what is the recommended treatment protocol and long-term prognosis for coccidioidomycosis in dogs?

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First-line treatment for canine coccidioidomycosis is fluconazole or itraconazole administered for a minimum of 6 to 12 months for pulmonary disease, with disseminated infections typically requiring 1 year or more — and often lifelong therapy. 1812 Fluconazole is the preferred azole for CNS involvement due to its blood-brain barrier penetration. 1 For CNS coccidioidomycosis, the regionally recommended dose is fluconazole 10 mg/kg PO q12h (20 mg/kg/day total), with a maximum of 400 mg/day. 7 The standard published dose is fluconazole 5 mg/kg PO q12h (10 mg/kg/day total), though no controlled comparison of these two doses has been performed. 7 For non-CNS disease, fluconazole 4 mg/kg PO q12h has been used in clinical practice. 4 Itraconazole 4 mg/kg PO q24h and itraconazole 4.8 mg/kg PO q24h have both been reported for non-CNS disseminated disease. 36 Ketoconazole is also cited as an alternative to itraconazole for osseous disease. 3 Compounded fluconazole formulations carry a meaningful risk of treatment failure and should be avoided in favor of generic formulations. Switching dogs from compounded to generic fluconazole at essentially the same prescribed dose resulted in neurologic improvement in 7 dogs with CNS coccidioidomycosis, consistent with evidence that compounded fluconazole provides unreliable serum concentrations. 7 For refractory cases — defined as failure to respond to at least two first-line treatments — posaconazole at 2.5 to 10 mg/kg/day is the recommended escalation. Six of 8 dogs with refractory coccidioidomycosis achieved recovery or clinical remission on posaconazole, with trough serum concentrations of 1.52 to >6 μg/mL. 10 Posaconazole was well tolerated in 7 of 8 dogs; 1 dog required dose reduction and ultimately discontinued treatment due to hepatotoxicosis. 10 Amphotericin B (IV, potentially nephrotoxic) is an additional option for refractory disease. 10 Treatment monitoring should combine serial serology, clinical signs, and clinicopathologic