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John N. Galgiani, Editorial Commentary: Elements of Style in Managing Coccidioidomycosis, Clinical Infectious Diseases, Volume 56, Issue 11, 1 June 2013, Pages 1586–1588, https://doi.org/10.1093/cid/cit117
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(See the Major Article by Levy et al on pages 1573–8and the Major Article by McCarty et al on pages 1579–85.)
In this issue of Clinical Infectious Diseases, we are provided glimpses into 2 California pediatric groups that report their experiences with the more severe spectrum of coccidioidomycosis as it affects children. Levy et al describe the use of voriconazole and caspofungin as combination salvage therapy for 9 children since 2003. In their experience, the eventual outcomes in these patients are encouraging. As they have carefully detailed, the clinical course of each patient differs widely. The only commonality seems to be that their doctors were convinced that current treatment was failing. The target of caspofungin and other echinocandins is a subunit of the β-1,3-glucan synthase and the gene encoding the subunit is essential to Coccidioides species [1]. Moreover, there is experimental evidence of caspofungin's therapeutic effect in mice [2, 3]. On the other hand, there is virtually no experience with caspofungin use as single-drug therapy for coccidioidomycosis, and Stevens et al recently published a series of adult patients salvaged with posaconazole alone [4]. In the other report, McCarty et al describe 33 pediatric patients who were admitted to a hospital in California's Central Valley for coccidioidomycosis over a 21-month period beginning in January 2010. The variety of illness that these children had was broader but still included 8 patients in whom initial therapy with liposomal amphotericin B was considered to have failed. Interestingly, although McCarthy is an author on both papers, posaconazole with caspofungin was not a second- or even a third-line treatment in the second report. As pointed out in both reports, most of the medical literature dealing with coccidioidomycosis neglects the disease in pediatrics. Even so, how to best treat the most difficult cases is no better understood in adults than it is children. However, for providers with extensive experience with managing such patients, it is abundantly evident that the best patient outcomes emerge from the orchestration of several different elements. This often takes time and does not receive appropriate reimbursement, because coordination of care is something that is just assumed to happen. In this commentary, I would like to put the selection of antifungal agents in the context of the other elements critical to management.
