Coccidioidomycosis

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Background

  • Fungal infection caused by Coccidioides immitis and C posadasii
  • Organisms found in soil in arid climates of southwestern US and nearby areas
  • Transmitted by inhalation of airborne spores

Clinical Features

  • Often asymptomatic
  • Most commonly affects lungs
  • Mild ILI 1-4 weeks after exposure
    • Fever
    • Sore throat
    • Cough
    • Headache
    • Fatigue
    • Pleuritic chest pain
  • More severe presentation
    • Fever
    • Arthralgias
    • Erythema nodosum or erythema multiforme
    • Chest pain
  • Rarely, respiratory failure
  • Disseminated disease, more common in immunosuppressed
    • Dramatic sweats
    • Dyspnea at rest
    • Fever
    • Weight loss
    • 50% develop meningitis

Differential Diagnosis

  • Acute respiratory distress syndrome
  • Blastomycosis
  • Enteropathic arthropathies
  • Eosinophilic Pneumonia
  • Histoplasmosis
  • Lung abscess
  • Lung cancer
  • Lymphoma
  • Myelophthisic anemia
  • Old granuloma
  • Paracoccidioidomycosis
  • Pericarditis (acute or chronic)
  • Pneumocystis jiroveci pneumonia
  • Sarcoidosis
  • Solitary pulmonary nodule
  • TB

Workup

  • Basic workup
    • Typically normal WBC count or mild lymphocytosis, monocytosis, and/or eosinophilia (>5%)
    • Elevated ESR.
    • CXR
    • LP if suspect meningitis
  • Special testing
    • Immunoglobulin testing
    • Culture
    • PCR testing
    • Skin testing

Treatment

  • Often self-limited mild disease not requiring treatment
  • Azoles first line
  • Treatment options
    • Itraconazole - 200 mg 2-3 times/day orally
    • Fluconazole - 400-800 mg/day orally or IV
    • Ketoconazole - 400 mg/day orally
    • Amphotericin B deoxycholate - 0.5-1.5 mg/kg/day IV
    • Lipid formulations of amphotericin B - 2-5 mg/kg/day IV

Sources

emedicine