In sarcoidosis, chronic pulmonary aspergillosis (CPA) may be associated with significant morbidity, and treatment failure rates are often high, even with newer triazole antifungal agents. We report a treatment regimen of cyclical caspofungin infusions in 10 patients with sarcoidosis and worsening CPA despite oral triazoles.
Chronic pulmonary aspergillosis (CPA, including aspergilloma) complicates 3–12% of cases of sarcoidosis1, and treatment failure rates remain high, even with newer triazole antifungals.2–5 We report a successful treatment regimen of cyclical caspofungin infusions in patients with sarcoidosis and worsening CPA despite oral triazoles.
Sarcoidosis and CPA were diagnosed in accordance with published criteria (described in the online supplement). Ten patients (six men; mean age 43.9±9.0 years) received treatment with caspofungin between 2008 and 2012. Nine patients were treated with oral triazoles (itraconazole n=5, voriconazole n=4) for a minimum of 4 months (up to 24 months) prior to caspofungin. Nine patients were receiving prednisolone (median dose 12.5 mg/day; range 7.5–20 mg), with four patients receiving additional immunosuppressive therapy (methotrexate n=1, azathioprine n=3). High-resolution CT (HRCT) demonstrated destructive fibrocavitary pulmonary changes (including aspergilloma) in all patients (figure 1). Detailed patient information (including treated disease course) is summarised in the online supplement.
Keir GJ, Garfield B, Hansell DM, Loebinger MR, Wilson R, Renzoni EA, Wells AU, Maher TM. Cyclical caspofungin for chronic pulmonary aspergillosis in sarcoidosis. Thorax. 2014 Mar;69(3):287-8.