Coccidioides immitis fungemia: clinical features and survival in 33 adult patients

Human Mycobiota and Its Role in Cancer Progression, Diagnostics and Therapeutics: A Link Lesser-Known

Although not as well studied as the bacterial component of the human microbiota, the commensal fungi or mycobiota play important roles in maintaining our health by augmenting our immune system. This mycobiota is also associated with various fatal diseases like opportunistic mycoses, and even cancer, with different cancers having respective type-specific mycobiota. The different fungal species which comprise these different intratumoral mycobiota play important roles in cancer progression. The aim of this review paper is to decipher the association between mycobiota and cancer, and shed light on new avenues in cancer diagnosis, and the development of new anti-cancer therapeutics.

Fatal septic shock due to disseminated coccidioidomycosis: a case series and review of the literature

BACKGROUND

Coccidioidomycosis is a fungal infection endemic to the southwestern United States and regions of Latin America. Disseminated disease occurs in < 1% of cases. Septic shock is even rarer, with high mortality despite therapy. We describe two cases of coccidioidal septic shock. Both patients were older men of Filipino ancestry presenting with respiratory failure and vasopressor-dependent shock. Antifungal drugs were initiated after failure to improve with empiric antibiotics; in both, Coccidioides was isolated from respiratory cultures. Despite aggressive care, both patients ultimately died of their infections. We provide a review of the published literature on this topic.

CONCLUSIONS

Most of the 33 reported cases of coccidioidal septic shock occurred in men (88%) of non-white race and ethnicity (78%). The overall mortality rate was 76%. All survivors received amphotericin B as part of their treatment. Coccidioidomycosis-related septic shock is a rare disease with poor outcomes; delays in diagnosis and treatment are common. Improved diagnostic testing for coccidioidomycosis could enhance recognition of this disease in the future. Although data are limited, early treatment with amphotericin B in cases of coccidioidal septic shock may reduce mortality.

Outcomes with severe pulmonary coccidioidomycosis and respiratory failure in the United States

Background:

Coccidioidomycosis is a fungal infection with presentations ranging from asymptomatic illness to severe pneumonia and respiratory failure. The outcomes of patients with severe pulmonary coccidioidomycosis requiring mechanical ventilation (MV) are not well understood.

Methods:

We performed a retrospective cohort analysis utilizing the Nationwide Inpatient Sample (NIS) from 2006 to 2017. Patients >18 years of age with a diagnosis of pulmonary coccidioidomycosis were included in the cohort.

Results:

A total of 11,045 patients were hospitalized with a diagnosis of pulmonary coccidioidomycosis during the study period. Of these, 826 (7.5%) patients required MV during their hospitalization with a mortality rate of 33.5% compared to 1.3% ( p < 0.01) for patients not requiring MV. Results of the multivariable logistic regression model show that risk factors for MV included the history of neurological disorders and paralysis (OR 3.38, 95% CI 2.70 to 4.20, p < 0.01; OR 3.13, 95% CI 1.91 to 5.15, p < 0.01, respectively) and HIV (OR 1.63, 95% 1.10 to 2.43, p < 0.01). Risk factors for mortality among patients requiring MV included older age (OR 1.24 per 10-year increase, 95% CI 1.08 to 1.42, p < 0.01), coagulopathy (OR 1.61, 95% CI 1.09 to 2.38, p = 0.01) and HIV (OR 2.83; 95% CI 1.32 to 6.10; p < 0.01).

Conclusions:

Approximately 7.5% of patients admitted with coccidioidomycosis in the United States require MV, and MV is associated with high mortality (33.5%).

Rates and risk factors for Coccidioidomycosis among prison inmates, California, USA, 2011

African American ethnicity is a risk factor for primary and disseminated disease in this population.

In California, coccidioidomycosis is a disease acquired by inhaling spores of Coccidioides immitis, a fungus found in certain arid regions, including the San Joaquin Valley, California, USA, where 8 state prisons are located. During 2011, we reviewed coccidioidomycosis rates at 2 of the prisons that consistently report >80% of California’s inmate cases and determined inmate risk factors for primary, severe (defined as pulmonary coccidioidomycosis requiring >10 hospital days), and disseminated coccidioidomycosis (defined by hospital discharge International Classification of Disease, Ninth Revision code). Inmates of African American ethnicity who were >40 years of age were at significantly higher risk for primary coccidioidomycosis than their white counterparts (odds ratio = 2.0, 95% CI 1.5–2.8). Diabetes was a risk factor for severe pulmonary coccidioidomycosis, and black race a risk factor for disseminated disease. These findings contributed to a court decision mandating exclusion of black inmates and inmates with diabetes from the 2 California prisons with the highest rates of coccidioidomycosis.

Beyond the superficial: Coccidioides immitis fungaemia in a man with fever, fatigue and skin nodules: a case of an emerging and evolving pathogen

Coccidioidomycosis is an insidious fungal disease, endemic to arid regions of the Americas, which is becoming more frequently recognised worldwide. While most infections resemble a mild respiratory illness, a subset of cases progress to severe pneumonia or systemic dissemination. Here, we describe a case of disseminated coccidioidomycosis in a 54-year-old immunocompetent African-American man with geographic and demographic risk factors for Coccidiodes acquisition who presented with 2 months of fevers, fatigue, weight loss and painful skin lesions. Blood count and serum chemistry studies initially demonstrated leukocytosis, anaemia, hyponatraemia and acute renal failure. Chest imaging revealed numerous small pulmonary nodules and skin biopsy, serological studies and blood cultures eventually confirmed disseminated infection with Coccidioides immitis. This case highlights important features regarding the risk factors, spectrum of clinical findings, evaluation and treatment of coccidioidomycosis relevant to providers in endemic areas and throughout the world.

Fatal fungemia due to Paracoccidioides lutzii

We report the first case of fungemia caused by Paracoccidioides lutzii in a 51-year-old male farm worker from the central-west region of Brazil. The fungus was isolated from blood cultures and the species was confirmed by phylogenetic identification. Despite specific treatment and intensive care, the patient died 39 days after admission.

Donor-derived Coccidioides immitis fungemia in solid organ transplant recipients

We report disseminated coccidioidomycosis in 3 transplant recipients from a donor in an endemic area found to have unrecognized meningeal coccidioidomycosis. All 3 transplant recipients presented within 3 weeks of receipt of their organ. Only 1 organ recipient survived the acute presentation of coccidioidomycosis. Serologic testing for Coccidioides immitis infection should be considered for organ donors residing in endemic areas.

Fatal septic shock due to a disseminated chronic form of paracoccidioidomycosis in an aged woman

Once rare, septic shock (SS) due to disseminated fungal infections has been increasingly reported due to a growing number of immunocompromised patients, but remains rare in non-immune-compromised individuals. In paracoccidioidomycosis, it has been described in only three patients with the severe, acute form of the disease. We describe the development of a refractory, fatal septic shock due to a severe disseminated chronic form of paracoccidioidomycosis in an older woman without any other microbial insults. A striking event in the evolution of her case was the severe depletion of lymphocytes from the peripheral blood and lymphoid organs. Lymphocyte depletion due to apoptosis is described in the late phase of sepsis and can contribute both to immunosuppression and the progression of SS. The possible mechanisms involved in the induction of SS in the chronic form of paracoccidioidomycosis are discussed.

The spectrum and presentation of disseminated coccidioidomycosis

PURPOSE

Extrapulmonary dissemination of Coccidioides species is associated with significant morbidity and mortality. The clinical manifestations vary widely according to the host, the severity of illness, and location of dissemination. The morbidity and mortality can be reduced by early recognition and treatment, which in turn depends on understanding the spectrum and presentation of disease.

METHODS

We performed a retrospective analysis of 150 cases with extrapulmonary nonmeningeal disease seen from 1996 to 2007 at a referral medical center in an endemic region.

RESULTS

Hematogenous dissemination was associated with high mortality and occurred primarily in immunocompromised patients, but only 30% of patients with more limited forms of dissemination were immunocompromised. In keeping with prior studies, there was a preponderance of males (nearly 2:1) and people of African or Asian (especially Pacific Islanders) descent. In contrast, Hispanics and diabetics were not at increased risk. Serology was frequently negative in immunocompromised patients, but the diagnosis could be established by isolation of the organism in culture, or in histologic or cytologic specimens.

CONCLUSIONS

Although coccidioidomycosis is a great imitator, the diagnosis can usually be made readily if a high level of suspicion is maintained and appropriate diagnostic testing is performed. In most patients, that will include serologic testing in addition to cultures and histology or cytology of appropriate samples.

Cell mediated immunity to fungi: a reassessment

Protective immunity against fungal pathogens is achieved by the integration of two distinct arms of the immune system, the innate and adaptive responses. Innate and adaptive immune responses are intimately linked and controlled by sets of molecules and receptors that act to generate the most effective form of immunity for protection against fungal pathogens. The decision of how to respond will still be primarily determined by interactions between pathogens and cells of the innate immune system, but the actions of T cells will feed back into this dynamic equilibrium to regulate the balance between tolerogenic and inflammatory responses. In the last two decades, the immunopathogenesis of fungal infections and fungal diseases was explained primarily in terms of Th1/Th2 balance. Although Th1 responses driven by the IL-12/IFN-gamma axis are central to protection against fungi, other cytokines and T cell-dependent pathways have come of age. The newly described Th17 developmental pathway may play an inflammatory role previously attributed to uncontrolled Th1 responses and serves to accommodate the seemingly paradoxical association of chronic inflammatory responses with fungal persistence in the face of an ongoing inflammation. Regulatory T cells in their capacity to inhibit aspects of innate and adaptive antifungal immunity have become an integral component of immune resistance to fungi, and provide the host with immune defense mechanisms adequate for protection, without necessarily eliminating fungal pathogens which would impair immune memory--or causing an unacceptable level of tissue damage. The enzyme indoleamine 2,3-dioxygenase and tryptophan metabolites contribute to immune homeostasis by inducing Tregs and taming overzealous or heightened inflammatory responses.

Successful treatment of relapsing disseminated coccidioidomycosis with cutaneous involvement with posaconazole

A 52-year-old woman with pulmonary sarcoidosis on immunosuppressive therapy developed pulmonary infiltrates and cutaneous granulomatous abscesses after a trip to the USA in April 2005. A hyphomycete was identified, further characterized by a gene probe as Coccidioides spp. and then definitively identified as Coccidioides posadasii by polymerase chain reaction and sequencing. Antibodies towards Coccidioides spp. were detected. The infection was successfully treated with posaconazole (Noxafil), 2 x 400 mg/d.