have assessed outcomes in less-severe disease. Commonly used indicators to judge the severity of illness include: Continuous fever for longer than 1 month Body-weight loss of more than 10% Intense night sweats that persist for more than 3 weeks Infiltrates that involve more than half of one lung or portions of both lungs Prominent or persistent hilar adenopathy Anticoccidioidal complement fixation IgG titers of 1:16 or higher Absence of dermal hypersensitivity to coccidioidal antigens Inability to work Symptoms that persist for more than 2 months Risk factors for dissemination (for which treatment should be initiated): Primary infection during infancy Primary infection during pregnancy, especially in the third trimester or immediately post partum Immunosuppression (e.g., patients with HIV/AIDS, transplant recipients, patients receiving high-dose corticosteroids, those receiving antitumor necrosis factor medications) Chronic debilitation or underlying disease, including diabetes mellitus or preexisting cardiopulmonary disease High inoculum exposures Certain ethnicities, such as Filipino, Black, or Hispanic Age greater than 55 years Azoles The introduction of azoles revolutionized treatment for coccidioidomycosis, and these agents are usually the first line of therapy. However, none of these azoles are safe to use in pregnancy and lactation because they have shown teratogenicity in animal studies. Of the azoles, ketoconazole is the only one approved by the U.S. Food and Drug Administration (FDA) for treatment of coccidioidomycosis. Nevertheless, although it was initially used in the long-term treatment of nonmeningeal extrapulmonary disease, more-potent, less-toxic triazoles (fluconazole and itraconazole) have replaced it. Itraconazole (400 mg/day) appears to have efficacy equal to that of fluconazole in the treatment of nonmeningeal infection and have the same relapse rate after therapy is discontinued. However, itraconazole seems to perform better in skeletal lesions, whereas fluconazole performs better in pulmonary and soft tissue infection. Serum levels of itraconazole are commonly obtained at the onset of long-term therapy because its absorption is sometimes erratic and unpredictable. Complications can include hepatic dysfunction. For patients who are unresponsive to fluconazole, options are limited. Several case reports have studied the efficacy of three newer antifungal agents in the treatment of disease that is refractory to first-line therapy: posaconazole and voriconazole (triazole compounds similar in structure to fluconazole) and caspofungin (glucan synthesis inhibitor of the echinocandin structural class). However, these drugs have not been FDA approved, and clinical trials are lacking. Susceptibility testing of Coccidioides species in one report revealed uniform susceptibility to most antifungal agents, including these newer drugs. In