Treatment of Lung Disease Caused by Dematiaceous Fungi

First-Line Therapy

The Infectious Diseases Society of America recommends voriconazole as the first-line therapy for pulmonary infections caused by dematiaceous fungi, with a dosing regimen of 6 mg/kg IV every 12 hours for 2 doses, followed by 4 mg/kg IV every 12 hours, or oral therapy at 200 mg twice daily 1, 2, 3
Therapeutic drug monitoring is advisable to ensure adequate serum levels of voriconazole 3

Itraconazole is an effective alternative for patients who cannot tolerate voriconazole, with a dosing regimen of 200 mg twice daily orally, and serum level monitoring recommended to achieve target levels >1.0 mg/mL 1, 2, 4
Lipid formulation of Amphotericin B (L-AmB) can be used for severe or rapidly progressing disease, with a dosing regimen of 3-5 mg/kg/day IV, and is often used as initial therapy before transitioning to oral azole therapy 1, 2, 5

Surgical intervention may be necessary alongside medical therapy, especially for localized lesions amenable to resection, pulmonary lesions near great vessels or the pericardium, and persistent hemoptysis from a cavitary lesion 1, 2

The minimum treatment duration is 6-12 weeks, with therapy continuing throughout the period of immunosuppression and until lesions have resolved in immunocompromised patients 3

Serial clinical evaluations and regular radiographic imaging (CT scans) are recommended to assess lesion progression/resolution, with the frequency of imaging individualized based on the severity of infection and clinical response 3