A 46-year-old man from New Mexico with a renal transplant presents with cough and fever. For suspected coccidioidomycosis, which treatment is recommended for an immunocompromised patient?

• A. Amphotericin B
• B. Ceftriaxone and azithromycin
• C. Fluconazole
• D. Supportive care

Answer: (C)

When managing coccidioidomycosis, the choice of antifungal depends on how sick the patient is and how well their immune system can handle infection. In an immunocompromised host, you want reliable antifungal therapy that treats disseminated disease without harming the transplanted kidney. Fluconazole fits this scenario well: it has good activity against Coccidioides, is easy to administer orally, penetrates tissues including the CNS, and has a more favorable safety profile than amphotericin B, which is notably nephrotoxic. That nephrotoxicity is especially concerning in someone with a renal transplant, where preserving kidney function is crucial.

Amphotericin B would be reserved for more severe or life-threatening disease or CNS involvement, where its stronger initial effect is needed, but it’s not ideal as initial therapy in a renal transplant patient. The other options are not antifungal therapies and would not treat the fungal infection. So, fluconazole is the best initial choice in this immunocompromised patient.