Bone and joint coccidioidomycosis treated with miconazole.

Results of therapy of 31 patients with musculoskeletal coccidioidomycosis with a new antifungal drug, miconazole, are described. Results with other therapeutic modalities have been poor in chronic disease, and cure is rare except where radical surgery (arthrodesis, amputation) is used. The disease in the patients was largely chronic (mean duration, 34.5 months), and unresponsive to amphotericin B, including 17 patients with arthritis, 13 with osteomyelitis, and one with tenosyno­ vitis. Seven patients with arthritis, two with osteomyelitis, and one with tenosynovitis responded objectively. The over-all response rate was 34%. (One patient with concomitant surgery is in­ clu~ed in the responding group.) Patients with multiple sites of bone and/or joint involvement generally failed to respond. Of those who responded, more than one-half relapsed subsequently_ Duration of treatment of 1 month or less was associated with later relapse_ After intravenous administration, the drug penetrates well into infected joints. Local irrigation with the drug was well tolerated. Response of coexisting coccidioidal disease outside the musculoskeletal system cor­ related with outcome of musculoskeletal disease. Side effects of this drug are principally hypo­ natremia, phlebitis, anemia, nausea, and pruritis, and necessitated discontinuation of therapy in 5 patients. No nephrotoxicity was seen, and all side effects were reversible on stopping the drug. The relative role of amphotericin Band miconazole therapy in this disease remains to be determined.