Case Study 6: Coccidioidomycosis

October 24, 20080 comments

Cultures of the biopsy samples grew Coccidioides immitis. In addition, a coccidioidomycosis immunoassay revealed a complement fixation (CF) titer of 1:128 with positive immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies.

Coccidioidomycosis, commonly referred to as "valley fever," is a fungal infection caused by inhaling the spores of C immitis, a fungus endemic to the semi-arid areas of the southwest United States, particularly central California, Arizona, parts of Texas, and Mexico. Epidemiologic studies show that approximately 50-60% of infected people experience no symptoms, whereas approximately 40% have cold- or flu-like symptoms, which often resolve without treatment. About 10% develop pulmonary disease. A small subset of patients develops disseminated disease, usually with involvement of the skin, bones, and CNS.

Less than 1% experience CNS involvement, which is associated with the greatest morbidity and mortality and which is generally fatal without treatment; these patients frequently require lifelong treatment. Risk factors for complications include the extremes of ages, any immunocompromised state (HIV, immunosuppressant use, cancer), and the third trimester of pregnancy.

The clinical manifestations depend on the organs involved. On clinical examination, patients who live in endemic regions or who have traveled to endemic regions may present with insidious symptoms of cough, fevers, chills, night sweats, weight loss, myalgias, and fatigue. Patients may also present with a rash, bone pain, and/or meningeal symptoms. Erythema nodosum, seen in about 25% of patients, is considered a good prognostic marker.

The diagnosis is often made by performing a serologic test (coccidioidomycosis panel, which is an enzymatic immunoassay). The CF titer indicates the severity of infection. Titers of 1:32 or greater should prompt an evaluation for dissemination by means of bone scanning and lumbar puncture.

In general, mild disease does not require treatment. Moderate disease may be treated with either fluconazole or itraconazole. Severe disease warrant treatment with amphotericin.

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