Coccidioidomycosis Posted by Abigail Place June 3rd, 2011

Coccidioidomycosis (or valley fever) is a systemic mycosis that is endemic to the southwestern United States and parts of Central and South America. Clinical Pearls How does coccidioidomycosis present? Sixty percent of patients with primary infection are asymptomatic; the rest have fever, night sweats, cough, pleuritic chest pain, arthralgias, rash, headache, or some combination of these symptoms 1 to 3 weeks after exposure. Primary coccidioidomycosis is manifested as consolidation, nodules, or opacities on chest imaging, with concurrent hilar adenopathy in up to 40% of patients. Mediastinal lymphadenopathy is less common. Dissemination occurs in about 1% of immunocompetent patients; the most common extrapulmonary sites are the meninges, skin, and skeletal system. How is coccidioidomycosis diagnosed? The diagnosis can be established by serologic tests, histopathological identification of characteristic spherules, or growth of coccidioides species in culture. In patients with solitary pulmonary nodules, culture of respiratory secretions has a low yield and is not recommended as the sole means of ruling out the diagnosis.

The latest article in our Clinical-Problem Solving series, A Recurrent Problem, presents this case: A 50-year-old woman from Texas had nasal stuffiness, postnasal drip, myalgias, cough, and hoarseness in early winter. Six weeks later, her nonproductive cough and hoarseness persisted. She had no fever, chills, night sweats, pain, weight loss, nausea, vomiting, or rash. A video of the laryngeal examination is included in the expert clinicians evaluation.

Morning Report Questions Q: What is the natural history of coccidioidomycosis? A: Most patients with uncomplicated primary coccidioidomycosis do not require antifungal therapy; symptoms resolve spontaneously over a period of several weeks. Q: Which patients with coccidioidomycosis should be treated? A: Antifungal therapy is indicated in patients with disseminated disease, concurrent immunosuppression, pregnant or postpartum status, or an age of more than 55 years, as well as in those with severe primary infection (as indicated by ongoing weight loss, persistent night sweats, infiltrates involving more than half of one lung or portions of both lungs, persistent lymphadenopathy, or a complement-fixation titer greater than or equal to 1:16). http://blogs.nejm.org/now/index.php/coccidioido mycosis/2011/06/03/ Coccidioidomycosis (Valley Fever)Valley Fever is an illness that usually affects the lungs. It is caused by a fungus called Coccidioides. Coccidioides lives in the dirt. A hardy form of the fungus can live for a long time under harsh environmental conditions such as heat, cold, and drought, and is spread through spores in the air when the dirt is disturbed. An estimated 150,000 Coccidioides infections occur each year in the United States, although more than half of these infections do not produce symptoms. Valley Fever fungus is found in some areas of the southwestern United States, and in parts of

Mexico and Central and South America. These areas have dirt and weather conditions that allow the fungus to grow. In California, the fungus is found in many areas of the San Joaquin Valley (Central Valley). People can get Valley Fever if they breathe in the dust from the dirt that contains fungal spores. Fungal spores can get into the air when dirt containing the fungus is disturbed by digging, during construction, or under strong winds. Construction and farm workers, military personnel, archaeologists, and others who breathe in dust from the dirt in the areas where Valley Fever is common may be exposed to the fungal spores. Valley Fever is difficult to prevent. There is currently no vaccine; efforts to develop a vaccine are ongoing. Persons at risk for Valley Fever or for getting severe illness from Valley Fever should avoid exposure to dusty air in areas where Valley Fever is common. Those exposed to dust during their jobs or outside activities in these areas should consider respiratory protection, such as a mask, during such activities. Summary

Most symptomatic coccidioidal infections are mild to severe episodes of pneumonia caused by Coccidioides species. Extrapulmonary infection in sites such as skin, soft tissue, or skeletal or central nervous system occurs infrequently. Common symptoms include fever, headache, dry cough, myalgia, and arthralgia, and may be accompanied by a rash. Treatment ranges from close observation without medical treatment in mild cases,

to medical therapy, primarily with azole antifungals in more severe episodes.