Clinical Manifestations and Management

Coccidioidomycosis is a highly variable illness. Upon inhalation of the spores, 60% of people may develop an asymptomatic infection or a mild respiratory illness and the rest will develop the disease in variable manner (1). Disseminated infection or progressive pulmonary infection occurs in 1-3% of people infected with Coccidioides spp. Dissemination is often an early clinical event, and the most common extrapulmonary sites include skin, lymph nodes, bones, joints and the most severe being the central nervous system.

While coccidioidomycosis manifests primarily as a respiratory illness, in certain groups the chance of dissemination or development of a chronic infection remains high. Individuals with HIV/AIDS and recipients of immune-modulating drugs or immunosuppressive drugs or high-dose corticosteroids are at high risk for dissemination and chronic infection (2). Diabetes mellitus is a significant risk factor for severe pulmonary infection, as well as chronic structural lung disease, or cardiopulmonary disease. Dissemination is more common in women in the third trimester of pregnancy or immediately post-partum (3, 4). There is also a several-fold higher relative risk of dissemination in individuals of African American and Filipino decent (1). Accordingly, mortality rates are observed to be higher in persons >65 years of age, men, Native Americans, and Hispanics, as well as those with conditions such as vasculitis, rheumatoid arthritis, systemic lupus erythematosus, HIV infection, tuberculosis, diabetes mellitus, chronic obstructive pulmonary disease and non-Hodgkin lymphoma (5). Treatment and/or monitoring of such groups should be approached carefully and with diligence.

Management entails careful periodic assessment. Limited pulmonary infections may not require treatment, while other patients may require short course, prolonged or lifetime antifungal therapy which is determined by co-morbidities, risk of dissemination, persistent systemic signs and symptoms such as fever, night sweats, weight loss of more than 10%, fatigue, radiographic findings of extensive infiltrates involving multiple lobes or effusion, and CF of 1:16 or higher (2).

• Primary Pulmonary Infection
• Diffuse Pneumonia and ARDS
• Residual Nodule, Cavities, And Chronic Infiltrates/Pneumonia
• Extrapulmonary Disease (eg bone, skin etc)
• Coccidioidal Meningitis

REFERENCES

1. Smith CE, Beard RR, et al. Varieties of coccidioidal infection in relation to the epidemiology and control of the diseases. American journal of public health and the nation's health 1946; 36(12): 1394-402.
2. 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.
3. Bercovitch RS, Catanzaro A, Schwartz BS, Pappagianis D, Watts DH, Ampel NM. Coccidioidomycosis during pregnancy: a review and recommendations for management. Clin Infect Dis 2011; 53(4): 363-8.
4. Powell BL, Drutz DJ, Huppert M, Sun SH. Relationship of progesterone- and estradiol-binding proteins in Coccidioides immitis to coccidioidal dissemination in pregnancy. Infection and immunity 1983; 40(2): 478-85.
5. Huang JY, Bristow B, Shafir S, Sorvillo F. Coccidioidomycosis-associated Deaths, United States, 1990-2008. Emerging infectious diseases 2012; 18(11): 1723-8.