Coccidioidomycosis

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Distribution

  • southwest US
    • 70% of US cases concentrated in AZ, 20% in CA
    • geographical association of creosote bush in AZ
    • San Joaquin Valley in CA, "Valley fever"
      • spores fly into town from deserts miles away
  • some central and south American countries

Pathogen

  • live in 10-20 cm underground soil
  • dimorphic fungus
    • filamentous in environment - arthroconidia
      • cultured coccidia is impossible to distinguish from other filamentous fungi macroscopically
    • yeast form in human parasitism - spherules
  • incubation 1-4 weeks
  • recurrence/reactivation possible for years even in decades
  • all healthy people susceptible
  • African American > Hispanic > Asian > Caucasian
  • very short time exposure may cause disease
    • even during transit at an airport in endemic area
    • earthquake in 1994 developed massive landslide in the valley, resulting in dispersion and spreading of spores and large outbreak of Valley fever
    • if accidentally cultured on petri dish, it is quite easily dispersed in aerosol = laboratory infection, highly biohazardous
  • no human to human transmission
    • the yeasts proliferate by endospore forming, clearly different from filamentous proliferation by sporing in environment
    • lab infection including autopsy or inappropriate handling of specimen possible

Clinical features

  • acute pulmonary form
    • most common
    • influenza like
    • erythema nodosum
      • EN in coccidiomycosis is allergic reaction, not infectious
    • spontaneous relief in most cases
  • diffuse pneumonia form
    • fatal
    • mostly in immunocompromised
  • chronic pulmonary form
    • most common in Japan cases
    • cough, hemoptysis
    • weight loss
    • low grade fever
    • or asymptomatic with incidental discovering of lung lesions
    • cavity development possible leading to rupture of the cavity and pneumothorax
  • disseminated form
    • meninge - mild symptoms
    • skin
    • bone
    • multiple organs in the most severe case


  • 50-60% acute form
  • 10% chronic form
  • 1% disseminated form

Diagnosis

  • pathology of skin/lung
  • smear of sputum
  • culture is very dangerous except for special laboratory
  • serology for antibody or antigen
  • PCR

Treatment

  • no treatment and follow up in asymptomatic/mild/no risk factor
  • azoles - fluconazole, itraconazole, posazonacol
  • liposomal AMPH-B in serious and pregnant