronic lesions affecting the skin and subcutaneous tissues.

Itraconazole in the treatment of chromoblastomycosis due to Fonsecaea pedrosoi

The efficacy and tolerability of itraconazole in chromoblastomycosis due to Fonsecaea pedrosoi were evaluated in a non-comparative open clinical trial in 19 Brazilian patients with histopathologically and mycologically proven active chromoblastomycosis. Patients were classified in terms of severity and received itraconazole at the dosage of 200 to 400 mg per day until previously described criteria of cure have been reached. Clinical, mycologic, histopathologic, and laboratory evaluations were performed before, during, and after therapy. The plasma levels of itraconazole and the in vitro susceptibility of the isolates were determined in 15 cases. Clinical and biologic cure were achieved by eight patients (42%) having mild to moderate disease, after a mean duration of therapy of 7.2 months (3.2-29.6 months). Sterile scarred lesions were observed in a post-therapy follow-up lasting on average 9.6 months that was carried out in this subgroup. Clinical cure alone occurred after a mean period of 25.1 months of treatment (16-30.5 months) in seven patients (36%) with moderate to severe disease. Finally, clinical improvement was obtained in four patients (21%) with severe lesions after a mean treatment time of 17.6 months (10.7-22.5 months). All patients responded favorably to itraconazole therapy. No significant side effects nor biochemical alteration during this trial were important enough to interrupt the treatment. Our results support those of previous trials, suggesting that itraconazole is an effective compound against chromoblastomycosis due to Fonsecaea pedrosoi.

Treatment of coccidioidomycosis osteomyelitis with itraconazole in a horse. A brief report

Itraconazole, a tricyclic azole effective against a number of deep mycotic diseases, was used to treat a Quarter Horse filly with coccidioidomycosis. The horse was almost normal after 90 days of treatment. Five months after discontinuing itraconazole treatment, the filly had severe neck pain and neurologic signs from recurrence of coccidioidomycosis and was treated with itraconazole for an additional 6 months. Her clinical condition improved to almost normal and the filly has remained normal for 2 years. There was no evidence of drug toxicity.

Itraconazole therapy for blastomycosis and histoplasmosis. NIAID Mycoses Study Group

OBJECTIVE

To assess the efficacy and toxicity of orally administered itraconazole in the treatment of nonmeningeal, nonlife-threatening forms of blastomycosis and histoplasmosis.

DESIGN

Prospective, nonrandomized, open trial.

SETTING

Multicenter trial at 14 university referral centers.

PATIENTS

Eighty-five patients with culture or histopathologic evidence of blastomycosis (48 patients) or histoplasmosis (37 patients). Patients receiving other systemic antifungal therapy were excluded.

INTERVENTIONS

Itraconazole was administered orally at doses of 200 to 400 mg/d. Patients in whom treatment was considered a success were treated for a median duration of 6.2 months (blastomycosis) and 9.0 months (histoplasmosis). Disease activity was assessed at baseline; drug efficacy and toxicity were evaluated at monthly intervals during therapy, and efficacy was evaluated at regular follow-up visits after completion of therapy. The median duration of posttreatment evaluation for successfully treated patients was 11.9 months (blastomycosis) and 12.1 months (histoplasmosis).

MEASUREMENTS AND MAIN RESULTS

Among the 48 patients with blastomycosis, success was documented in 43 (90%). The success rate for patients treated for more than 2 months was 95% (38 of 40). Among the 37 patients with histoplasmosis, success was documented in 30 (81%). The success rate for patients treated for more than 2 months was 86% (30 of 35). All patients with histoplasmosis in whom treatment failed had chronic cavitary pulmonary disease. Toxicity was minor; only 25 (29%) patients experienced any side effects, and itraconazole toxicity necessitated stopping therapy in only 1 patient.

CONCLUSIONS

Itraconazole is a highly effective therapy for nonmeningeal, nonlife-threatening blastomycosis and histoplasmosis. The drug is associated with minimal toxicity.

Treatment of human cutaneous sporotrichosis with itraconazole

Eighteen adult white male patients with cutaneous sporotrichosis were treated with itraconazole following different daily dose schemes. Cure was obtained in all cases after periods of 15-75 days (median 44 days) with total doses between 3.1 and 14.8 g (median 8.4 g). No serious side effects were observed and no relapses occurred in the follow-up period of between 1 and 26 months (median 14.7). These results show that itraconazole represents a safe and effective drug for the treatment of sporotrichosis. Comparison with other studies leads us to consider a daily dose of 200 mg as the most appropriate. A concomitant warming of the affected limbs should be recommended.

Itraconazole in antifungal therapy

OBJECTIVE

This overview compares and contrasts the pharmacotherapy of itraconazole with that of other antifungal agents.

DATA SOURCES

Primary literature on itraconazole was identified through a medical literature search from 1976 through 1991. This search included journal articles, abstracts, conference proceedings, and reports of animal and human research published in the English language.

STUDY SELECTION

All primary literature was reviewed regardless of the study design or outcome. Literature evaluations of efficacy were ranked using a literature rating scale (Dalen JE, Hirsh J. Arch Intern Med 1986;146:462-72), which was slightly modified to include case reports and observations.

DATA EXTRACTION

All data were collected and represented with a primary focus on itraconazole's mechanism of action, pharmacokinetics, clinical efficacy in systemic mycotic infections, drug interactions, and adverse reactions. All articles were referenced in the final data presentation unless grouped data had been accurately reviewed and published.

DATA SYNTHESIS

Despite the paucity of controlled comparative trials with itraconazole in patients with deep mycoses, results on efficacy are encouraging. It is still unclear what role itraconazole will have in the prophylaxis of fungal infections in immunocompromised hosts. The favorable pharmacokinetic profile permits once- or twice-daily administration and itraconazole appears to be safe and well tolerated.

CONCLUSIONS

Itraconazole should prove to be a useful replacement for ketoconazole on hospital formularies. This recommendation is based on itraconazole's greater apparent safety and efficacy. Reevaluation of this agent will be necessary upon the release of newer imidazoles and triazoles.

Antifungal agents used for deep-seated mycotic infections

The increased use of immunosuppressive regimens in organ transplantation and in the treatment of malignant lesions and the epidemic of acquired immunodeficiency syndrome (AIDS) are major reasons for the greater prevalence of fungal infections seen in clinical practice during the past decade. The traditional cornerstone of antifungal treatment, amphotericin B, continues to play a major role in deep-seated mycotic infections. The indications for intravenously administered miconazole have become limited. Orally administered flucytosine remains useful in certain infections, particularly cryptococcal meningitis. The new orally administered antifungal agents ketoconazole and fluconazole have been approved for clinical use and have supplanted amphotericin B in certain situations. Investigational antifungal agents, including liposomal amphotericin B, itraconazole, and saperconazole, hold promise for the future. Active investigation in the development of new antifungal agents is expected to continue.

Treatment of deep mycoses with itraconazole

Four patients with deep mycoses were treated with itraconazole. Two patients had chromoblastomycosis, one patient each had aspergillosis and Rhinofacial zygomycosis. These patients were either resistant to or showed poor response to Amphotericin B and/or ketoconazole. After the initial clinical and mycological evaluation, itraconazole was given in a daily dose of 200 mg orally. All patients responded to the drug very well. No adverse effects attributable to itraconazole were detected.

Chromoblastomycosis with malignant transformation and cutaneous-synovial secondary localization. The potential therapeutic role of itraconazole

A case of neoplastic transformation of lesions of chromoblastomycosis is reported in a 67-year-old farmer from French Guyana. An interesting aspect of this case was the appearance of new cutaneous lesions of chromoblastomycosis, in a different site from the original lesion, and the presence of an infected synovial cyst. The potential therapeutic role of itraconazole is discussed.

New therapeutic agents in veterinary dermatology

The rapid development of therapeutic agents will continue to provide veterinarians with new options in treating dermatologic disease. However, we must not overlook the possibility of new applications for older drugs. Ideally, before a drug can be recommended for routine use, it should be evaluated for safety and efficacy using unbiased scientific methods. Unfortunately, this type of testing is expensive and may take years to complete. Veterinarians faced with managing a difficult skin disease may have to make decisions based on anecdotal information or case reports. The importance of good client communication cannot be overemphasized. The veterinarian must explain the benefits and risks of each therapeutic option. A written informed consent statement is advisable when using a drug in a manner not approved by the FDA.

Treatment of chromoblastomycosis

Treatment of chromoblastomycosis is frequently difficult and unsatisfactory. A representative case is presented of this chronic subcutaneous fungal infection, characterized by warty, cauliflower-like lesions usually on the extremities. Chromoblastomycosis and its treatment are reviewed, with attention to itraconazole, a new triazole compound, as the possible drug of choice.

Itraconazole therapy for nonmeningeal coccidioidomycosis: clinical and laboratory observations

Itraconazole, a new oral triazole antifungal agent, was administered in 75 courses to patients with chronic coccidioidomycosis at dosages of 50 to 400 mg/day for a median duration of 10 months. Assessment of efficacy was made with a standardized scoring system. Responses were seen in 42 of 58 assessable courses (72%). Nonresponse occurred exclusively in patients who had failed previous therapy and was most common in pulmonary disease. Toxicity was minimal at the doses studied. Pharmacokinetic analysis of itraconazole in serum at steady state showed negligible circadian variation; differences in serum concentrations among patients were large. Clinical isolates of Coccidioides immitis showed uniform in vitro susceptibility to itraconazole. Itraconazole shows impressive activity in this series of patients with refractory coccidioidomycosis. Further evaluation of itraconazole in this and in other systemic mycoses is in order.

New antifungal agents for the systemic mycoses

The azoles are the prominent broad spectrum oral antifungal agents in use or under clinical investigation for the systemic mycoses. This class of antifungal agents is represented by the marketed drug ketoconazole (Nizoral) and the experimental triazoles furthest along in clinical trials in the United States, itraconazole and fluconazole. Ketoconazole use is limited by its side effect profile and activity spectrum. Itraconazole appears to be better tolerated and less toxic to liver function, does not cause adrenal suppression and is more active against Aspergillus and Sporothrix schenckii. Fluconazole appears to be a highly promising agent due its highly favorable pharmacokinetic profile; it is water soluble, is well tolerated, is not metabolized to inactive constituents, it has a long half-life and, unlike the other azoles, high cerebrospinal fluid levels are readily attained for consideration in meningeal mycoses. It remains to be determined what place these new triazoles have in managing immunosuppressed patients including those with acquired immune deficiency syndrome known as AIDS. Other experimental antifungal agents, including ambruticin, amphotericin B methyl ester and saramycetin are also described. Sales figures are presented of drugs marketed in the United States for the systemic mycoses and reflect the growing problem of fungal diseases in the population.

Sporotrichosis

Forty-nine patients with culture-proven sporotrichosis were treated between 1957 and 1986. Infections were lymphocutaneous in 36 patients, pulmonary in two, intraarticular in four, and involved multiple deep tissues in seven. Thirty-six infections involved an upper extremity. Five patients with deep infection had some evidence of being immunocompromised. Delay in diagnosis after presentation averaged 4 months overall and 25 months for those with deep infection. Ten of 12 joint infections resulted in significant functional impairment. Treatment with saturated potassium iodide solution was effective for lymphocutaneous infection. Four patients with infection of deeper tissues remain infected despite multiple operations and systemic courses of antifungal medication.

New antifungal agents

For more than two decades, amphotericin B has been the single broad-spectrum agent for the treatment of systemic mycoses. Amphotericin B is not always effective, must be given parenterally, and is associated with a host of adverse reactions. Despite amphotericin B toxicity, until recently the systemic mycoses did not rate enough attention to prompt a search for new alternatives. However, three recent events have overcome this inertia: the gradually increasing use of potent immunosuppressive agents and broad-spectrum antibacterial drugs; the discovery of the relatively nontoxic azole classes of antifungal drugs in the 1980s and the rapid emergence of AIDS, with its severe accompanying opportunistic fungal infections. In just ten years we have seen the emergence of second-generation imidazole and third-generation triazole antifungal drugs and, most recently, entirely new classes of agents. It is remarkable that so many alternatives are becoming available just at the time when new antifungal drugs have become a major need. This discussion will concentrate on the new antifungal drugs of the past ten years, with the exception of developments in the polyenes and flucytosine, which are covered elsewhere.

Itraconazole vs amphotericin B: in vitro comparative evaluation of the minimal inhibitory concentration (MIC) against clinically isolated yeasts

Itraconazole is a triazole compound which, following several clinical trials, has begun to be used for therapy of mycotic infections. This new drug, with a broad-spectrum antifungal activity, can be orally administered. The Authors studied the in vitro susceptibility to amphotericin B and itraconazole of the following clinical isolates of pathogenic yeasts: 100 Candida albicans, 20 C. tropicalis, 20 C. parapsilosis, 8 C. guilliermondii, 6 C. pseudotropicalis, 24 Torulopsis glabrata and 16 Cryptococcus neoformans. Serial two-fold dilution, from 100 micrograms/ml to 0.04 micrograms/ml, of each drug were prepared in Yeast Nitrogen Base + Glucose 5%, after dissolving the itraconazole in dimethylsulfoxide (DMSO) and amphotericin B in 5% glucose solution. Amphotericin B (MIC90: 3.12 micrograms/ml) was found to have an average in vitro MIC six-fold lower than itraconazole (MIC90: 25 micrograms/ml). Thus, even though itraconazole is active, amphotericin B remains one of the most effective of the antifungal drugs.

Phaeohyphomycosis due to Phialophora richardsiae

Phaeohyphomycosis, an infection characterised by dematiaceous yeast-like cells, hyphae and pseudohyphae in tissue, is an uncommon condition, often affecting immunosuppressed patients. A sixty four year old boat-builder, receiving treatment with prednisone and azathioprine developed multiple cutaneous nodules on the extremities. Histology showed a mixed dermal inflammatory infiltrate with scattered spores and hyphae. Culture revealed two organisms, Phialophora richardsiae and Exophiala jeanselmei. Fluorocytosine was initially given but the organism was found to be resistant. Since side effects have been associated with long term ketoconazole therapy, a less toxic and more potent triazole compound, itraconazole, was used. After three months, the lesions had completely resolved without adverse clinical or biochemical changes.

Treatment of chromoblastomycosis with itraconazole

The results of long-term itraconazole therapy in 10 patients with active chromoblastomycosis due to F. pedrosoi were reported. Therapy consisted of 100 or 200 mg/day of itraconazole, the length of therapy depending on the patient's response (12 to 24 months). This new triazole proved effective in reducing the number, size, and severity of the lesions in nine of the patients. Those patients with minor involvement profited more from therapy and were cured; patients with moderate involvement achieved either minor or major improvement. In most cases, signs and symptoms began to improve after 6 months of therapy. Mycological tests (in which tissue samples were treated with potassium hydroxide and cultured) became negative in six patients, but the fungus was eradicated in only three patients. Itraconazole produced no side effects. In spite of the need for long-term therapy, this new azole derivative effectively controls the disease.

Antifungal agents used for deep-seated mycotic infections

The main antifungal agents used for deep-seated mycotic infections are the broad-spectrum antifungal drug amphotericin B, the narrow-spectrum agent flucytosine, and the newer broad-spectrum agents ketoconazole, miconazole, and itraconazole. Amphotericin B remains the cornerstone of antifungal therapy. For the treatment of cryptococcal meningitis, the current recommendation is for the combined use of amphotericin B and flucytosine. Published clinical experience with the newer agents is limited. Not all patients from whom fungal agents have been isolated require treatment; the extent of the fungal infection should be determined, when possible, for evaluation of the need for treatment.