coccidioidomycosis meningitis. in pregnancy

Q: 32 year old female with 12 weeks of pregnancy is admitted to ICU with coccidioidomycosis meningitis. CSF pressure reported normal on Lumbar Puncture (LP). What would be the first line of therapy? 

A) fluconazole 
B) Itraconazole 
C) Intrathecal amphotericin B 
D) echinocandins
E) Repeated LP


Answer: C

Azoles may have teratogenic effects on fetal bone formation. They are contraindicated in the first trimester of pregnancy. In such scenarios, intrathecal amphotericin B deoxycholate is the recommended therapy. Experts recommend avoiding azoles throughout the pregnancy.

Fluconazole and Itraconazole are azoles (choices A & B).

Interestingly, despite being very potent antifungals, echinocandins have no role in coccidioidal meningitis (choice D).


Repeated LPs are recommended for symptomatic relief only if CSF pressure is high (choice E).


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References:

1. Bercovitch RS, Catanzaro A, Schwartz BS, et al. Coccidioidomycosis during pregnancy: a review and recommendations for management. Clin Infect Dis 2011; 53:363. 

2. Mølgaard-Nielsen D, Svanström H, Melbye M, et al. Association between use of oral fluconazole during pregnancy and risk of spontaneous abortion and stillbirth. JAMA 2016; 315:58.

3. Galgiani JN, Ampel NM, Blair JE, et al. 2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Treatment of Coccidioidomycosis. Clin Infect Dis 2016; 63:e112.