coccidioidomycosis
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Etiology
Risk factors for disseminated disease:
- Black
- Filipino
- Asians, Mexicans, Native Americans may be at increased risk
- adult men develop disseminated disease more frequently than women
- pregnant
- debilitated
- immunocompromised
- severe primary infection
- complement fixation (CF) titers > 1:32
- persistent symptoms, > 6 weeks duration
- negative skin test
Epidemiology
- southwestern United States
- San Joaquin Valley of California as far north as Fresno
- Southern Arizona
- Southwestern New Mexico
- West Texas
- Central America
- South America
- disease is acquired via arthroconidia of the mold phase of Coccidioides immitis which disperse into the air
- epidemic infections may occur
- symptomatic infection uncommon in immunocompetent persons
Pathology
- primary infection is in the lung:
- primary skin infection is rare
- tissue response is granulomatous with & without caseation
- developing spherules
- found in macrophages & multinucleated giant cells
- 10-80 um in size
- endospores within spherules: 2-5 um in size
- lung cavity may be noted on chest CT
- dimorphic pathogen
- arthroconidia in specimen are infective; disease may be contracted directly from laboratory specimen
Clinical manifestations
- most frequently asymptomatic
- incubation period 1-3 weeks
- pulmonary signs/symptoms
- community-acquired pneumonia presenting 1-3 weeks after exposure
- symptomatic disease may mimic bacterial pneumonia
- solitary pulmonary nodules (may persist)
- unilateral hilar adenopathy
- skin lesions
- erythema nodosum or erythema multiforme
- more frequent in adult women than in men
- may accompany primary infection
- are good prognostic signs
- papules
- ulcers
- draining sinuses
- subcutaneous abscesses
- erythema nodosum or erythema multiforme
- disseminated disease most commonly affects:
- skin
- skeletal system: arthritis most commonly results from involvement of adjacent bone
- meninges:
- meningeal signs/symptoms
- may be acute
- most commonly indolent & chronic
- weight loss
Laboratory
- Coccidioides serology & Coccidioides immitis serology
- rapid serologic tests may be useful for screening
- enzyme immunoassay (EIA) & immunodiffusion recommended first[19]
- latex agglutination
- complement fixation (CF)
- useful for assessing extent & prognosis (in contrast to histoplasmosis & blastomycosis)
- antibodies detected 2-6 weeks after infection
- higher titers increase probability of disseminated disease
- rising titers suggest poor outcome
- rapid serologic tests may be useful for screening
- Coccidioides immitis antigen in tissue/body fluid
- molecular diagnostic testing
- cytologic methods
- sensitivity only 50%
- wet preparations
- Calcofluor white staining
- 10-30% KOH may remove interfering tissue elements
- spherules may be demonstrated in:
- hyphae may be seen in cavitary lesions
- culture
- cultures are infective (use special precautions)
- organism grows rapidly (< 1 week)
- colonies are extremely variable in appearance
- alternating barrel-shaped arthroconidia with empty disjunctor cells
- skin testing
- does not produce seroconversion as in histoplasmosis
- disseminated infection may be accompanied by anergy to skin testing
- CSF analysis
- lymphocytic pleocytosis
- elevated CSF protein
- low CSF glucose
- CSF esosinophils (70%)
- complete blood count
Radiology
- chest X-ray
- solitary pulmonary nodules (may persist)
- unilateral hilar adenopathy
- chest CT
- lung cavity may be noted
Complications
- pneumothorax
- empyema
- pericarditis
- atelectasis
- progressive pulmonary infection (resembles tuberculosis)
- dissemination (see clinical manifestations)
- chronic residual disease
Differential diagnosis
- Blastomyces dermatitidis (non-budding form)
- Cryptococcus neoformans (non-budding form)
- adiaspiromycosis (fungal form)
- rhinosporidiosis (fungal form)
- histoplasmosis
Management
- rapidly progressive or disseminated disease:
- liposomal amphotericin B until improvement, then fluconazole or itraconazole[3]
- intrathecal amphotericin B only in patients who have not responded to fluconazole[3]
- lumbar puncture to assess meningeal involvement
- fluconazole for coccidioidal meningitis[3][14]
- fluconazole 400 mg PO QD
- mild to moderately severe disease
- drug of choice in coccidioidal meningitis
- treatment should be continued for 1 year after resolution of signs & symptoms & indefinitely in patients with AIDS or coccidioidal meningitis
- 3-6 months for uncomplicated primary pulmonary infection[3]
- itraconazole not recommended in MKSAP18[3]
- the majority of primary infections resolve spontaneously without specific treatment
More general terms
Additional terms
References
- ↑ Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 324
- ↑ Clinical Diagnosis & Management by Laboratory Methods, 19th edition, J.B. Henry (ed), W.B. Saunders Co., Philadelphia, PA. 1996, pg 1234
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2018, 2021.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ PubMed Health: Valley fever http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002299/
- ↑ Wikipedia: Coccidioidomycosis http://en.wikipedia.org/wiki/Coccidioidomycosis
- ↑ Centers for Disease Control and Prevention Coccidioidomycosis (Valley Fever) http://www.cdc.gov/fungal/coccidioidomycosis/
- ↑ Medline Plus: Valley fever http://www.nlm.nih.gov/medlineplus/ency/article/001322.htm
- ↑ Medscape (emedicine): Coccidioidomycosis Hospenthal DR and Cunha BA http://emedicine.medscape.com/article/215978-overview
- ↑ Galgiani JN et al Coccidioidomycosis. Clin Infect Dis. 2005; 41(9):1217-23 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16206093
- ↑ Parish JM and Blair JE Coccidioidomycosis. Mayo Clin Proc. 2008; 83(3):343-48 PMID: https://www.ncbi.nlm.nih.gov/pubmed/18316002
- ↑ Centers for Disease Control and Prevention Increase in Coccidioidomycosis - California, 2000-2007. MMWR Morb Mortal Wkly Rep. 2009; 58(5):105-9 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/19214158 <Internet> http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5805a1.htm
- ↑ Centers for Disease Control and Prevention Increase in Reported Coccidioidomycosis - United States, 1998-2011 MMWR. March 29, 2013 / 62(12);217-221 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6212a1.htm
- ↑ Ampel NM. New perspectives on coccidioidomycosis. Proc Am Thorac Soc. 2010 May;7(3):181-5. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20463246
- ↑ 14.0 14.1 Mathisen G, Shelub A, Truong J, Wigen C. Coccidioidal meningitis: clinical presentation and management in the fluconazole era. Medicine (Baltimore). 2010 Sep;89(5):251-84. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20827104 Free Article
- ↑ Welsh O, Vera-Cabrera L, Rendon A, Gonzalez G, Bonifaz A. Coccidioidomycosis. Clin Dermatol. 2012 Nov-Dec;30(6):573-91. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23068145
- ↑ Stockamp NW, Thompson GR 3rd. Coccidioidomycosis. Infect Dis Clin North Am. 2016 Mar;30(1):229-46. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26739609
- ↑ Myers RA, Zmarlicka MT Disseminated Coccidioidomycosis N Engl J Med 2019; 380:e44. June 6, 2019 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31167055 https://www.nejm.org/doi/full/10.1056/NEJMicm1811100
- ↑ Twarog M, Thompson GR 3rd. Coccidioidomycosis: Recent Updates. Semin Respir Crit Care Med. 2015 Oct;36(5):746-55 PMID: https://www.ncbi.nlm.nih.gov/pubmed/26398540 Review.
- ↑ 19.0 19.1 Smith DJ, Free RJ, Thompson Iii GR et al. Clinical testing guidance for coccidioidomycosis, histoplasmosis, and blastomycosis in patients with community-acquired pneumonia for primary and urgent care providers. Clin Infect Dis 2023 Oct 6; [e-pub]. PMID: https://www.ncbi.nlm.nih.gov/pubmed/37802909 https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciad619/7295325