Primary prophylaxis, before development of infection, is generally not recommended for endemic fungi but may be considered for patients who are severely immunocom-promised. Patients with HIV infection with CD4 cell counts less than 150 cells/mm3 (histoplasmosis) or less than 250 cells/mm3 (coccidioidomycosis) living in endemic areas with high endemic case rates (greater than 10 cases per 100 patient-years) or with positive IgM or IgG antibodies to the fungal pathogen serology should re-

ceive itraconazole 200 mg daily. Secondary prophylaxis or suppressive therapy with itraconazole 200 mg daily, to prevent recurrence of infection is recommended for blastomycosis in immunosuppressedpatients if immunosuppression cannot be reversed.6,12 In patients with prior CNS disease, fluconazole or voriconazole are the preferred drug due to the limited penetration of itraconazole into the CNS.

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