Fungal arthritis. II. Coccidioidal synovitis: clinical, diagnostic, therapeutic, and prognostic considerations

This is the second phase of a review of fungal arthritis that will be presented in three parts. Coccidioidal synovitis will be discussed in this issue. Part I was a review of Candida arthritis; part III will be a review of cryptococcal, sporotrichal, histoplasmal, and blastomycotic arthritis.

Coccidioidomycosis of the prostate gland and its therapy

A case of disseminated coccidioidomycosis was diagnosed from a prostatic biopsy. Patients with sterile pyuria, prostatic nodules or symptoms of prostatitis who have lived in or traveled through an endemic area need careful evaluation of the lower genitourinary tract. Immunological treatment with a transfer factor currently is under investigation. Miconazole may offer a promise for future treatment of this fungal infection and, particularly, for patients with impaired renal function.

Tempest from Tehachapi takes toll or Coccidioides conveyed aloft and afar

New cases of acute primary coccidioidomycosis in large numbers resulted from a windstorm that blew through Kern County, California, on December 20, 1977. In most of these cases clinically apparent infections developed in early and mid-January 1978 and occurred not only in persons exposed directly to the dust raised by the windstorm but also among those in many areas to the north and west of Kern County. The exposure to the dustborne Coccidioides immitis was brief because of the arrival of drenching rains, but the continued heavy rainfall increased the potential for large numbers of cases of coccidioidomycosis to occur in the summer-fall season.

Otomycosis due to coccidioidomycosis

The course and treatment of two patients with otomycosis due to Coccidioides immitis, believed to be the first such cases reported, are described. Both infections appeared due to reactivation of hematogenously disseminated foci. Local and systemic chemotherapy plus surgery resulted in remission, and host immune response also appears to be an important factor. One patient, with systemic lupus erythematosus, required more extensive surgery, more chemotherapy, and reduction in steroid dose to arrest the disease. A combined surgical and chemotherapeutic approach appears necessary when otomycosis is due to invasive fungi such as C immitis.

Disseminated coccidioidomycosis: clinical, immunologic and therapeutic aspects

A patient with disseminated coccidioidomycosis initially had pulmonary and skin manifestations and survived for 14 years before dying of meningitis due to Coccidioides immitis. In addition to several courses of amphotericin B therapy the patient received injections of transfer factor derived from appropriate donors and miconazole nitrate therapy. The immunologic defence mechanisms of the patient during the course of his disease were studied and the possibility of a cell-mediated immunologic defect, potentially reversible by transfer factor, was demonstrated.

Coccidioidomycosis of the extensor tenosynovium of the wrist. A case report

A 59-year-old man had isolated coccidioidomycosis infestation of the tenosynovium of the wrist extensor tendons resistent to surgical and amphotericin chemotherapy. Some improvement has been noted on Miconazole chemothearapy, but neither the long term side effects nor clinical results are known.

Therapy for disseminated coccidioidomycosis with transfer factor from a related donor

A 17 year old caucasian woman in whom disseminated coccidioidomycosis developed with culture positive meningitis during her third trimester of pregnancy was treated with amphotericin B and subsequently with transfer factor prepared from her father's peripheral lymphocytes. Clinical response and in vivo and in vitro immunologic data indicated that this transfer factor afforded a significant contribution to her survival whereas previous therapy with transfer factor from an unrelated donor provided only transient immunologic reactivity. This experience suggests that transfer factor prepared from a related donor with positive responses to C. immitis may be more efficacious than that prepared from an unrelated donor.

Coccidioidal arthritis and its treatment -- 1975

The clinical course of disseminated coccidioidomycosis is highly variable. Neither spontaneous cure nor spontaneous ankylosis has ever been demonstrated in an adult with the disease in one or more disseminated articular foci. Coccidioidomycotic arthritis may fluctuate in activity, and may be compatible with years of limited function and moderate morbidity. Amputation as well as arthrodesis accompanied by adequate excision of diseased tissue are generally reliable methods of treatment of infected joints, but the decision whether or not to "cover" such patients with systemic doses of amphotericin is still difficult, and the roles of synovectomy and topical amphotericin remain to be determined.

Treatment of coccidioidomycosis infection of bone with local amphotericin B suction-irrigation. Report of a case

A 29-year-old man with coccidioidomycosis of the tarsal bones and toxic reactions to intravenous Amphotericin B was treated by surgical curettage and local suction-irrigation system of Amphotericin B. The patient responded to treatment and was free of disease 2 years later. Local suction-irrigation with Amphotericin B may be a valuable adjunct in the treatment of coccidioidomycosis infection of bone.

Immunotherapy of coccidioidomycosis

Transfer factor (TF) derived from donors with strong delayed hypersensitivity to coccidioidin (CDN) was administered to four patients with active disseminated or progressive pulmonary coccidioidomycosis. The clinical and immunologic response to TF was studied. Before the administration of TF, all four patients had defective thymus-derived lymphocyte (T-cell) function. In no case were lymphocytes in culture stimulated to incorporate [(3)H]thymidine when exposed to CDN. Cases 1 and 2 had no skin test response to CDN or other antigen, nor was antigen-induced migration inhibition factor (MIF) release detected. Cases 3 and 4 had skin reactivity to CDN as well as MIF release. Lymphocyte reactivity to phytohemagglutinin (PHA), as measured by the incorporation of [(3)H]thymidine, was low or absent in all. After the administration of TF, patients with negative skin tests became reactive to CDN, MIF release was present in all but case 1, and lymphocyte stimulation was present in response to CDN in all. Lymphocyte reactivity to PHA was also increased after the administration of TF in all cases. All responses to single doses of TF were transient, lasting no more than 10 days. Subsequent doses were less effective at restoring lymphocyte stimulation once it had waned. Multiple doses of TF administered at frequent intervals appear to be the most effective way to maintain lymphocyte reactivity. Clinical response to the administration of TF correlated closely with specific transfer as measured by response to CDN in skin test, lymphocyte stimulation, and MIF release. After TF administration, all patients mounted a more effective host response against the infecting fungus. In each patient, smears and cultures became negative. Fistulas, when present, diminished in extent or closed; and pulmonary infiltrates cleared. Nonspecific signs of infection such as fever, weight loss, and anorexia also improved. Clinical improvement paralleled immunologic improvement. When immunologic improvement was transient so was clinical improvement. Multiple doses of TF at frequent intervals may maintain transferred T-cell reactivity. TF may prove to be a useful adjunct in the management of patients with coccidioidomycosis. Whether TF from CDN-negative donors may have similar effects is not known and requires exploration.

Coccidioidal meningitis. The use of amphotericin B in treatment

Amphotericin B is the first agent to alter favorably the course of coccidioidal meningitis. The morbidity and toxicity of the drug are at present its chief limiting factors. Although no cures were obtained in a series of 11 cases, significant remissions usually followed a course of therapy. Comparison with similar groups showed a significant prolongation of life in adequately treated cases.

Treatment of disseminated coccidioidomycosis with amphotericin B; report of a case

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Coccidioidomycosis; treatment with isonicotinic acid hydrazide

Since coccidioidal granulomas are histologically indistinguishable from tuberculous granulomas, a long course of isonicotinic acid hydrazide therapy was tried experimentally in three cases of coccidioidomycosis, with good results. In two cases the disease was far advanced and prognosis poor before INH therapy was begun. In one case the disease was mild and symptoms abated after a short course of small doses of INH. It recurred when INH therapy was discontinued, and again resolved when larger doses of INH were given over a longer period.INH seemed to have an effect on appetite also, although the patients were taking B-complex vitamins both before and during INH treatment. The three patients ill with coccidioidomycosis averaged a weight gain of four and a half pounds a month during the period of INH therapy. Six well persons who were underweight and lacked appetite were given INH without other drugs, and they then had an increase in appetite and in weight.

Cortisone in coccidioidomycosis

Cortisone administered orally, in low dosages for brief periods, promptly suppressed the allergic manifestations accompanying primary pulmonary coccidioidomycosis in 19 cases. There was no interference with the coccidioidin skin test reaction or with the usual serologic pattern. Dissemination of the disease as a sequel to the administration of cortisone and/or corticotropin has not been reported. A survey of physicians and of the known instances of disseminated coccidioidomycosis in Kern County failed to reveal any such episode. In none of the cases in which the authors gave cortisone in the presence of coccidioidomycosis was there any complication or undesirable sequel-specifically, no subsequent dissemination of the disease. The data presented are not to be interpreted as a therapeutic recommendation, but as a contribution to the information available concerning the effects of these drugs in infectious diseases.