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Treatment of sporotrichosis depends on the severity and location of the disease. The following are treatment options for this condition:
- Saturated potassium iodide solution
- Itraconazole (Sporanox) and fluconazole
- Amphotericin B
- Terbinafine
- Newer triazoles
- Surgery
The majority of sporotrichosis cases occur when the fungus is introduced through a cut or puncture in the skin while handling vegetation containing the fungal spores. Prevention of this disease includes wearing long sleeves and gloves while working with soil, hay bales, rose bushes, pine seedlings, and sphagnum moss. Also, keeping cats indoors is a preventative measure. If you are moving to endemic areas, like Central and South America, make sure you are warned about Sporotrichosis.
In the majority of immunocompetent individuals, histoplasmosis resolves without any treatment. Antifungal medications are used to treat severe cases of acute histoplasmosis and all cases of chronic and disseminated disease. Typical treatment of severe disease first involves treatment with amphotericin B, followed by oral itraconazole.
Liposomal preparations of amphotericin B are more effective than deoxycholate preparations. The liposomal preparation is preferred in patients that might be at risk of nephrotoxicity, although all preparations of amphotericin B have risk of nephrotoxicity. Individuals taking amphotericin B are monitored for renal function.
Treatment with itraconazole will need to continue for at least a year in severe cases, while in acute pulmonary histoplasmosis, 6 to 12 weeks treatment is sufficient. Alternatives to itraconazole are posaconazole, voriconazole, and fluconazole. Individuals taking itraconazole are monitored for hepatic function.
Nocardiosis requires at least 6 months of treatment, preferably with trimethoprim/sulfamethoxazole or high doses of sulfonamides. In patients who do not respond to sulfonamide treatment, other drugs, such as ampicillin, erythromycin, or minocycline, may be added.
Treatment also includes surgical drainage of abscesses and excision of necrotic tissue. The acute phase requires complete bed rest; as the patient improves, activity can increase.
A new combination drug therapy (sulfonamide, ceftriaxone, and amikacin) has also shown promise.
Significant disease develops in fewer than 5% of those infected and typically occurs in those with a weakened immune system. Mild asymptomatic cases often do not require any treatment, and the symptoms will go away within a few months. Those with severe symptoms may benefit from anti-fungal therapy, which usually requires 3–6 months of treatment. There is a lack of prospective studies that examine optimal anti-fungal therapy for coccidioidomycosis.
On the whole, oral fluconazole and intravenous amphotericin B are used in progressive or disseminated disease, or in immunocompromised individuals. Amphotericin B used to be the only available treatment, although now there are alternatives, including itraconazole or ketoconazole may be used for milder disease. Fluconazole is the preferred medication for coccidioidal meningitis, due to its penetration into CSF. Intrathecal or intraventricular amphotericin B therapy is used if infection persists after fluconazole treatment. Itraconazole is used for cases that involve treatment of infected person's bones and joints. The antifungal medications posaconazole and voriconazole have also been used to treat coccidioidomycosis. Because the symptoms of valley fever are similar to the common flu and other respiratory diseases, it is important for public health professionals to be aware of the rise of valley fever and the specifics of diagnosis. Greyhound dogs often get valley fever as well, and their treatment regimen involves 6–12 months of Ketoconazole, to be taken with food.
The current medical treatments for aggressive invasive aspergillosis include voriconazole and liposomal amphotericin B in combination with surgical debridement.
For the less aggressive allergic bronchopulmonary aspergillosis findings suggest the use of oral steroids for a prolonged period of time, preferably for 6–9 months in allergic aspergillosis of the lungs. Itraconazole is given with the steroids, as it is considered to have a "steroid sparing" effect, causing the steroids to be more effective, allowing a lower dose.,
Other drugs used, such as amphotericin B, caspofungin (in combination therapy only), flucytosine (in combination therapy only), or itraconazole,
are used to treat this fungal infection. However, a growing proportion of infections are resistant to the triazoles. "A. fumigatus", the most commonly infecting species, is intrinsically resistant to fluconazole.
Prevention of aspergillosis involves a reduction of mold exposure via environmental infection-control. Anti-fungal prophylaxis can be given to high-risk patients. Posaconazole is often given as prophylaxis in severely immunocompromised patients.
Conventional "amphotericin B desoxycholate" (AmB: used since the 1950s as a primary agent) is known to be associated with increased drug-induced Nephrotoxicity (Renal toxicity) impairing Renal function. Other formulations have been developed such as lipid soluble formulations to mitigate such side-effects as direct proximal and distal tubular cytotoxicity. These include liposomal amphotericin B, "amphotericin B lipid complex" such as Abelcet (brand) "amphotericin B phospholipid complex" also as "AmBisome Intravenous", or "Amphotec Intravenous" (Generic; Amphotericin B Cholesteryl Sul) and, "amphotericin B colloidal dispersion", all shown to exhibit a decrease in nephrotoxicity. The later was not as effective in one study as "amphotericin B desoxycholate" which had a 50% murine morbidity rate versus zero for the AmB colloidal dispersion.
The cost of AmB deoxycholate in 2015, for a patient of at 1 mg/kg/day dosage, was approximately $63.80, compared to 5 mg/kg/day of liposomal AmB at $1318.80. This may be a concern in resource-limited settings.
Fungal pneumonia can be treated with antifungal drugs and sometimes by surgical debridement.
The drug of choice for the treatment of uncomplicated strongyloidiasis is ivermectin. Ivermectin does not kill the "Strongyloides" larvae, only the adult worms, therefore repeat dosing may be necessary to properly eradicate the infection. There is an auto-infective cycle of roughly two weeks in which Ivermectin should be re-administered however additional dosing may still be necessary as it will not kill "Strongyloides" in the blood or larvae deep within the bowels or diverticula. Other drugs that are effective are albendazole and thiabendazole (25 mg/kg twice daily for 5 days—400 mg maximum (generally)). All patients who are at risk of disseminated strongyloidiasis should be treated. The optimal duration of treatment for patients with disseminated infections is not clear.
Treatment of strongyloidiasis can be difficult and "Strongyloides" has been known to live in individuals for decades; even after treatment. Continued treatment is thus necessary even if symptoms resolve.
Because of the high cost of Stromectol, the veterinary formula Ivomec can be used. Government programs are needed to help citizens finance lifelong medication.
Clothes and sheets must be washed with enzyme washing powder and dried on hot daily.
There is no effective treatment for this condition. It has been reported that clearance of lesions can be done with melphalan and cyclophosphamide alone or in combination with prednisone. Both isotretinoin and etretinate have also been shown to improve the conditions. All medications listed can cause adverse symptoms, with isotretinoin and etretinate particularly dangerous since they are both teratogens. Other attempted treatments include interferon-alpha, cyclosporine, PUVA photochemotherapy, electron-beam therapy, IVIg, and dermabrasion. However, the overall prognosis for the disease is poor. There are reported instances of remission of the disease when treated with a combination of Revlimid and Dexamethasone over a 24-month period.
One strategy for the prevention of infection transmission between cats and people is to better educate people on the behaviour that puts them at risk for becoming infected.
Those at the highest risk of contracting a disease from a cat are those with behaviors that include: being licked, sharing food, sharing kithchen utensils, kissing, and sleeping with a cat. The very young, the elderly and those who are immunocompromised increase their risk of becoming infected when sleeping with their cats (and dogs). The CDC recommends that cat owners not allow a cat to lick your face because it can result in disease transmission. If someone is licked on their face, mucous membranes or an open wound, the risk for infection is reduced if the area is immediately washed with soap and water. Maintaining the health of the animal by regular inspection for fleas and ticks, scheduling deworming medications along with veterinary exams will also reduce the risk of acquiring a feline zoonosis.
Recommendations for the prevention of ringworm transmission to people include:
- regularly vacuuming areas of the home that pets commonly visit helps to remove fur or flakes of skin
- washing the hands with soap and running water after playing with or petting your pet.
- wearing gloves and long sleeves when handling cats infected with.
- disinfect areas the pet has spent time in, including surfaces and bedding.
- the spores of this fungus can be killed with common disinfectants like chlorine bleach diluted 1:10 (1/4 cup in 1 gallon of water), benzalkonium chloride, or strong detergents.
- not handling cats with ringworm by those whose immune system is weak in any way (if you have HIV/AIDS, are undergoing cancer treatment, or are taking medications that suppress the immune system, for example).
- taking the cat to the veterinarian if ringworm infection is suspected.
The prognosis of nocardiosis is highly variable. The state of the host's health, site, duration, and severity of the infection all play parts in determining the prognosis. As of now, skin and soft tissue infections have a 100% cure rate, and pleuropulmonary infections have a 90% cure rate with appropriate therapy. The cure rate falls to 63% with those infected with dissemented nocardiosis, with only half of those surviving infections that cause brain abscess. Additionally, 44% of people who are infected in the spinal cord/brain die, increasing to 85% if that person has an already weakened immune system. Unfortunately, there is not a preventative to nocardiosis. The only recommendation is to protect open wounds to limit access.
It is not practical to test or decontaminate most sites that may be contaminated with "H. capsulatum", but the following sources list environments where histoplasmosis is common, and precautions to reduce a person's risk of exposure, in the three parts of the world where the disease is prevalent. Precautions common to all geographical locations would be to avoid accumulations of bird or bat droppings.
The US National Institute for Occupational Safety and Health (NIOSH) provides information on work practices and personal protective equipment that may reduce the risk of infection. This document is available in English and Spanish.
Authors at the University of Nigeria have published a review which includes information on locations in which histoplasmosis has been found in Africa (in chicken runs, bats and the caves bats infest, and in soil), and a thorough reference list including English, French, and Spanish language references.
People with AIDS are given macrolide antibiotics such as azithromycin for prophylactic treatment.
People with HIV infection and less than 50 CD4+ T-lymphocytes/uL should be administered prophylaxis against MAC. Prophylaxis should be continued for the patient's lifetime unless multiple drug therapy for MAC becomes necessary because of the development of MAC disease.
Clinicians must weigh the potential benefits of MAC prophylaxis against the potential for toxicities and drug interactions, the cost, the potential to produce resistance in a community with a high rate of tuberculosis, and the possibility that the addition of another drug to the medical regimen may adversely affect patients' compliance with treatment. Because of these concerns, therefore, in some situations rifabutin prophylaxis should not be administered.
Before prophylaxis is administered, patients should be assessed to ensure that they do not have active disease due to MAC, M. tuberculosis, or any other mycobacterial species. This assessment may include a chest radiograph and tuberculin skin test.
Rifabutin, by mouth daily, is recommended for the people's lifetime unless disseminated MAC develops, which would then require multiple drug therapy. Although other drugs, such as azithromycin and clarithromycin, have laboratory and clinical activity against MAC, none has been shown in a prospective, controlled trial to be effective and safe for prophylaxis. Thus, in the absence of data, no other regimen can be recommended at this time.The 300-mg dose of rifabutin has been well tolerated. Adverse effects included neutropenia, thrombocytopenia, rash, and gastrointestinal disturbances.
Postinfection treatment involves a combination of antituberculosis antibiotics, including rifampicin, rifabutin, ciprofloxacin, amikacin, ethambutol, streptomycin, clarithromycin or azithromycin.
NTM infections are usually treated with a three-drug regimen of either clarithromycin or azithromycin, plus rifampicin and ethambutol. Treatment typically lasts at least 12 months.
Although studies have not yet identified an optimal regimen or confirmed that any therapeutic regimen produces sustained clinical benefit for patients with disseminated MAC, the Task Force concluded that the available information indicated the need for treatment of disseminated MAC. The Public Health Service therefore recommends that regimens be based on the following principles:
- Treatment regimens outside a clinical trial should include at least two agents.
- Every regimen should contain either azithromycin or clarithromycin; many experts prefer ethambutol as a second drug. Many clinicians have added one or more of the following as second, third, or fourth agents: clofazimine, rifabutin, rifampin, ciprofloxacin, and in some situations amikacin. Isoniazid and pyrazinamide are not effective for the therapy of MAC.
- Therapy should continue for the lifetime of the patient if clinical and microbiologic improvement is observed.
Clinical manifestations of disseminated MAC—such as fever, weight loss, and night sweats—should be monitored several times during the initial weeks of therapy. Microbiologic response, as assessed by blood culture every 4 weeks during initial therapy, can also be helpful in interpreting the efficacy of a therapeutic regimen.Most patients who ultimately respond show substantial clinical improvement in the first 4–6 weeks of therapy. Elimination of the organisms from blood cultures may take somewhat longer, often requiring 4–12 weeks.
Treatment usually involves high doses of steroids such as dexamethasone. While high doses of steroids may risk laminitis, low doses are associated with refractory cases. Antibiotics are used to treat any residual nidus of "S. equi". Non-steroidal anti-inflammatory drugs (NSAIDs), such as phenylbutazone or flunixin, may be useful to reduce fever and relieve pain. Intravenous DMSO is sometimes used as a free-radical scavenger and anti-inflammatory. Additionally, wrapping the legs may reduce edema and skin sloughing. Supportive care with oral or IV fluids may also be required.
Fungal meningitis is treated with long courses of high dose antifungal medications. The duration of treatment is dependent upon the causal pathogen and the patient's ability to stave off the infection; for patients with a weaker immune system or diabetes, treatment will often take longer.
Prognosis is good with early, aggressive treatment (92% survival in one study).
Disseminated protothecosis is most commonly seen in dogs. The algae enters the body through the mouth or nose and causes infection in the intestines. From there it can spread to the eye, brain, and kidneys. Symptoms can include diarrhea, weight loss, weakness, inflammation of the eye (uveitis), retinal detachment, ataxia, and seizures.
Dogs with acute blindness and diarrhea that develop exudative retinal detachment should be assessed for protothecosis. Diagnosis is through culture or finding the organism in a biopsy, cerebrospinal fluid, vitreous humour, or urine. Treatment of the disseminated form in dogs is very difficult, although use of antifungal medication has been successful in a few cases. Prognosis for cutaneous protothecosis is guarded and depends on the surgical options. Prognosis for the disseminated form is grave. This may be due to delayed recognition and treatment.
Dermatophytids are fungus-free disseminated skin lesions resulting from induced sensitization in patients with ringworm infections.
The most common dermatophytid is an inflammation in the hands resulting from a fungus infection of the feet. Dermatophytids normally disappear when the primary ringworm infection is treated.
Dermatophytids may resemble erythema nodosum.
It can be treated with systemic antiviral drugs, such as aciclovir or valganciclovir. Foscarnet may also be used for immunocompromised host with Herpes simplex and acyclovir-resistant Herpes simplex.
Protothecosis is a disease found in dogs, cats, cattle, and humans caused by a type of green alga known as "Prototheca" that lacks chlorophyll. It and its close relative "Helicosporidium" are unusual in that they are actually green algae that have become parasites. The two most common species are "Prototheca wickerhamii" and "Prototheca zopfii". Both are known to cause disease in dogs, while most human cases are caused by "P. wickerhami". "Prototheca" is found worldwide in sewage and soil. Infection is rare despite high exposure, and can be related to a defective immune system. In dogs, females and Collies are most commonly affected.
The first human case was identified in 1964 in Sierra Leone.
Progressive disseminated histoplasmosis is an infection caused by Histoplasma capsulatum, and most people who develop this severe form of histoplasmosis are immunocompromised or taking systemic corticosteroids. Skin lesions are present in approximately 6% of patients with dissemination.
Cryptosporidiosis is a parasitic disease that is transmitted through contaminated food or water from an infected person or animal. Cryptosporidiosis in cats is rare, but they can carry the protozoan without showing any signs of illness. Cryptosporidiosis can cause profuse, watery diarrhea with cramping, abdominal pain, and nausea in people. Illness in people is usually self-limiting and lasts only 2–4 days, but can become severe in people with weakened immune systems. Cryptosporidiosis (Cryptosporidium spp.) Cats transmit the protozoan through their feces. The symptoms in people weight loss and chronic diarrhea in high-risk patients. More than one species of this genus can be acquired by people. Dogs can also transmit this parasite.