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PubMed1993

Acute pulmonary coccidioidomycosis mimicking bacterial pneumonia and septic shock: a report of two cases.

Two patients with acute pulmonary coccidioidomycosis presenting as acute bacterial pneumonia and sepsis are described. One patient died despite appropriate antifungal therapy, whereas the diagnosis in the other patient was only established after postmortem examination. In both cases, coccidioidomycosis had disseminated beyond the lungs. Factors leading to overwhelming coccidioidomycosis are discussed, and the relation of the sepsis syndrome to coccidioidomycosis is reviewed.

Acute Disease↗

PubMed1992

Peritoneal coccidioidomycosis associated with human immunodeficiency virus infection.

Peritoneal coccidioidomycosis is extremely rare. This report describes a patient infected with the human immunodeficiency virus who presented with unexplained ascites and was found to have peritoneal coccidioidomycosis. The ascites had a low serum-ascites albumin gradient, and laparoscopy showed peritoneal implants that grew Coccidioides immitis. This case is unique in several ways; this is the first case in which a patient's acquired immunodeficiency syndrome-defining illness was peritoneal coccidioidomycosis, and the serum-ascites albumin gradient determination as well as laparoscopy provided information critical to the diagnosis. This patient's dramatic response to systemic antifungal therapy, as evidenced by resolution of ascites and constitutional symptoms, underscores the importance of timely diagnosis and prompt therapy. In summary, this report reviews the previous cases of coccidioidal peritonitis and reports the first case in which localized peritoneal coccidioidomycosis was the acquired immunodeficiency syndrome-defining illness in a human immunodeficiency virus-infected patient.

Adult↗

PubMed1992

Clinicopathologic spectrum of specific cutaneous lesions of disseminated coccidioidomycosis.

BACKGROUND: Disseminated coccidioidomycosis merits greater attention because the number of persons living and traveling in endemic areas is increasing. OBJECTIVE: Our purpose was to study the clinical and histopathologic findings in patients with specific cutaneous disseminated coccidioidomycosis. METHODS: In six patients with specific skin lesions of disseminated coccidioidomycosis, the diagnosis was confirmed by identification of the organism in tissue or by positive results of tissue culturing. RESULTS: Clinical lesions included solitary granulomatous plaques in two patients and multiple papular, nodular, or pustular lesions in four patients, two of whom also had subcutaneous abscesses. Identifying organisms directly in tissue was possible in only 8 of 17 biopsy specimens and in five of six patients. The histopathologic features showed various degrees of three primary patterns: (1) abscess formation with necrosis, (2) epithelial hyperplasia and granuloma formation with microabscesses, and (3) vascular and perivascular proliferative and inflammatory cell reactions at times suggesting vasculitis. Tissue eosinophilia, present in all patients, was striking in two (eosinophilic abscess formation) and notable in another (vascular inflammation with eosinophilia). CONCLUSION: Cutaneous manifestations of disseminated coccidioidomycosis may be more common and varied than usually recognized.

Adolescent↗

PubMed1980

Surgical manifestations and results of treatment of pulmonary coccidioidomycosis.

Fifty consecutive patients with pulmonary coccidioidomycosis undergoing operation in an eight-year period were analyzed with regard to clinical and roentgenographic indications, surgical procedure, complications, and recurrence. Surgical indications could be divided into operation necessary primarily for diagnosis (22 out of 50, 44%) and operation because of suspected residual complications of coccidioidomycosis requiring therapy (28 out of 50, 56%). Of 16 patients with solitary nodules, 2 had lobectomy and 14 had wedge resection with no recurrence. Of 24 patients with coccidioidomycosis cavities, 14 underwent lobectomy and 10 had lesser resections, with three recurrences. Results indicate that (1) resection for primary pulmonary coccidioidomycosis for both diagnosis and therapy is associated with low perioperative risk, (2) routine administration of amphotericin is not indicated, (3) skin tests, serological study, bronchoscopy, and mediastinoscopy may not be diagnostic, and (4) lobectomy is not necessarily indicated since lesser resections are associated with equally low recurrence and complications rates.

Coccidioidomycosis↗

PubMed1988

Quantitative pathology of coccidioidomycosis in acquired immunodeficiency syndrome.

This study examines the laboratory aspects of diagnosis of coccidioidomycosis in 11 patients with acquired immunodeficiency syndrome (AIDS) and the qualitative and quantitative differences between host responses of AIDS and non-AIDS patients who died with disseminated coccidioidomycosis. Material obtained at bronchoscopy confirmed the diagnosis of pulmonary coccidioidomycosis in 67% (6/9) of the patients. Patients with AIDS had a generally poor granulomatous response and statistically significantly increased numbers of spherules in lung tissue compared with non-AIDS patients. Neither antifungal therapy nor duration of clinical disease influenced the number of organisms present. The findings suggest a parallel between AIDS-associated coccidioidomycosis and other granulomatous diseases such as leprosy and schistosomiasis, in which the type of granuloma formation and organism numbers are influenced by the T-lymphocyte milieu.

Acquired Immunodeficiency Syndrome↗

PubMed1981

Isolated nodular cutaneous coccidioidomycosis. The initial manifestation of disseminated disease.

Cutaneous manifestations of coccidioidomycosis may be divided into primary and secondary lesions. Since such lesions may be the only evidence of infection, the distinction is important. Primary (inoculation) lesions are rare. Secondary lesions develop from primary pulmonary disease, commonly. An isolated nodule on the scalp was the presenting sign of disseminated coccidioidomycosis in our patient. Because of the rarity of primary cutaneous coccidioidomycosis, cutaneous lesions due to it should alert the physician to the presence of disseminated disease. The clinical spectrum of such lesions is wide. Our patient was an elderly man with a hyperkeratotic scalp nodule clinically felt to be an actinic keratosis or an early squamous cell carcinoma. We suggest that patients with a travel or resident history in endemic areas be viewed with a high index of suspicion for skin lesions of cutaneous coccidioidomycosis. The advent of orally administered imidazole antifungal agents makes early and aggressive diagnosis of these lesions even more important.

Aged↗

PubMed2001

Coccidioidomycosis complicating solid organ transplantation.

Coccidioidomycosis is the most common endemic mycosis to cause disease in solid-organ transplant patients in North America. Underlying renal and liver disease, T-lymphocyte suppression from antirejection medication, and activation of immunomodulating viruses, such as cytomegalovirus, all increase the risk for coccidioidomycosis among these patients. About one half of all cases are the result of reactivation of previously acquired coccidioidal infection and occur during the first year after transplantation. Although disseminated infection is common, most cases manifest pulmonary symptoms. Culture of pulmonary secretions from bronchoscopy is frequently diagnostic. Serologic tests are particularly useful for identifying patients who are at high risk for reactivating coccidioidomycosis posttransplantation. Amphotericin B and azoles are the mainstay of therapy. Although there are no established approaches to preventing coccidioidomycosis among these patients, studies are underway examining the use of prophylactic azole antifungals with documented prior coccidioidal infection.

Coccidioidomycosis↗

PubMed2001

Primary pulmonary coccidioidomycosis.

Coccidioidomycosis is an infection caused by the soil-inhabiting fungus Coccidioides immitis. The fungus is endemic in the desert Southwest, which is a major area for tourism and growth. Travel through this region results in many new coccidioidal pulmonary infections annually, including pneumonia, cavities, and nodules. Patients with coccidioidomycosis are therefore likely to present with pulmonary manifestations of infection when they return home to nonendemic parts of the country. This makes coccidioidomycosis a fungal infection of nationwide importance, and it is crucial that physicians everywhere have a heightened awareness of this disease to avert delays in diagnosis and treatment. This article describes primary pulmonary coccidioidomycosis and its complications for clinicians practicing both in endemic and nonendemic areas.

Coccidioidomycosis↗

PubMed2002

Coccidioidomycosis: case report and update on diagnosis and management.

Coccidioidomycosis is a disease known for its endemicity to the Southwest United States. However, given the current trends of more frequent tourist and business travel, an increasing number of coccidioidomycosis infections are being seen in patients in other areas of the United States. Because the majority of patients with disseminated disease experience cutaneous manifestations, dermatologists can be of primary importance in the diagnosis of this disease. We report a case of coccidioidomycosis manifesting as granulomatous cutaneous nodules on the face of an otherwise healthy white man. We attempt to provide an update on the diagnosis, management, and treatment of patients who present with cutaneous lesions caused by coccidioidomycosis infection.

Biopsy, Needle↗

PubMed2005

Coccidioidomycosis in hematopoietic stem cell transplant recipients.

Coccidioidomycosis is an endemic fungal infection of the desert southwestern United States that can cause devastating disseminated infection in immunocompromised persons. Clinical coccidioidomycosis, which is caused by Coccidioides species, has been well characterized in patients who have had solid organ transplants, but it has rarely been described in patients who have received a hematopoietic stem cell transplant (HSCT). We report the experience of 121 consecutive HSCT recipients at a single tertiary care institution in an endemic area. One patient had fatal disseminated coccidioidomycosis after receiving an allogeneic transplant, and 2 patients had pulmonary infection before successful autologous HSCT; 1 of these 2 had a reactivation of coccidioidal infection after HSCT but was treated and survived. Coccidioidomycosis was not commonly identified in HSCT recipients, even in the endemic area. A prospective evaluation is required to address the optimal use of coccidioidal serologic tests, antifungal protocols, and secondary prophylaxis in these patients.

Adult↗

PubMed2000

Coccidioidomycosis in human immunodeficiency virus-infected persons in Arizona, 1994-1997: incidence, risk factors, and prevention.

From 1 January 1995 through 31 June 1997, 153 cases of coccidioidomycosis in human immunodeficiency virus (HIV)-infected persons were identified in Arizona (incidence, 41/1000 persons living with AIDS). A case-control study was conducted to evaluate risk factors for coccidioidomycosis in HIV-infected persons. A case was defined as laboratory-confirmed, incident coccidioidomycosis in a person infected with HIV for > or =3 months, and each case patient had 3 control patients matched by county, age group, sex, HIV/AIDS status, and CD4 lymphocyte count. Multivariable analysis identified black race and a history of oropharyngeal or esophageal candidiasis to be associated with increased risk of coccidioidomycosis; protease inhibitor therapy was associated with a reduced risk. In persons with previous history of oropharyngeal or esophageal candidiasis, having received an azole drug was associated with a reduced risk (odds ratio, 0.4; 95% confidence interval, 0.2-0.9; P=.04). Physicians may need to consider azole chemoprophylaxis for HIV-infected persons who live in areas of endemicity, have CD4 cell counts <200/microL, are black, or have a history of thrush.

AIDS-Related Opportunistic Infections↗

PubMedDate not supplied

Therapeutic evaluation of ketoconazole in patients with coccidioidomycosis.

Eleven adult patients (seven men and four nonpregnant women) with coccidioidomycosis were treated orally with ketoconazole (R41,400). Two patients presented with disseminated coccidioidomycosis, six with pulmonary coccidioidomycosis, and three with the chronic cutaneous form of the disease. Diagnosis was established by culture of Coccidioides immitis and/or histopathologic identification of the fungus. All patients received 400 mg of ketoconazole per day for the first 10 days; afterwards four of them received 200 mg per day. Evaluation indicated that nine patients improved, one did not, and one could not be assessed. Treatment of coccidioidomycosis with ketoconazole appears to be reasonably effective and produces fewer adverse effects than does amphotericin B; however, further studies of the efficacy of this new drug are needed.

Adult↗

PubMed1995

Coccidioidomycosis of the central nervous system: neuropathological and vasculopathic manifestations and clinical correlates.

Infection due to the fungus Coccidioides immitis, which is endemic to the southwestern United States, is currently occurring in epidemic proportions. Although it usually presents as a subclinical infection or a mild, self-limited pulmonary infection, disseminated infection can occur, especially in immunosuppressed patients. In patients with disseminated coccidioidomycosis, CNS spread is commonly responsible for significant morbidity and mortality. The neurological presentations of C. immitis infection of the CNS are variable. The spectrum of neuropathological change ranges from meningitis to meningoencephalitis and meningomyelitis with extensive parenchymal destruction, sometimes as a result of an associated endarteritis obliterans. We describe a patient with AIDS who developed CNS coccidioidomycosis, and we report the findings of a clinicopathological analysis of eight patients with fatal CNS coccidioidomycosis who were autopsied at UCLA Medical Center. CNS coccidioidomycosis should be considered in the differential diagnosis of patients with neurological symptoms, especially when they are immunosuppressed and live in regions where the disease is endemic.

AIDS-Related Opportunistic Infections↗

PubMed1996

Coccidioidomycosis in patients infected with human immunodeficiency virus: review of 91 cases at a single institution.

We retrospectively evaluated the clinical manifestations, diagnosis, treatment, and outcome of coccidioidomycosis in 91 patients infected with human immunodeficiency virus (HIV) at a single institution. Coccidioidomycosis was the AIDS-defining illness in 37 patients. Fever and chills, weight loss, and night sweats were the most frequent symptoms. The lung was the most frequently involved organ (80%), followed by the meninges (15%). A diffuse reticulonodular infiltrate was seen in 59 patients (65%), and 13 (14%) had focal pulmonary disease; for 15 patients (16%), the chest radiograph was normal. Coccidioidal serologies were positive for 60 patients (68%), while for 23% with proven coccidioidomycosis such tests were negative Most patients were treated with systemic amphotericin B and then an oral azole. The mortality for the whole group was 60%. Patients with diffuse pulmonary disease had the highest mortality (68%), with a median duration of survival of 54 days (P < .05; 95% confidence interval, 147-175 days). The presence of diffuse pulmonary disease and a CD4 lymphocyte count of < 50/microL were independent predictors of death. In our experience, coccidioidomycosis is an important opportunistic infection that causes substantial morbidity and mortality among HIV-infected patients living in an area of endemicity.

AIDS-Related Opportunistic Infections↗

PubMed1990

Coccidioidomycosis in human immunodeficiency virus-infected patients.

Coccidioidomycosis is at best a complicated fungal infection; often it is life-threatening. Coccidioidomycosis is confined epidemiologically to the southwestern region of the USA, and most cases have occurred in that area, particularly in Arizona. However, we have seen several cases in San Francisco in patients with only a history of travel to endemic areas. In part because of its regional distribution, information about the clinical presentation, diagnosis, and treatment of patients with coccidioidomycosis has lagged behind information about other, more commonly encountered AIDS-associated opportunistic infections. Drs. Galgiani and Ampel have probably had the largest single experience with coccidioidomycosis in individuals infected with the human immunodeficiency virus. These specialists share their experience and make recommendations as to how these complicated conditions should be approached.

Acquired Immunodeficiency Syndrome↗

PubMed2004

Hypercalcemia in patients with disseminated coccidioidomycosis.

OBJECTIVE: Granulomatous disorders may be associated with hypercalcemia. In sarcoidosis, the pathogenesis of hypercalcemia has been clarified, whereas in other granulomatous disorders, such as coccidioidomycosis, the mechanism is unclear. We present 13 patients with coccidioidomycosis and hypercalcemia to illustrate the clinical course and the mechanism of hypercalcemia. METHODS: We retrospectively reviewed all patients admitted to Kern Medical Center, a 270-bed public hospital, from 1990 through 1997 with coccidioidomycosis and a serum calcium level of greater than 10.5 mg/dL on at least 3 occasions. In addition, no other causes for hypercalcemia were identified. RESULTS: The mean highest serum calcium level was 12.7 +/- 1.8 mg/dL. All patients had disseminated disease. Six patients were nonambulatory and 4 had bone involvement. Of the 9 patients in whom parathyroid hormone was measured, it was normal in 6 and suppressed in 3. Of the 9 patients in whom 25-hydroxyvitamin D was measured, it was normal in 6, suppressed in 2, and elevated in 1. Of the 7 patients in whom 1,25-dihydroxyvitamin D was measured, it was normal in 3 and suppressed in 4. Urinary calcium was elevated in 2 patients, both of whom were ambulatory. Nonambulatory patients had significantly higher serum calcium levels (14.3 +/- 1.0 mg/dL) than ambulatory patients (11.3 +/- 0.46 mg/dL) (P<0.001). CONCLUSIONS: The mechanism of hypercalcemia in coccidioidomycosis is unrelated to increased production of 1,25-dihydroxyvitamin D. Nonambulatory status is associated with higher mean serum calcium.

Adult↗

PubMed2004

Coccidioidomycosis: a descriptive survey of a reemerging disease. Clinical characteristics and current controversies.

Coccidioidomycosis is a fungal disease with protean manifestations endemic to the Lower Sonoran Life Zone, which includes the hot deserts of the southwestern United States and areas of Mexico. Two hundred and twenty-three patients were found to have coccidioidomycosis at our institution from 1994-2002, the largest reported cohort of coccidioidomycosis patients since the 1950s. Of these patients, 58% presented with isolated pulmonary disease, 14% had high (>1:16) complement fixation titers without clear evidence of dissemination, 22% had definite disseminated disease, and 5% had unclassified disease. Enzyme immunoassay was a reliable diagnostic tool in those with symptomatic disease, but had a low specificity in those who were asymptomatic. Complement fixation titers of > or =1:16 were associated with dissemination to bone or skin but were not helpful in evaluating central nervous system disease. Thirteen percent of patients with high complement fixation titers (>1:16) without clear evidence of dissemination on presentation and 7% of those with isolated pulmonary disease eventually progressed to disseminated disease; 30% of Filipino patients with pulmonary disease progressed to disseminated disease. Nonwhite race was a predictor for dissemination; African American patients more often developed disseminated bony disease while Filipinos were more likely to develop cutaneous or central nervous system disease. Relapse of disseminated coccidioidomycosis occurred in 24% of patients; the risk was highest (71%) among those with central nervous system disease. Azole therapy was generally inferior to amphotericin B in disseminated disease. Predictors of permanent disability included African American or Filipino race, central nervous system disease, and bony disease.

Adolescent↗

PubMed2000

[An imported case of primary pulmonary coccidioidomycosis].

Coccidioides immitis is a causative agent of coccidioidomycosis, which is one of the most dreadful mycosis because of its infectious and pathogenic nature. The endemic areas are in the southwestern parts of the United States and other semi-arid regions throughout the Western Hemisphere. During the early 1990s, the incidence of coccidioidomycosis in California increased dramatically, resulting in recognition for this mycosis as a reemerging infectious disease in the United States. The patients included a large number of non-informed visitors from non-endemic countries. Our report is on an imported case of primary pulmonary coccidioidomycosis. A 35-year-old Japanese male, after living in the United States for nine months, suffered from a combination of headache and fever. He was given a serological examination, and a chest radiograph in Phoenix, Arizona in the United States and was diagnosed as coccidioidomycosis. A daily dosage of 400 mg of fluconazole was administered and he returned to Japan. His headache and skin rash persisted and he was admitted to our hospital to evaluate the severity of his disease. There were no fungi cultured from neither bronchoalveolar nor cerebrospinal fluid and he was discharged. The patient had been treated with fluconazole and his symptoms, high-resolution CT and serological antibody titer were monitored. After 18 months, his clinical and radiological evolution was favorable and his serological IgM titer was below its sensitivity medication was stopped and there were no relapses.

Adult↗