Miconazole therapy for keratomycosis

I treated seven patients with keratomycosis (four with Candida infections and three with Aspergillus infections) with topical and subconjunctival miconazole. Progressive corneal ulceration stopped in each case, and clinical evidence of corneal infection disappeared. Posttreatment visual acuities were at least as good as (and usually better than) pretreatment visual acuities. Superficial punctate keratitis was associated with prolonged (one to two weeks) hourly instillation of miconazole, but there was no evidence of serious ocular toxicity.

Activity of imidazoles against Leishmania tropica in human macrophage cultures

The anti-leishmanial activity of four imidazoles has been determined in Leishmania tropica-infected human monocyte-derived macrophage cultures. One of the imidazoles, hydrolyzed ketoconazole [cis-1-[4-[2-(2,4-dichlorophenyl)-2-(1H-imidazol-1-ylmethyl)-1,3-dioxolan-4-yl] methoxyphenyl]piperazine], eliminated 80 and 95% of the parasites at drug concentrations (2.0 and 2.5 microgram/ml) that are achievable in vivo by a structurally similar compound, ketoconazole. These results demonstrate that an imidazole has anti-leishmanial activity in a model system, and suggests that hydrolyzed ketoconazole should be considered for in vivo trials in animal models of the disease.

An effective and safe treatment for dermatophytosis

This study demonstrates the efficacy and safety of ketoconazole, a broad-spectrum oral antifungal agent administered to 20 patients with severe, extensive, and recalcitrant Trichophyton rubrum infection. The average patient has had continuous infection for 20 years. Sixteen patients had glabrous skin infection that encompassed an average of 40% of their skin surface. The remaining four patients had palmar-plantar infection. Ketoconazole was administered for 27 to 70 days in a daily oral dose of 200 or 400 mg. Initial clinical and mycological response occurred within five to seven days, and the glabrous and/or palmar-plantar skin changes improved at least 90% in all patients. In 13 of these patients, the infection cleared completely. The only side effects experienced--pruritus in four patients and photophobia in two patients--did not necessitate interruption of therapy. Overall, ketoconazole was found to be an effective and safe therapy for dermatophytosis. Follow-up examinations of our cases five months later showed recrudescence in 75% of them, which was not unexpected with these severe infections.

Ultrastructure of Coccidioides immitis after exposure to the imidazole antifungals miconazole and ketoconazole

Scanning and transmission electron microscopy was performed on the various phases of Coccidioides immitis, exposed for different periods of time to the imidazole antifungals miconazole and ketoconazole. The development of spherules into endospores, which takes place in cultures under normal growth conditions, was suppressed in the drug treated cultures. Typical ultrastructural changes were localized at the cell periphery and in the vacuolar system. The drugs did induce changes in mature, resting endospore cultures and in cultures incubated statically at room temperature. Aerobically growing endospores were not susceptible to either drug. The transformation of arthroconidia into mycelium was fully prevented after treatment. Mycelial cells were most susceptible to the antifungals for necrosis was induced in a substantial part of the hyphae after exposure for 24 h.

Familial chronic mucocutaneous candidiasis successfully treated with oral ketoconazole

A father and son, both suffering from chronic mucocutaneous candidiasis, were successfully treated with oral ketoconazole, a water-soluble imidazole compound. No toxic side-effects occurred during treatment. Treatment was given for about 8 months with diminishing does of ketoconazole. The disease cleared completely about half-way through the course of treatment and did not relapse within 1 month of discontinuing the drug. The only immunological abnormality was a depression in vitro of neutrophil chemotaxis. This became normal during therapy and was regarded as being a result of the disease and not as its cause.

[Oral ketoconazole therapy of a case of pulmonary histoplasmosis]

A 46-year-old man with recurrent pulmonary histoplasmosis was given oral treatment with ketoconazole (a new imidazole derivative related to miconazole) in a dose of 400 mg/day for 3 months, followed by 200 mg daily for 6 months. The clinical and microbiological signs disappeared and the chest X-ray cleared. The drug was well tolerated without clinical or biological side-effects. The pharmacology of ketoconazole, its indications and the results of treatment of other deep mycoses are discussed. Unlike amphotericin B, ketoconazole can be administered orally without noticeable toxicity and appears to have approximately the same fungicidal activity.

Liquid chromatographic assay of ketoconazole

A reverse-phase, high-pressure liquid chromatographic method for the rapid and quantitative determination of ketoconazole has been developed. Drug levels from 0.5 to 10 microgram/ml can be determined in either yeast nitrogen base medium or human serum by using an octadecylsilane column. A retention time of 4.9 +/- 0.1 min resulted when the drug was eluted from a column with 75% methanol-25% 0.02 M (pH 7.5) phosphate buffer at a flow rate of 2 ml/min. Optimum sensitivity was obtained at a wavelength of 231 nm.

Determination of the antifungal agent, ketoconazole, in human plasma by high-performance liquid chromatography

A rapid and selective high-performance liquid chromatographic (HPLC) assay for the quantitative determination of ketoconazole, an orally active antifungal agent, in human plasma is described. After extraction of the drug from plasma, the compound is separated by HPLC using a reversed-phase column and detected by UV light at 205 nm. Quantitation is accomplished by external standardization and the determination of peak areas is performed with the aid of an integrating computer. The average recovery of ketoconazole over a concentration range of 0.1-20.0 microgram/ml was 88.2 +/- 4.07% S.D. The maximum sensitivity of the assay is less than 0.1 microgram/ml. The assay is suitable for use in pharmacokinetic studies following the administration of therapeutic doses of ketoconazole to humans.

Treatment of chronic mucocutaneous candidiasis with ketoconazole: a controlled clinical trial

Twelve patients with chronic mucocutaneous candidiasis were assigned by random allocation to a 6-month course of treatment with ketoconazole or placebo in a double-blind trial. All six recipients of ketoconazole had remission of symptoms and virtually complete regression of mucosal, skin, and nail lesions, whereas only two of the six receiving placebo had even temporary mucosal clearing, and none had improvement of skin or nail disease. The clinical outcome in the ketoconazole-treated group was significantly more favorable (p = 0.001) than in the placebo-treated group. The six patients receiving placebo in the controlled trial were then treated with ketoconazole in an open trial, and all responded favorably. Hepatitis, probably drug induced, developed in one patient after 6 months of treatment but proved to be mild and reversible. Oral ketoconazole is an effective treatment for chronic mucocutaneous candidiasis.

Successful treatment of chronic mucocutaneous candidiasis with ketoconazole

Ketoconazole, a new oral antifungal agent, was evaluated in the treatment of four patients with severe chronic mucocutaneous candidiasis refractory to standard antifungal therapy. Three had Candida esophagitis, and too had previously received intravenous amphotericin B. Initial ketoconazole dosage was 100 mg daily for patients weighing less than 30 kg and 200 mg daily for patients over 30 kg. All four patients showed dramatic improvement on the initial dose; three had complete clearing of mucous membrane and skin lesions within three weeks. Of the three patients with Candida esophagitis, one had complete clearing of esophagitis within one month and two were markedly improved. One patient required 400 mg daily to obtain complete clearing of skin and mucous membrane lesions. Two patients were maintained free of overt disease on one dose three times weekly but two patients relapsed and have required daily ketoconazole therapy to keep them free of Candida. The only side effects were mild nausea (two patients) occasional emesis at higher doses (two patients), and transient hypocholesterolemia (one patient). No adverse hematologic, gastrointestinal, or renal effects were noted. Ketoconazole appears to be a valuable oral antifungal agent for some patients with CMC.

Ketoconazole treatment of chronic mucocutaneous candidiasis

Five patients received ketoconazole treatment of chronic mucocutaneous candidiasis. One also had disseminated histoplasmosis and cryptococcosis. Ketoconazole was well absorbed after an oral dose of 200 mg and produced detectable antifungal blood levels for more than eight hours after each dose. Thrush cleared in less than two weeks in all patients. Cutaneous lesions cleared slowly during several months of treatment. A patient with polymycotic infection had a rapid clearing of candidiasis, but her histoplasmosis did not respond to three weeks of treatment. Adverse drug effects were minimal. Ketoconazole is a promising new agent for treatment of chronic mucocutaneous candidiasis.

Treatment of paracoccidioidomycosis, candidiasis, chromomycosis, lobomycosis, and mycetoma with ketoconazole

The authors present the use of ketoconazole in 27 cases of paracoccidioidomycosis, eight of mycetoma, seven of chromomycosis, four of systemic candidiasis and one of lobomycosis. The drug was administered orally in a dosage of 200 to 400 mg per day within a period of up to 90 days. The results of the treatment for paracoccidioidomycosis were of cicatrization of the cutaneous lesions in three to four weeks in 24 patients and in two, from six to seven weeks. Out of 27 patients, 14 presented pulmonary lesions. The evolution within a 90-day period showed radiological cure in one case, improvement in seven, and unaltered picture in five patients. In one, there was no further control. In the three out of four cases of candidiasis there was clinical and mycological cure and in one case marked improvement. In seven cases of chromomycosis there was marked improvement in two, moderate in four, and slight in one case. There was slight improvement in one case of lobomycosis, and in eight cases of mycetoma moderate improvement in three, slight in three and none in two, but the mycological examinations were still positive. The drug tolerance was excellent.

The activity of ketoconazole in mixed cultures of leukocytes and Candida albicans

A system is described which allows the semi-quantitative investigation of the interaction between Candida albicans and leukocytes in culture with and without the addition of chemotherapeutic agents. Both polymorphonuclear leukocytes and macrophages avidly engulfed added yeast cells. However, they did not succeed in eradicating the fungus even when only 450 yeast cells were added to 3 X 10(6) leukocytes. This is probably due to several factors, including the decline in the functiontional capacity of the leukocytes with time in culture. The major way for the fungus to escape intracellular killing, however, seems to be the switch to the mycellial form in the presence of leukocytes. Engulfed yeasts produce germ tubes, grow out of the leukocytes and form hyphae which are much more resistant to the lytic action of the leukocytes. The leukocytes become necrotic through their interaction with the mycelia. Ketoconazole, a potent, orally active systemic antifungal agent inhibited the growth of C. albicans and completely suppressed the formation of mycelia in culture at very low concentrations (0.01 microgram ml-1). It was toxic to the leukocytes themselves only at 100 microgram ml-1. Addition of ketoconazole (10 (10-1.01 microgram ml-1) to mixed cultures of leukocytes and C. albicans allowed complete elimination of the fungus, probably because the leukocytes could easily remove the remaining yeast cells. The data show the usefulness of the system in the search for systemic antifungals and provide a possible explanation for the efficacy of ketoconazole in vivo.

Ketoconazole in paracoccidioidomycosis: efficacy of prolonged oral therapy

Ketoconazole, a new oral imidazole derivative, was employed for the treatment of five patients with paracoccidioidomycosis. The response was excellent, with objective clinical improvement and healing of both mucocutaneous and pulmonary lesions. Mycological and serological tests, as well as delayed hypersensitivity, were assessed and found to correlate with clinical improvement. Therapy was conducted for 12 months with a dose of 200 mg day in 2 patients; in the remainder the dose was reduced (100 mg day) after the first 6 months and maintained as such for an equal period. No side-effects or toxicity were noted despite prolonged treatment. The advantages of the new therapeutic approach are discussed.

Treatment of pityriasis versicolor with ketoconazole

Eighty-two patients with pityriasis versicolor were treated orally with ketoconazole in tablet form (200 mg). The tablets were taken at least 90 min before a meal, and patients who received only one tablet daily were told to refrain from bathing except immediately before ingestion of the drug and only once a day. Dosage of ketoconazole varied from a single dose of 400 mg to 200--400 mg per day for four weeks. Seventy-seven patients reported no adverse effects. There were reports from others of headache, gastralgia, nausea, dyspnea, dizziness, or tinnitus. In most affected patients, these symptoms stopped with the first meal eaten after initiation of treatment. Follow-up examinations were performed at different intervals. The maximal therapeutic effect of ketoconazole was seen three to six weeks after initiation of therapy. Seventy-eight patients were considered cured; one had received only one tablet. Only hypopigmented macules remained. Examination of these areas with a Wood lamp revealed no fluorescence, and scrapings examined with the light microscope did not contain Malassezia furfur. These results indicate that ketoconazole is effective in the treatment of pityriasis versicolor, but the problem of protecting susceptible persons from infection and reinfection remains.

Ketoconazole in experimental candidosis

A relatively large number of animal models of candidosis exist in which the efficacy of antifungal substances can be evaluated. These include models of candidosis of the skin, gastrointestinal tract, genital system, and internal organs in a variety of animal species. The efficacy of ketoconazole administered orally and topically was evaluated; when given orally in relatively low doses, ketoconazole was found to be efficacious in all of the experimental models used. Scanning and transmission electron micrographs of infected tissue demonstrated the rapidity with which Candida albicans was eradicated from the host after administration of ketoconazole.

Combination therapy of experimental histoplasmosis and cryptococcosis with amphotericin B and ketoconazole

Combinations of amphotericin B and ketoconazole had an additive effect in vitro against Histoplasma capsulatum and Cryptococcus neoformans; ketoconazole combined with flucytosine exerted an indifferent effect against C. neoformans. In vivo studies in athymic nude (nu/nu) mice and their heterozygous (nu/+) littermates demonstrated that treatment with the ketoconazole-amphotericin B combination resulted in longer survival of mice with cryptococcosis than did treatment with ketoconazole plus flucytosine. However, mice given ketoconazole plus amphotericin B did not survive significantly longer than those given amphotericin B alone (cryptococcosis) or ketoconazole alone (histoplasmosis). Combination chemotherapy with ketoconazole and amphotericin B may offer a modest therapeutic advantage over therapy with either drug alone.

Therapy of disseminated or pulmonary coccidioidomycosis with ketoconazole

Oral therapy with ketoconazole for active disseminated or progressive pulmonary coccidioidomycosis was evaluated according to defined criteria of objective improvement for 39 patients, most of whom had received other antifungal chemotherapy. Minimal inhibitory concentrations of ketoconazole for isolates of Coccidioides immitis were below mean peak serum concentrations. Eighteen patients responded at all sites of disease, one patient failed to respond, and the others either are being evaluated or cannot be evaluated. Most patients who responded to therapy required more than three months of treatment before the response was clearly noted. Responses were seen with skin, soft tissue, skeletal, and pulmonary infection as well as other conditions. Reversions of cultures for C. immitis to negative and decreases in titers of complement-fixing antibody were common. One patient relapsed after a course of therapy of only four months. In general, patients with skin disease who responded required only 200 mg per day, whereas those with skeletal disease required 400 mg per day. Adverse effects were uncommon despite extensive monitoring and were generally limited to transient nausea (with vomiting in patients receiving 400 mg per day). The data show that ketoconazole appears to be a promising new drug for treatment of coccidioidomycosis.

Treatment of dermatomycoses with ketoconazole

Forty patients (22 males and 18 nonpregnant females) with tegumentary mycoses were treated with ketoconazole (R41,400). The group included 39 patients with dermatophytoses and one with tinea versicolor. Ketoconazole was administered in one dose per day taken with water 2 hr before or after breakfast for one month; patients weighing < 30 kg received 100 mg of ketoconazole per day, whereas those weighing > 30 kg received 200 mg per day. Twenty-one patients had complete clinical and mycologic cure, two responded clinically but the last culture was positive, eight had partial improvement, and three had no improvement at all. In six cases the treatment was stopped (in one because of gastric intolerance). The main adverse effect of ketoconazole was nausea; only one patient had vomiting. The results indicate that ketoconazole is a safe and effective drug for treatment of dermatomycosis.

Chemotherapy for the systemic mycoses: the prelude to ketoconazole

Successful chemotherapy of the systemic mycoses now covers a span of more than 75 years and dates to the first reported use of potassium iodide for treatment of sporotrichosis. The second drug with efficacy was stilbamidine, and its currently available successor, hydroxystilbamidine isethionate, still has a role in therapy of some patients with nonprogressive blastomycosis of the skin. The introduction in 1957 of amphotericin B marked the first time there was an effective agent for such diseases as cryptococcosis, histoplasmosis, candidosis, and with lesser success, for coccidioidomycosis, mucormycosis, and aspergillosis. However, amphotericin B is nephrotoxic, depresses bone marrow (especially erythropoeisis), and, if patients are not monitored and controlled closely, the drug produces hypokalemic muscle weakness and cardiotoxicity. Flucytosine has a narrower spectrum of activity (cryptococcosis, candidosis, cladosporiosis, and chromomycosis) but a preferable route of administration (oral). Newer agents presently available are miconazole and clotrimazole; the latter is for topical use only.

Ketoconazole in vulvovaginal candidosis

The efficacy of ketoconazole, a new oral antimycotic agent, was evaluated in an open trial. Forty-two nonpregnant women were selected on the basis of proven vulvovaginal candidosis and were divided into two groups. One group received 400 mg of ketoconazole per day for three days, and the other group received 200 mg per day for three days. Of the 26 patients who received the 400-mg dosage, 24 were cured; of the 16 patients who received the 200-mg dosage, nine were cured. No adverse effects attributable to the drug were found.

Chronic mucocutaneous candidosis and other superficial and systemic mycoses successfully treated with ketoconazole

Four patients with chronic mucocutaneous candidosis from early infancy were treated successfully with ketoconazole given orally. All thrush lesions were clinically and mycologically cured within a few days of treatment with 100-400 micrograms of ketoconazole daily; skin lesions were cured within a few weeks, and nails were cured after about three months of treatment. Delayed cutaneous hypersensitivity to candidin was acquired by the third month. Cellular and humoral immunologic responses were related to the suppression of Candida albicans antigen by ketoconazole. A fifth patient with chronic lingual granuloma due to C. albicans improved considerably. Favorable results also were seen in individual patients with oral and disseminated histoplasmosis due to Histoplasma capsulatum; laryngeal, pulmonary, and hepatic disease with continuous fever also due to H. capsulatum; pulmonary histoplasmosis due to Histoplasma duboisii; cutaneous sporotrichosis; and cutaneous blastomycosis due to Blastomyces dermatitidis and in three patients with favus due to Trichophyton schoenleinii; six of seven patients with tinea capitis due to Trichophyton violaceum (after one month of treatment); and four patients with infections due to Petriellidium boydii, Phialophora pedrosoi, or Beauveria species. All patients responded rapidly to 400 mg of ketoconazole per day given orally. Only the patient with hepatic histoplasmosis required 800 mg per day. Measurements of ketoconazole in the serum during treatment were useful in the evaluation of therapy.

Ketoconazole in the treatment of paracoccidioidomycosis and histoplasmosis

Ketoconazole was given orally to 33 patients with paracoccidioidomycosis and 23 with histoplasmosis. There were 55 men and one woman, and ages ranged from 28 to 67 years. Each patient had either the chronic disseminated or the chronic pulmonary form of disease. The diagnosis was established in 54 patients by culture of Paracoccidioides brasiliensis or Histoplasma capsulatum from lesions and in two patients by the clinical picture and results of serologic tests for histoplasmosis. The initial dosage was 400 mg per day. The dosage was reduced to 200 mg when a cure was achieved. The duration of treatment ranged from two to 18 months. Results of treatment were classified as very good (clinical and serologic cure) in 23 (41%) of the patients; good (clinical cure only) in 28 (50%); fair (partial improvement) in one (2%); and poor (no improvement) in three (5%). The results were not assessable in one patient who did not complete therapy. The three patients who did not respond to treatment had less than or equal to 0.19 microgram of ketoconazole/ml in their blood. The drug was well tolerated, and no side effects were reported.

Treatment of coccidioidomycosis with ketoconazole: clinical and laboratory studies of 18 patients

Ketoconazole was given to 18 patients with coccidioidomycosis. Fourteen had received prior antifungal chemotherapy with amphotericin B, miconazole, or both. Ten patients had pulmonary disease, two had meningitis, and six had extrameningeal disseminated disease. The initial dose of ketoconazole was 200 mg per day; it was later increased to 400 mg per day for some patients. All strains of Coccididioides immitis tested were sensitive to ketoconazole. Approximately 2-4 hr after an oral dose of 200 mg of ketoconazole, levels of the drug in blood peaked at approximately 2 micrograms/ml. Higher concentrations in blood were achieved with a 400-mg dose. Improvement was measured by physical examination, conversion of cultures previously positive for C. immitis to negative, decrease in erythrocyte sedimentation rate by 50%, and decrease in titer of complement fixation antibody by two or more dilutions. One patient died after one week of treatment with ketoconazole and could not be evaluated; two other patients with coccidioidal meningitis could not be evaluated. Six of nine patients with pulmonary disease showed radiographic improvement, and their sputum cultures, which had been positive, became negative. Four of the six patients with disseminated disease improved. There were few adverse reactions to ketoconazole, which can be safely administered for prolonged periods to patients with coccidioidomycosis. These findings suggest that ketoconazole may be effective for treatment of this disease and indicate that trials comparing the efficacy of ketoconazole with that of amphotericin B are warranted.

Ketoconazole in early and late murine coccidioidomycosis

Ketoconazole (35 mg/kg) was administered orally to mice twice daily, beginning at different intervals after intranasal infection with arthrospores of Coccidioides immitis. When treatment was begun on the fourth day after infection, before extensive extrapulmonary dissemination of the infection had occurred, all animals survived, and extension of the disease from lungs to liver, spleen, and kidneys was prevented. Mortality was 90% in untreated control animals. In most of the drug-treated animals, lung lesions were not rendered free of fungus after 21 days of treatment. When treatment was begun on the 12th day of infection, after extrapulmonary dissemination had occurred, the drug was life-preserving. However, lesions of the peritoneal organs of 30%--60% of the surviving animals and pulmonary lesions of 90% of these animals harbored viable fungi after 82 days of treatment. Mortality was lower when treatment was given from the 35th through the 120th day after infection to survivors of a challenge dose that was lethal to 28% of the animals within 30 days. These data indicate that the antifungal activity of the drug observed in vitro also operates in vivo. Mycologic cure was optimal when infections were treated early. It became difficult to eradicate the fungus once it became entrenched in lesions of the peritoneal organs or lungs.

A multi-center, double-blind comparison of ketoconazole and griseofulvin in the treatment of infections due to dermatophytes

The efficacy and safety of daily doses of 200 mg of ketoconazole or 250 mg of griseofulvin (Fulvicin-P/G, Schering, Kenilworth, N.J.) in the treatment of patients with infections due to dermatophytes are being evaluated in a three-center study. Patients with chronic dermatomycoses resistant to topical treatment or with infections that involve large areas of the body, a condition that indicates oral therapy, are being treated for a minimum of four weeks. Eleven (38%) of 29 patients treated with ketoconazole for four weeks and five (24%) of 21 patients treated with grisofulvin for the same amount of time were rated as cured. At completion of therapy (four to eight weeks), 24 (83%) of 29 patients treated with ketoconazole and six (32%) of 19 patients treated with griseofulvin were rated as cured (P = < 0.001). One (7%) of 14 patients treated with ketoconazole and four (80%) of five patients treated with griseofulvin were rated as relapsed within 28 days after completion of therapy (P = 0.006). No significant adverse effects have been reported for either treatment group. The preliminary results of this study have shown ketoconazole to be more effective than griseofulvin in the treatment of dermatomycoses.

The activity of ketoconazole in the treatment of onychomycosis

Ketoconazole was administered orally in daily doses of 200 mg to 70 patients with onychomycosis. Complete recovery was attained by 48 patients, improvement of > 50% by 10 patients, and for three patients therapy failed. For the remaining nine patients the results could not be evaluated. The average duration of treatment was 7.5 months for disease due to Trichophyton species and 6.5 months for disease due to Candida species. There were no adverse effects or signs of toxicity attributable to the administration of ketoconazole. It is concluded that ketoconazole is a positive development in the effort to control the difficult problems presented by onychomycosis.

Therapeutic evaluation of ketoconazole in patients with coccidioidomycosis

Eleven adult patients (seven men and four nonpregnant women) with coccidioidomycosis were treated orally with ketoconazole (R41,400). Two patients presented with disseminated coccidioidomycosis, six with pulmonary coccidioidomycosis, and three with the chronic cutaneous form of the disease. Diagnosis was established by culture of Coccidioides immitis and/or histopathologic identification of the fungus. All patients received 400 mg of ketoconazole per day for the first 10 days; afterwards four of them received 200 mg per day. Evaluation indicated that nine patients improved, one did not, and one could not be assessed. Treatment of coccidioidomycosis with ketoconazole appears to be reasonably effective and produces fewer adverse effects than does amphotericin B; however, further studies of the efficacy of this new drug are needed.