Infectious Disease Compendium

Coccidioidomycosis

Microbiology

A fungus. C. immitis or C. posadasii.

Epidemiologic Risks

Inhaling dust from the US SW (Coccidioides immitis) as well as parts of South and Central America (C. posadasii). It is in Washington (PubMed)(PubMed). I hate saying Washington State. I live in Oregon. There is Washington and Washington DC.

And now Missouri (PubMed). Have to wonder if this is due to climate change.

Rates have been going up this decade (the teens) in California (PubMed).

Syndromes

Valley Fever: cough, headache, pneumonia (29% of people presenting with pneumonia in Az had cocci (EID)), hilar lymphadenopathy, +/- erythema nodosum or erythema multiforme; will often leave a thin walled cavity to later become colonized/infected with aspergillus.

Chronic progressive pneumonia: looks and acts like tuberculosis. Commonly found in those with borderline immune systems: diabetics for example.

Disseminated disease: It can disseminate (esp in non Caucasians, pregnancy, immunoincompetent) anywhere and reactivate in patients with advanced immunodeficiency like AIDS or infliximab therapy (PubMed).

Meningitis: esp in non Caucasians, pregnancy, immunoincompetent.  There is a CSF antigen test to aid in diagnosis (PubMed).

Treatment

For details read the IDSA guidelines.

Valley Fever: probably needs no therapy in normal people. However, everyone probably gets fluconazole. And treatment has little effect on clinical course for mild to moderate pneumonia, which is protracted "Median times from symptom onset to 50% reduction and to complete resolution for patients in treatment and nontreatment groups were 9.9 and 9.1 weeks, and 18.7 and 17.8 weeks (PubMed)."

Chronic progressive pneumonia: High dose fluconazole OR itraconazole OR Amphotericin B. Posaconazole is effective in pneumonia and non meningeal disseminated disease (PubMed).

Disseminated disease: High dose fluconazole OR itraconazole OR Amphotericin B. Type and duration of therapy depends on host and extent of disease. Posaconazole 800 mg a day may be effective in refractory disease (PubMed).

Meningitis: Amphotericin B at 1 mg/kg until titer has fallen, then followed by life time high dose fluconazole OR itraconazole.

If a patient has a stroke as a complication of meningitis, steroids will stop a second. (PubMed). But steroids from primary pervention? No idea as of 2017.

Unlike love, cocci meningitis is forever.

If fluconazole fails, voriconazole and posaconazole (PubMed) are reasonable alternatives, but not 'infallible' (PubMed).

Notes

Complement fixation serology > 1:32 means disseminated disease. Not that you can get a complement fixation test anymore. Despite 30 years of literature on the complement fixation tests, most of my referral labs have changed to the worthless ELISA. Sometime I hate progress. Do not get me started on electronic medical records. Caspofungin works in mice and in vitro. My one case I treated failed two months of therapy. See in my experience.

Fluconazole used early in disease (within 2 weeks of symptom onset) will prevent an IgG response (PubMed).

Hypercalcemia can occur, as with all granulomatous diseases (PubMed).