Extrapulmonary Disease (EP)

EP disease often develops through hematogenous or lymphatic spread and can involve one or multiple sites. Patients in certain risk groups or with impaired immunity as previously discussed are also at higher risk of dissemination. Depending on the anatomic site of infection, patients invariably require prolonged antifungals, with some needing concomitant surgical intervention for debridement and stabilization. This is especially important with vertebral column involvement with associated neurologic deficit(s). Surgical intervention can be essential where there is formation of abscesses, clinical evidence of worsening or incomplete disease control, persisting focal symptoms and neurologic or physiologic compromise (1, 2). Dissemination to a wide range of tissues has been described. Common sites of dissemination include the meninges, skeleton, skin, and joints, but there are reports of involvement in glandular tissue, peritoneum, visceral organs including liver and pancreas, the pericardium, bone marrow, kidney and bladder, and male and female reproductive organs (3, 4).

The initial antifungal therapy recommended is fluconazole or itraconazole. However, the preferred treatment of osseous coccidioidomycosis is itraconazole (5). For patients with disseminated infections that seem to be worsening rapidly or who do not respond to initial oral azole therapy, strategies include switching therapy to another azole, or to amphotericin B deoxycholate, or a lipid amphotericin B formulation, or even an azole in combination with an amphotericin B formulation. These choices are frequently based on case reports and the clinical experience of the treating physician. Treatment duration is prolonged; often several years until disease is inactive both clinically and serologically with close follow-up for relapses.

REFERENCES

1. Galgiani JN, Ampel NM, Blair JE, et al. Coccidioidomycosis. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America 2005; 41(9): 1217-23.
2. Szeyko LA, Taljanovic MS, Dzioba RB, Rapiejko JL, Adam RD. Vertebral coccidioidomycosis: presentation and multidisciplinary management. The American journal of medicine 2012; 125(3): 304-14.
3. Nelson EC, Thompson GR, 3rd, Vidovszky TJ. Image of the month. Disseminated coccidioidomycosis. Archives of surgery 2012; 147(1): 95-6.
4. Nguyen C, Barker BM, Hoover S, et al. Recent advances in our understanding of the environmental, epidemiological, immunological, and clinical dimensions of coccidioidomycosis. Clin Microbiol Rev 2013; 26(3): 505-25.
5. Galgiani JN, Catanzaro A, Cloud GA, et al. Comparison of oral fluconazole and itraconazole for progressive, nonmeningeal coccidioidomycosis. A randomized, double-blind trial. Mycoses Study Group. Annals of internal medicine 2000; 133(9): 676-86.