Therapy for disseminated coccidioidomycosis with transfer factor from a related donor

Coccidioidomycosis in pregnancy: case report and review of the literature

BACKGROUND

Coccidioidomycosis is an uncommon fungal infection during pregnancy. We report a case and review the literature on coccidioidomycosis in pregnancy.

METHODS

We searched MEDLINE (1966-2005), PubMed (1950-2005), Embase (1974-2005), the Cochrane Library, and the Index-Catalogue of the Library of the Surgeon-General's Office United States Army (1880-1961) for cases of coccidioidomycosis occurring during pregnancy. We describe a woman with disseminated coccidioidomycosis during the last trimester of pregnancy with fungemia, respiratory failure, a miliary pattern on chest radiograph, and skin and bony involvement.

RESULTS

We identified 80 additional cases of coccidioidomycosis occurring with pregnancy in the literature. The mean age of patients was 26 years (range 16-38 years). Disseminated disease was strongly associated with the trimester of pregnancy; 40% of the cases diagnosed before pregnancy, 50% of the cases diagnosed in the first trimester, 62% of the cases diagnosed in the second trimester, and 96% of the cases diagnosed in the third trimester had dissemination (P<.001). In addition, African American women had a 13-fold increased risk of dissemination compared with white women (P=.007).

CONCLUSIONS

Mortality rates have improved over time in association with the timely administration of antifungal therapy. Disseminated coccidioidomycosis may occur during pregnancy, especially during the third trimester. Improved maternal and fetal survival is associated with early disease recognition and administration of amphotericin B.

Treatment of fungal infections of the central nervous system

The recent development of new antifungal antimicrobials that can be administered in combination with amphotericin B or as alternatives to it has expanded the dimensions of treatment for fungal infections of the central nervous system. These disorders have acquired increasing importance as patients with malignant and other illnesses associated with immunosuppression survive longer and as renal transplantation is more widely applied. Amphotericin B has remained the most effective therapeutic preparation for most types of neurological fungal disease, although important roles for 5-fluorocytosine, miconazole, and, more recently, ketoconazole are being recognized.

Operative management of chronic coccidioidomycosis

Nine of fourteen patients with chronic coccidioidomycosis were treated operatively for therapeutic and diagnostic indications. Complications were minimal and no reactivation or spread of the disease resulted. This series emphasizes the role of the surgeon in the diagnosis and management of chronic coccidioidomycosis and demonstrates the need for the surgeon to be familiar with its natural history and diverse presentations.