354


EQUINE VETERINARY EDUCATION / AE / july 2022


results in plasma, CSF, synovial fluid, aqueous humor and urine concentrations above the MIC reported for several


equine fungal pathogens (Latimer et al., 2001). Compounded fluconazole formulations are very stable. The cost of fluconazole has been markedly reduced since the availability


of generic products and would be the treatment of choice for coccidioides in equids (Stewart, 2020b). The proprietary itraconazole solution (Sporanox [Janssen,


Titusville, N.J.]) is absorbed well orally (bioavailability 60%), with a dose of 5 mg/kg bwt per os q. 24 h recommended (Davis & Gilger, 2004), however, it is often cost prohibitive for use in large animals (Stewart, 2005, 2020b). The use of compounded itraconazole is not recommended. It is very unstable (requires low pH), and owing to its lipophilic nature it is difficult to formulate in aqueous solution (Davis et al., 2004; Stewart, 2020b). Although associated with a significant risk of renal side effects, in rapidly progressing disease, intravenous amphotericin B may be recommended in humans (Galgiani & Thompson, 2016). The duration of antifungal therapy is difficult to determine


for any chronic fungal infection (Stewart, 2019, 2020a; Stewart et al., 2009). Resolution of clinical signs, bloodwork abnormalities and serum coccidioides IgM titres, with dramatic reduction in serum IgG titres may help the clinician determine when to eliminate antifungal therapy. After discontinuation of therapy, reassessment of serum titres every 3–6 months may help to determine if there is recrudescence of the coccidioides infection. Post infection, most people develop lifelong immunity and serum IgG titres may persist (Galgiani & Thompson, 2016). Fluconazole therapy in the donkey described by Soren had been administered for 3 years, where the serum IgM titre was negative for coccidioides, and the IgG titre having decreased from ≥1:256 to 1:8 (Sorum et al., 2022). Although there was mild lameness, radiographic persistence of bony proliferation of the left femur and a slight anaemia, the


coccidioides infection may have resolved. Discontinuation of fluconazole and monitoring of serum IgM and IgG titres every 3–6 months could be considered, with immune function testing if the condition reoccurred to determine if life-long therapy was truly required.


Author’s declaration of interests No conflicts of interest have been declared.


Ethical animal research Not applicable.


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