American Board of Internal Medicine (ABIM) Certification Practice Exam

What is the first-line treatment for cutaneous, pulmonary, or extrapulmonary blastomycosis?

1. Itraconazole only

2. Lipid formulation of amphotericin B followed by itraconazole

3. Fluconazole only

4. Conventional amphotericin B only

The correct answer is: Lipid formulation of amphotericin B followed by itraconazole

The first-line treatment for cutaneous, pulmonary, or extrapulmonary blastomycosis involves the use of a lipid formulation of amphotericin B followed by itraconazole. This approach takes into account the severity of the infection and the patient's overall condition. Amphotericin B, especially the lipid formulations, is preferred in initial treatment due to its efficacy in cases of severe blastomycosis, as it can rapidly reduce fungal burden. This is crucial for more severe infections where the patient may be experiencing significant symptoms or complications. After stabilization and improvement in the patient's condition, transitioning to itraconazole for maintenance treatment is common. Itraconazole, an azole antifungal, is effective for the treatment of less severe forms of blastomycosis and for prevention of recurrence. In contrast, other options presented do not represent the preferred treatment strategy. For example, itraconazole is not used alone in severe cases; it is more suitable as continuation therapy after initial treatment with amphotericin B. Fluconazole lacks effectiveness against Blastomyces dermatitidis, the causative organism of blastomycosis, making it inappropriate for initial management of this disease. Conventional amphotericin B may be used, but it is less favored compared