Coccidioidomycosis

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• most deadly fungus in the world
  • Coccidioides immitis & C. posadasii
  • コクシジオイデス症とは｜感染研

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