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Paracoccidioidomycosis Treatment & Management

  • Author: Duane R Hospenthal, MD, PhD, FACP, FIDSA, FASTMH; Chief Editor: Mark R Wallace, MD, FACP, FIDSA  more...
Updated: Mar 23, 2015

Approach Considerations

Systemic antifungal medications are the mainstay of medical management in paracoccidioidomycosis. Supportive measures and hospitalization may be warranted for patients with severe disease. If present, anemia and nutritional deficiencies should be treated.


Paracoccidioidomycosis is uncommon in women of childbearing age. In one case of paracoccidioidomycosis in pregnancy, P brasiliensis was found in the placenta, but the child was not infected.

Amphotericin B is the only antifungal medication in pregnancy category B that is effective against P brasiliensis. All of the other medications that are currently used are category C or D.

Patients with HIV/AIDS

Patients with AIDS acquire a form of paracoccidioidomycosis that resembles the subacute juvenile type. Widespread disease quickly develops, and the meninges are more commonly involved in patients with AIDS than in patients who do not have AIDS.

Paracoccidioidomycosis is an AIDS-associated opportunistic infection. However, the incidence is lower than that expected by comparison to other endemic fungal infections. The use of trimethoprim-sulfamethoxazole (TMP-SMZ) for Pneumocystis jiroveci pneumonia prophylaxis and azoles (eg, fluconazole, itraconazole, ketoconazole) for oropharyngeal candidiasis prophylaxis in HIV-infected patients may aid in the reduction in disseminated paracoccidioidomycosis.

AIDS is seen primarily in urban areas, whereas paracoccidioidomycosis is found mainly in rural areas, possibly contributing to the fact that the rate of paracoccidioidomycosis occurrence is lower than expected.

The paracoccidioidin skin test is frequently negative in infected patients with AIDS.

Supportive care

Supportive care among patients with paracoccidioidomycosis includes the following:

  • Treatment of anemia
  • Improvement of diet
  • Ensuring patient rest
  • Advising the patient to stop smoking and consuming alcohol


Occasionally, specific surgical treatments are warranted for life- or organ-threatening disease, such as neurosurgical procedures to relieve granuloma-induced spinal cord compression or hydrocephalus. Reconstructive surgery is sometimes needed to alleviate fibrotic sequelae.


No vaccine against Paracoccidioides has been developed, although several peptide vaccines have been studied. No known control measures prevent paracoccidioidomycosis.


Antifungal Treatment

Triazoles (itraconazole, voriconazole, posaconazole)

Itraconazole is considered the drug of choice for paracoccidioidomycosis, with a reported effectiveness of 95%. The course of therapy is typically 200 mg/day for 6 months. Itraconazole is considered superior to ketoconazole because of shorter treatment course, lower toxicity profile, and lower relapse rate (3-5%). Fluconazole is not typically used, because of its lower response rates and more frequent relapse.

Voriconazole, a newer azole agent, has in vitro activity against the yeast cells of P brasiliensis and has been shown in open-label trials to be an effective agent.[27] Another newer azole, posaconazole, has been used with reported success in this disease.

Imidazoles (ketoconazole)

Ketoconazole is also an effective agent for paracoccidioidomycosis, with a cure rate of 85-90% and an associated relapse rate of less than 10%. A dose of 200-400 mg/day in adults or 5 mg/kg/day in children for 6-18 months is required. Ketoconazole is associated with significant toxicities, including hepatic dysfunction and sex hormone alterations, as well as with many drug-drug interactions.

Sulfonamides (sulfadiazine, trimethoprim-sulfamethoxazole)

The maximum dose of sulfadiazine is 4 g/day in adults and 60-100 mg/kg/day in divided doses in children. Once clinical and mycologic response is evident, this dose can be cut in half. For long-acting compounds, the dosing is 0.5 g/day, following an initial dose of 1 g/day for 2-3 weeks. Patients should be treated for 3-5 years. This results in a 70% cure rate, but there is also a 30% relapse rate.

Trimethoprim-sulfamethoxazole (TMP-SMX) is typically dosed as one double-strength tablet (160 mg trimethoprim, 800 mg sulfamethoxazole) twice daily (8-10 mg/kg/day [based on trimethoprim] for children). Compared to itraconazole in a recent study, TMP-SMX treatment was associated with a 51% cure rate (versus 86% for itraconazole) with a median treatment time of 23 months (versus 12 months for itraconazole).[28]

Amphotericin B

Reserve this drug for severe cases of paracoccidioidomycosis that are refractory to other forms of therapy. Cumulative doses range from 1-2 g based on clinical response. The drug is not curative; therefore, maintenance therapy with a sulfonamide or an azole is subsequently required. Only the intravenous formulation of this drug is effective, but its use is limited because of associated toxicities. The associated rate of improvement and relapse rate are similar to those of sulfonamide.



Consult an infectious disease specialist for difficult diagnoses, especially in nonendemic areas, and for patients who require long-term treatment with potentially toxic medications (eg, amphotericin B).

Consider the following consultations as well, depending on organ involvement and severity of disease:

  • Pulmonologist
  • Internal medicine specialist
  • Dermatologist
  • Surgeon

Long-Term Monitoring

During and after treatment for paracoccidioidomycosis with antifungal medications, patients must be regularly evaluated to ensure an adequate response to therapy and monitor for relapse.

Complement fixation tests can be used to track the response to therapy; antibody levels decrease with improvement. Complement fixation also can be used to detect relapse because antibody levels increase again. The new antibody tests directed against P brasiliensis antigenic glycoproteins may prove useful in monitoring disease activity and response to therapy.

Absence of symptoms for 2 years after antifungal therapy is considered by some to indicate a cure. Others believe that mycologically negative results in 3 specimens after the cessation of therapy indicate a cure.

Contributor Information and Disclosures

Duane R Hospenthal, MD, PhD, FACP, FIDSA, FASTMH Adjunct Professor of Medicine, Department of Medicine, University of Texas Health Science Center at San Antonio

Duane R Hospenthal, MD, PhD, FACP, FIDSA, FASTMH is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, International Society for Infectious Diseases, International Society of Travel Medicine, Medical Mycological Society of the Americas, Armed Forces Infectious Diseases Society, International Society for Human and Animal Mycology, American College of Physicians, American Society for Microbiology, Society for Healthcare Epidemiology of America

Disclosure: Nothing to disclose.


Kendall M Egan, MD, FAAD Dermatologist, Veteran's Affairs Medical Center; Dermatologist, Spruce Health, Dermatologist, DermOne

Kendall M Egan, MD, FAAD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists

Disclosure: Nothing to disclose.

Chief Editor

Mark R Wallace, MD, FACP, FIDSA Clinical Professor of Medicine, Florida State University College of Medicine; Clinical Professor of Medicine, University of Central Florida College of Medicine

Mark R Wallace, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, International AIDS Society, Florida Infectious Diseases Society

Disclosure: Nothing to disclose.


Asgar A Boxwalla, MD Staff Physician, Department of Internal Medicine, Division of Infectious Diseases, St John Detroit Riverview Hospital

Disclosure: Nothing to disclose.

David F Butler, MD Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Pranatharthi Haran Chandrasekar, MBBS, MD Professor, Department of Internal Medicine, Director of Infectious Disease Fellowship, Harper Hospital, Wayne State University School of Medicine

Pranatharthi Haran Chandrasekar, MBBS, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Julie E Dixon, MD, FAAD Private Practice, Ironwood Dermatology, Tucson, Arizona

Julie E Dixon, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and American Medical Association

Disclosure: Nothing to disclose.

Dirk M Elston, MD Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Franklin Flowers, MD Chief, Division of Dermatology, Professor, Department of Medicine and Otolaryngology, Affiliate Associate Professor of Pediatrics and Pathology, University of Florida College of Medicine

Franklin Flowers, MD, is a member of the following medical societies: American College of Mohs Micrographic Surgery and Cutaneous Oncology

Disclosure: Nothing to disclose.

Ronald A Greenfield, MD Professor, Department of Internal Medicine, University of Oklahoma College of Medicine

Ronald A Greenfield, MD is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Central Society for Clinical Research, Infectious Diseases Society of America, Medical Mycology Society of the Americas, Phi Beta Kappa, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology

Disclosure: Pfizer Honoraria Speaking and teaching; Gilead Honoraria Speaking and teaching; Ortho McNeil Honoraria Speaking and teaching; Abbott Honoraria Speaking and teaching; Astellas Honoraria Speaking and teaching; Cubist Honoraria Speaking and teaching; Forest Pharmaceuticals Speaking and teaching

Norman Levine, MD Private Practice, Tucson, AZ

Norman Levine is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Jeffrey J Miller, MD Associate Professor of Dermatology, Pennsylvania State University College of Medicine; Staff Dermatologist, Pennsylvania State Milton S Hershey Medical Center

Jeffrey J Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Association of Professors of Dermatology, North American Hair Research Society, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Christina M Schofield, MD Instructor of Medicine, Uniformed Services University of the Health Sciences; Consulting Staff, Department of Infectious Disease, Wilford Hall Medical Center, Lackland Air Force Base

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment


The views expressed in this manuscript are those of the authors and do not reflect the official policy of the Department of the Navy, Department of the Army, Department of Defense, or the U.S. Government.

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Approximate distribution of paracoccidioidomycosis in North, Central, and South America, based on case reports.
Granulomatous lesion involving the nose in patient with paracoccidioidomycosis; note the resemblance to cutaneous leishmaniasis.
Potassium hydroxide (KOH) preparation from pus; note the multiple budding and variation in cell size with Paracoccidioides.
Crusted plaques over the central part of the face in a man with paracoccidioidomycosis. Courtesy of Rolando Vasquez, MD, Professor of Dermatology, Guatemala.
Ulcerated nodule on the tongue in a man with paracoccidioidomycosis. Courtesy of Heidi Logemann, Professor of Mycology, Universidad de San Carlos, Guatemala.
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