Correct!
1. Fluconazole
Any of these medications can be used to treat coccidioidomycosis. However, fluconazole is usually considered the drug of choice although there are no controlled trials supporting its preferred use. He had actually been started on oral fluconazole several days earlier and was switched from oral to IV therapy. Unfortunately, he continued to do poorly. Over the next 3 days his respiratory status deteriorated, requiring hi-flow 40 lpm and 80% FIO2.
Liposomal amphotericin B was initiated but he continued to do poorly. Chest x-ray and subsequent CT confirmed worsening of multifocal infiltrates with small effusions (Figure 3).
Figure 3. A: Repeat portable chest x-ray and B: CT scan in lung windows done on 10/30.
He required intubation on 10/31. Liposomal amphotericin B was continued and fluconazole switched to posaconazole. He slowly improved and was able to be extubated after on 11/9. A chest x-ray showed improvement (Figure 4).
Figure 4. Repeat portable chest x-ray taken after 10 days of mechanical ventilation just prior to extubation.
Two days later on 11/11, he had worsening oxygenation, again requiring high flow oxygen with 80% FIO2. Diuresis had been continued with creatinine now at 2.5 mg/dL and his serum Na+ was 151 mEq/L. Repeat echo indicated his ejection fraction was 62% with a normal inferior vena cava. A portable chest radiograph showed worsening consolidation (Figure 5).
Figure 5. Repeat portable chest x-ray done on 11/11.
At this juncture, the patient said he had enough and made himself do not intubate/do not resuscitate (DNI/DNR).
What should be done at this time? (Click on the correct answer to be directed to the seventh and final page)