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Information for Healthcare Professionals about Valley Fever (Coccidioidomycosis)

Clinical features

Symptomatic persons (40% of cases) usually present 1 to 3 weeks after exposure with fatigue, cough, dyspnea, headache, night sweats, myalgias, and rash.1-3 Primary pulmonary disease is often self-limiting, but some patients fail to recover and develop complications or chronic pulmonary disease (approximately 5 to 10% of cases). Disseminated disease occurs in an estimated 1% of cases (higher rates of dissemination are observed in certain risk groups), with bones/joints, soft tissues, and meninges most commonly affected.

Etiologic agent

Coccidioides immitis (typically in California) and Coccidioides posadasii (typically outside of California).4 Clinical differences between the two species have not been observed.

Reservoir and endemic areas

Soil in the southwestern United States, parts of Mexico, and South America. Highly endemic areas include southern Arizona and California’s southern San Joaquin Valley.

Transmission

Coccidioidomycosis is typically acquired via inhalation of airborne arthroconidia, often after disturbance of contaminated soil (e.g., small-scale activities including construction or excavation, or large-scale events such as dust storms and earthquakes). Primary cutaneous coccidioidomycosis,5 solid organ donor-derived coccidioidomycosis,6 and fomite-transmitted coccidioidomycosis 7-8 can also occur but are very uncommon.

Sequelae

In persons who develop progressive, chronic, or disseminated disease, symptoms may persist for months or even longer. Meningitis can lead to permanent neurologic damage. Mortality is high in HIV-infected persons with diffuse lung disease.

Diagnosis

Serologic tests to detect IgM and IgG antibodies are most often used to diagnose coccidioidomycosis.9 Other methods include culture and microscopy.

  • Serology:
    • Enzyme immunoassay (EIA): A very sensitive and commonly used method for diagnosing coccidioidomycosis. Two Coccidioides EIAs are currently available
      • Premier ® Coccidioides EIA – Meridian Bioscience, Inc.
      • Coccidioides Antibody Enzyme Immunoassay – Immuno Mycologics, Inc. (IMMY)
    • Immunodiffusion (ID): detects IgM antibodies; positive early in the course of infection.
    • Complement Fixation (CF): detects IgG antibodies and allows for assessment of disease severity.
  • Culture: Can be performed on tissue and respiratory specimens; however, sputum can be difficult to obtain for culture since patients’ coughs are often non-productive.
  • Microscopy: for detection of spherules in tissue or respiratory secretions; low sensitivity.
  • Urinary antigen detection: Not widely used, but may have some utility in diagnosing coccidioidomycosis in immunocompromised patients with severe forms of the disease.10
  • Polymerase Chain Reaction (PCR): PCR for detection of Coccidioides directly from clinical specimens is still experimental, but promising.11,12

Laboratory culture of Coccidioides immitis

Lung tissue with Coccidioides spherule

Treatment

The optimal management for patients with uncomplicated primary pulmonary coccidioidomycosis is unclear. Some infections will resolve without antifungal treatment, but some physicians choose to treat all symptomatic patients. Infectious Disease Society of America (IDSA) guidelines suggest treatment for primary pulmonary coccidioidomycosis in patients who:

  • Are immunosuppressed (due to HIV/AIDS, receipt of an organ transplant, or receipt of high-dose corticosteroids or TNF-inhibitors)
  • Have diabetes mellitus or underlying cardiopulmonary disease
  • Are pregnant
  • Are black or Filipino
  • Have severe illness

Oral azoles are a popular first-line therapy. Although ketoconazole is the only one that has been approved by the FDA for use in coccidioidomycosis, most experts prefer either fluconazole or itraconazole. Some studies have indicated that azoles should be used at a minimum dose of 400mg daily and that relapses are frequent after discontinuation of therapy.13-14 Fluconazole has shown to be the most effective for treating coccidioidal meningitis.15 For the management of severely ill patients or pregnant women, some clinicians still turn to intravenous amphotericin B. However, amphotericin B intravenously is ineffective for coccidioidal meningitis and must be administered intrathecally. For detailed treatment guidelines, please refer to the Infectious Disease Society of America’s Practice Guidelines for the Treatment of Coccidioidomycosis

Risk groups

People in endemic areas, particularly those who have occupations or participate in activities exposing them to dust (e.g., construction or agricultural workers, archaeologists, and military trainees). Risk factors for severe or disseminated coccidioidomycosis include African-American race16 or Filipino ethnicity,17 HIV/AIDS,18 use of immunosuppressive medications,19 organ transplant,20 diabetes mellitus,16 or pregnancy.21

Surveillance and statistics

Coccidioidomycosis is nationally notifiable and is reportable in the following states: Arizona, Arkansas, California, Delaware, Louisiana, Maryland, Michigan, Minnesota, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Dakota, Ohio, Oregon, Rhode Island, South Dakota, Utah, Washington, and Wyoming. Check with your local, state, or territorial public health department for more information about disease reporting requirements and procedures in your area. Click here for coccidioidomycosis statistics.

Areas for further research

  • Determining the optimal treatment regimen for primary pulmonary coccidioidomycosis
  • Identifying host factors associated with increased risk for dissemination in select racial/ethnic groups to target prevention efforts
  • Understanding the factors associated with increasing incidence in endemic areas
  • Determining the influence of climate change on Coccidioides’ geographic distribution
  • Developing improved methods for detection of Coccidioides in environmental samples
  • Creating an effective vaccine

Other resources

References

  1. Galgiani JN, Ampel NM, Blair JE, et al. Coccidioidomycosis. Clin Infect Dis 2005;41:1217-23.
  2. Crum NF, Lederman ER, Stafford CM, Parrish JS, Wallace MR. Coccidioidomycosis: a descriptive survey of a reemerging disease. Clinical characteristics and current controversies. Medicine 2004;83:149-75.
  3. Thompson GR, 3rd. Pulmonary coccidioidomycosis. Semin Respir Crit Care Med 2011;32:754-63.
  4. Fisher MC, Koenig GL, White TJ, Taylor JW. Molecular and phenotypic description of Coccidioides posadasii sp. nov., previously recognized as the non-California population of Coccidioides immitis. Mycologia. 2002 Jan-Feb;94(1):73-84.
  5. Chang A, Tung RC, McGillis TS, Bergfeld WF, Taylor JS. Primary cutaneous coccidioidomycosis. J Am Acad Dermatol. 2003 Nov;49(5):944-9.
  6. Dierberg KL, Marr KA, Subramanian A, Nace H, Desai N, Locke JE, et al. Donor-derived organ transplant transmission of coccidioidomycosis. Transpl Infect Dis. 2012 Jun;14(3):300-4.
  7. Dweik M, Baethge BA, Duarte AG. Coccidioidomycosis pneumonia in a nonendemic area associated with infliximab. South Med J. 2007 May;100(5):517-8.
  8. Stagliano D, Epstein J, Hickey P. Fomite-transmitted coccidioidomycosis in an immunocompromised child. The Pediatric infectious disease journal. 2007 May;26(5):454-6.
  9. Ampel NM. The diagnosis of coccidioidomycosis. F1000 Med Rep. 2010
  10. Durkin M, P C, T K, R M, BM K, D B, et al. Diagnosis of Coccidioidomycosis with Use of the Coccidioides Antigen Enzyme Immunoassay. Clin Infect Dis. 2008;47:e69-73.
  11. Binnicker MJ, Buckwalter SP, Eisberner JJ, Stewart RA, McCullough AE, Wohlfiel SL, et al. Detection of Coccidioides species in clinical specimens by real-time PCR. J Clin Microbiol. 2007 Jan;45(1):173-8.
  12. Sheff KW, York ER, Driebe EM, et al. Development of a rapid, cost-effective TaqMan Real-Time PCR Assay for identification and differentiation of Coccidioides immitis and Coccidioides posadasii. Med Mycol 2009;48:466-469.
  13. Graybill JR, Stevens DA, Galgiani JN, Dismukes WE, Cloud GA. Itraconazole treatment of coccidioidomycosis. NAIAD Mycoses Study Group. Am J Med. 1990 Sep;89(3):282-90.
  14. Catanzaro A, Galgiani JN, Levine BE, Sharkey-Mathis PK, Fierer J, Stevens DA, et al. Fluconazole in the treatment of chronic pulmonary and nonmeningeal disseminated coccidioidomycosis. NIAID Mycoses Study Group. Am J Med. 1995 Mar;98(3):249-56.
  15. Galgiani JN, Catanzaro A, Cloud GA, Higgs J, Friedman BA, Larsen RA, et al. Fluconazole therapy for coccidioidal meningitis. The NIAID-Mycoses Study Group. Ann Intern Med. 1993 Jul 1;119(1):28-35.
  16. Rosenstein NE, Emery KW, Werner SB, Kao A, Johnson R, Rogers D, et al. Risk factors for severe pulmonary and disseminated coccidioidomycosis: Kern County, California, 1995-1996. Clin Infect Dis. 2001 Mar 1;32(5):708-15.
  17. Crum NF, Lederman ER, Stafford CM, Parrish JS, Wallace MR. Coccidioidomycosis: a descriptive survey of a reemerging disease. Clinical characteristics and current controversies. Medicine 2004;83:149-75.
  18. Woods CW, McRill C, Plikaytis BD, Rosenstein NE, Mosley D, Boyd D, et al. Coccidioidomycosis in human immunodeficiency virus-infected persons in Arizona, 1994-1997: incidence, risk factors, and prevention. J Infect Dis. 2000 Apr;181(4):1428-34.
  19. Bergstrom L, Yocum DE, Ampel NM, Villanueva I, Lisse J, Gluck O, et al. Increased risk of coccidioidomycosis in patients treated with tumor necrosis factor alpha antagonists. Arthritis and rheumatism. 2004 Jun;50(6):1959-66.
  20. Blair JE, Logan JL. Coccidioidomycosis in solid organ transplantation. Clin Infect Dis. 2001 Nov 1;33(9):1536-44.
  21. 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 Aug;53(4):363-8.
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