Coccidioidomycosis in Persons Infected with HIV Type 1

When to suspect and how properly early detect and treat patients with endemic mycoses

Endemic mycoses are caused by dimorphic fungi and eventually molds, as the case of implantation mycoses. In general, these diseases are acquired through trauma or inhalation of fungal elements in the environment, and less frequently by zoonotic acquisition or transmitted during organ transplantation. The target population for endemic mycoses is usually represented by normal hosts with low-income and intensive outdoor activities. Awareness of these diseases remains limited, even in regions with high prevalence, resulting in delayed diagnosis, and affecting the quality of life and outcomes of patients who suffer from these entities. In this review, we summarized relevant information about epidemiological, clinical, diagnostic, and treatment aspects of the most common endemic mycoses, including blastomycosis, coccidioidomycosis, histoplasmosis, paracoccidioidomycoses, talaromycosis, and implantation mycoses. The main goal of this review is to provide key concepts in terms of when to suspect, how early diagnose, and properly treat patients with these mycoses.

Valley-Forecast: Forecasting Coccidioidomycosis incidence via enhanced LSTM models trained on comprehensive meteorological data

Coccidioidomycosis (cocci), or more commonly known as Valley Fever, is a fungal infection caused by Coccidioides species that poses a significant public health challenge, particularly in the semi-arid regions of the Americas, with notable prevalence in California and Arizona. Previous epidemiological studies have established a correlation between cocci incidence and regional weather patterns, indicating that climatic factors influence the fungus's life cycle and subsequent disease transmission. This study hypothesizes that Long Short-Term Memory (LSTM) and extended Long Short-Term Memory (xLSTM) models, known for their ability to capture long-term dependencies in time-series data, can outperform traditional statistical methods in predicting cocci outbreak cases. Our research analyzed daily meteorological features from 2001 to 2022 across 48 counties in California, covering diverse microclimates and cocci incidence. The study evaluated 846 LSTM models and 176 xLSTM models with various fine-tuning metrics. To ensure the reliability of our results, these advanced neural network architectures are cross analyzed with Baseline Regression and Multi-Layer Perceptron (MLP) models, providing a comprehensive comparative framework. We found that LSTM-type architectures outperform traditional methods, with xLSTM achieving the lowest test RMSE of 282.98 (95% CI: 259.2-306.8) compared to the baseline's 468.51 (95% CI: 458.2-478.8), demonstrating a reduction of 39.60% in prediction error. While both LSTM (283.50, 95% CI: 259.7-307.3) and MLP (293.14, 95% CI: 268.3-318.0) also showed substantial improvements over the baseline, the overlapping confidence intervals suggest similar predictive capabilities among the advanced models. This improvement in predictive capability suggests a strong correlation between temporal microclimatic variations and regional cocci incidences. The increased predictive power of these models has significant public health implications, potentially informing strategies for cocci outbreak prevention and control. Moreover, this study represents the first application of the novel xLSTM architecture in epidemiological research and pioneers the evaluation of modern machine learning methods' accuracy in predicting cocci outbreaks. These findings contribute to the ongoing efforts to address cocci, offering a new approach to understanding and potentially mitigating the impact of the disease in affected regions.

Voriconazole-induced periostitis in a patient with HIV treated for coccidioidomycosis meningitis

Voriconazole-induced periostitis is a rare adverse effect in patients on long-term therapy, characterised by periosteal inflammation and associated bony pain. The accompanying lab abnormalities (elevated serum alkaline phosphatase and fluoride) and characteristic imaging findings (uptake of radionuclide tracer on nuclear bone scan) are critical for diagnosis. The disease process is thought to be secondary to excess fluoride from voriconazole which stimulates bone formation and decreases osteoclast bone resorption. Management includes stopping voriconazole and switching to another agent.

Coccidioidomycosis

Coccidioidomycosis, caused by the dimorphic pathogenic fungi Coccidioides immitis and Coccidioides posadassi, is endemic to the southwestern United states and Central and South America. The incidence of coccidioidomycosis continues to increase. Coccidioidomycosis is typically a self-limiting influenza-like respiratory illness; however, it can lead to disseminated disease outside of the lungs. Not all nondisseminated cases require therapy, but antifungal therapy is typically beneficial requiring treatment ranging from months to lifelong. Clinical factors related to treatment decisions include severity of symptoms, radiography, coccidioidomycosis serologic results, and concurrent medical problems including immunosuppression. This review summarizes the epidemiology, clinical manifestations, and treatment options.

Infected Aneurysm of the Native Aorta due to Coccidioides posadasii

Coccidioidomycosis is an endemic fungal infection that is typically asymptomatic or associated with pulmonary disease. Extrapulmonary disease may involve the skin, bones, or central nervous system, yet endovascular infections are exceedingly rare. We report the first case, to our knowledge, of coccidioidomycosis of the native aorta in an immunocompromised host.

Host-Pathogen Interactions in Coccidioidomycosis: Prognostic Clues and Opportunities for Novel Therapies

PURPOSE

Coccidioidomycosis (CM) is a systemic fungal disease caused by the dimorphic fungi Coccidioides immitis and Coccidioides posadasii. In its endemic areas of the United States, CM is growing as a public health challenge with a marked increase in incidence in the last 15 years. Although Coccidioides infection is asymptomatic in most cases, symptomatic pulmonary disease occurs in ~40% and disseminated coccidioidomycosis (DCM) occurs in ~1% of previously healthy children and adults. DCM is markedly more common in immunocompromised people, who often experience life-threatening disease despite use of antifungal medications. Although options for antifungal therapy have improved, lifelong therapy is needed for those who develop coccidioidal meningitis. The purpose of this article was to review the state of antifungal therapy and recent studies of host-pathogen interactions in CM in light of advances in immunomodulatory therapy.

METHODS

The study included a review of PubMed and abstracts of the Coccidioidomycosis Study Group (years 2000-2019).

FINDINGS

Current therapy for CM relies upon azole and polyene antifungal agents. Murine models and studies of DCM in patients with monogenic primary immunodeficiency states and acquired immunodeficiency have revealed the importance of both innate and adaptive immune responses in the control of infections with Coccidioides species. In particular, defects in sensing of fungi and induction of cellular immune responses have been frequently reported. More recently, polymorphisms in key signaling pathways and in the generation of Th17 and Th1 immune responses have been linked with DCM.

IMPLICATIONS

Antifungal therapy is sufficient to control disease in most cases of CM, but treatment failure occurs in cases of severe pulmonary disease and nonmeningeal disseminated disease. Lifelong therapy is recommended for meningitis in view of the very high risk of recurrence. Corticosteroid therapy is advised by some experts for severe pulmonary disease and for some neurologic complications of DCM. DCM is only rarely the result of a severe monogenic immunodeficiency. Case studies suggest that reorienting cellular immune responses or augmenting effector immune responses may help resolve DCM. Systematic investigation of immunotherapy for coccidioidomycosis is advisable and may help to address the recent marked increase in reports of the disease in endemic areas.

HIV-Related Skin Disease in the Era of Antiretroviral Therapy: Recognition and Management

Antiretroviral therapy (ART) has revolutionized the treatment and prognosis of people living with HIV (PLHIV). With increased survival and improved overall health, PLHIV are experiencing dermatologic issues both specific to HIV and common to the general population. In this new era of ART, it is crucial for dermatologists to have a strong understanding of the broad range of cutaneous disease and treatment options in this unique population. In this review, we outline the most common skin diseases in PLHIV, including HIV-associated malignancies, inflammatory conditions, and infections, and focus on the role of ART in altering epidemiology, clinical features, diagnosis, and treatment of cutaneous conditions.

Coccidioidomycosis: What a long strange trip it's been

The recorded history of coccidioidomycosis began in 1892 with the report of the illness of Domingo Escurra by Alejandro Posadas followed by a description of the first North American cases by Rixford and Gilchrist. Originally considered a protozoan, William Ophüls determined that Coccidioides was a fungus and that the lungs were the apparent initial site of infection. During the 1930s, both Gifford and Dickson determined that a self-limited illness, Valley Fever, was caused by the same fungus that caused the often fatal coccidioidal granuloma. Charles Smith, over a period of approximately 2 decades, comprehensively described the clinical and geographic epidemiology of coccidioidomycosis in California. Demosthenes Pappagianis continued this work after Smith's death. In 1957, one year before Marshall Fiese published his masterful monograph on coccidioidomycosis, the use of the first effective agent for the therapy of coccidioidomycosis, amphotericin B, was reported. This was followed by descriptions of its appropriate clinical use by William Winn and by Hans Einstein, among others. The development of the much less toxic azole antifungal agents greatly simplified therapy in many cases, but much of the management of patients with coccidioidomycosis still relies more on art than science. The search for the “Holy Grail” - a vaccine capable of preventing this disease-continues.

Opportunistic Invasive Mycoses in AIDS: Cryptococcosis, Histoplasmosis, Coccidiodomycosis, and Talaromycosis

PURPOSE OF REVIEW

The goal of this review is to provide an update on the epidemiology, diagnosis, and treatment of opportunistic fungal infections in patients with human immunodeficiency virus (HIV) infection including Cryptococcus spp., Histoplasma spp., Coccidioides spp., and Talaromyces marneffei, formerly Penicillium marneffei.

RECENT FINDINGS

In many settings, despite increasing roll out of antiretroviral therapy (ART), opportunistic invasive mycoses produce a substantial burden of disease. The prevalence of specific fungal pathogens depends on their endemicity. Viral suppression achieved by greater access to ART and increased the availability of point-of-care testing with rapid diagnostic tests (RDTs) aid to curtail the associated fungi morbidity. RDTs allow earlier screening to preemptively initiate treatment of opportunistic fungal pathogens. Identifying asymptomatic cryptococcal infection before starting ART is crucial in reducing the risk of the immune reconstitution inflammatory syndrome (IRIS). There is an urgent need to decrease the burden of opportunistic invasive fungal infections in individuals with HIV/AIDS through different interventions: (a) continue to expand the deployment of ART to the most affected populations to achieve viral suppression; (b) ensure early diagnosis of fungal pathogen with point-of-care testing;

Treatment considerations in pulmonary coccidioidomycosis

INTRODUCTION

Coccidioidomycosis is an endemic fungal infection caused by the soil-dwelling fungi, Coccidioides species. Coccidioidal infections may be asymptomatic in up to two-thirds of infected persons. Pulmonary coccidioidomycosis is the most common form of symptomatic infection. Fluconazole is the antifungal agent typically used to treat pulmonary coccidioidomycosis. Other azoles and amphotericin B products may be prescribed to treat nuanced aspects of coccidioidomycosis.

AREAS COVERED

This review discusses current literature regarding medical treatment options, including the various triazoles and amphotericin B products. In addition, we discuss uncomplicated and complicated pulmonary infections and their sequelae and the approach to managing coccidioidomycosis in certain populations of patients, such as pregnant women, transplant recipients, individuals infected with human immunodeficiency virus, and recipients of tumor necrosis factor-α inhibitors. Expert commentary: Symptomatic coccidioidomycosis can present physicians with a number of challenges, including the lack of sensitivity and specificity of diagnostic tests and lack of a standard treatment approach for all patients with the infection. Ongoing and future clinical trials will determine the optimal diagnostic, therapeutic, and prophylactic approaches, particularly for patients with comorbid conditions.

New insights on the development of fungal vaccines: from immunity to recent challenges

Fungal infections are emerging as a major problem in part due to high mortality associated with systemic infections, especially in the case of immunocompromised patients. With the development of new treatments for diseases such as cancer and the acquired immune deficiency syndrome pandemic, the number of immunosuppressed patients has increased and, as a consequence, also the number of invasive fungal infections has increased. Several studies have proposed new strategies for the development of effective fungal vaccines. In addition, better understanding of how the immune system works against fungal pathogens has improved the further development of these new vaccination strategies. As a result, some fungal vaccines have advanced through clinical trials. However, there are still many challenges that prevent the clinical development of fungal vaccines that can efficiently immunise subjects at risk of developing invasive fungal infections. In this review, we will discuss these new vaccination strategies and the challenges that they present. In the future with proper investments, fungal vaccines may soon become a reality.

Recent advances in our understanding of the environmental, epidemiological, immunological, and clinical dimensions of coccidioidomycosis

Coccidioidomycosis is the endemic mycosis caused by the fungal pathogens Coccidioides immitis and C. posadasii. This review is a summary of the recent advances that have been made in the understanding of this pathogen, including its mycology, genetics, and niche in the environment. Updates on the epidemiology of the organism emphasize that it is a continuing, significant problem in areas of endemicity. For a variety of reasons, the number of reported coccidioidal infections has increased dramatically over the past decade. While continual improvements in the fields of organ transplantation and management of autoimmune disorders and patients with HIV have led to dilemmas with concurrent infection with coccidioidomycosis, they have also led to advances in the understanding of the human immune response to infection. There have been some advances in therapeutics with the increased use of newer azoles. Lastly, there is an overview of the ongoing search for a preventative vaccine.

Chronic and subacute meningitis

PURPOSE OF REVIEW

This article describes the background, clinical presentation, diagnosis, and treatment of selected etiologies of subacute and chronic meningitis. Key diagnostic considerations when evaluating a patient presenting with chronic inflammation of the CNS are discussed, and several specific infectious, neoplastic, and autoimmune etiologies are reviewed in detail.

RECENT FINDINGS

With recent advancement in serologic and CSF diagnostic testing, specific infectious, neoplastic, or autoimmune etiologies of chronic meningitis can be identified. Eliminating previous diagnostic uncertainty of chronic inflammation in the CNS has led to rapid and specific treatment regimens that ultimately improve patient outcomes. Recent advances in imaging have also aided clinicians in both their diagnostic approach and the detection of inflammatory complications such as hydrocephalus, hemorrhage, and ischemic stroke.

SUMMARY

Meningitis is defined as inflammation involving the meninges of the brain and spinal cord. Meningitis can be categorized as acute, subacute, or chronic based on duration of inflammation. This article focuses on the most common causes of subacute and chronic meningitis. Chronic meningitis is commonly defined as inflammation evolving during weeks to months without resolution of CSF abnormalities. Determining the time course of meningitis is important for creating a differential diagnosis. Most organisms causing acute meningitis rarely persist more than a few weeks. Although numerous etiologies of subacute and chronic meningitis have been identified, this article focuses on the most common etiologies: (1) infectious, (2) autoimmune, and (3) neoplastic.

Systemic mycoses in immunodepressed patients (AIDS)

Infectious and noninfectious skin diseases are observed in about 90% of HIV patients, and their incidence increases and is more severe as the immune system weakens. Cutaneous manifestations are considered good clinical predictors for the immunological condition of the patient with AIDS and the introduction of highly effective antiretroviral therapy totally changed the prognosis of the mycoses, among other diseases associated with AIDS, permitting longer survival and acceptable level of quality of life for these patients. This contribution describes the systemic mycoses that are more frequent in the seropositive population, that is, patients with HIV/AIDS, which are cryptococcosis, histoplasmosis, coccidioidomycosis, blastomycosis, paracoccidioidomycosis, sporotrichosis, penicilliosis, and aspergillosis. Their causative agents, mode of transmission, clinics, laboratorial diagnosis and therapy, in the aspects related to immunodepressed patients, are reviewed.

Epidemiology of endemic systemic fungal infections in Latin America

Although endemic mycoses are a frequent health problem in Latin American countries, clinical and epidemiological data remain scarce and fragmentary. These mycoses have a significant impact on public health, and early diagnosis and appropriate treatment remain important. The target population for endemic disease in Latin America is mostly represented by low-income rural workers with limited access to a public or private health system. Unfortunately, diagnostic tools are not widely available in medical centers in Latin America; consequently, by the time patients are diagnosed with fungal infection, many are already severely ill. Among immunocompromised patients, endemic mycoses usually behave as opportunistic infections causing disseminated rather than localized disease. This paper reviews the epidemiology of the most clinically significant endemic mycoses in Latin America: paracoccidioidomycosis, histoplasmosis, and coccidioidomycosis. The burdens of disease, typically affected populations, and clinical outcomes also are discussed.

Coccidioidomycosis in India: Report of a third imported case

We describe the third fatal case of imported coccidioidomycosis in India in a 31-year-old mechanical engineer originally from Andhra Pradesh, India, who lived in Gwinner, North Dakota. He had traveled to Arizona in summer of 2006, where he drove tractors in a dusty environment at a tractor production facility near Phoenix, Arizona. He was human immunodeficiency virus (HIV) positive. Initially, he was treated in Fargo, North Dakota, in 2006, with liposomal amphotericin B followed by oral fluconazole. Antiretroviral treatment for HIV infection was started. He moved back to India and was admitted to the intensive care unit of St. John's Medical College and Hospital, Bangalore, India. His blood cultures yielded Coccidioides sp. The identity of the isolate was confirmed using the Gen Probe Accuprobe test at the Centers for Disease Control and Prevention, Atlanta, Georgia. In spite of initiation of treatment with antifungal agents (amphotericin B and fluconazole), his condition deteriorated and he expired three days following his admission to the hospital.

Coccidioidomycosis in liver transplant recipients in an endemic area

Coccidioidomycosis is an infection caused by Coccidioides species, which are endemic for the Southwestern United States and parts of Central America and South America. Most infected individuals are asymptomatic or have mild-to-moderate respiratory illness. Coccidioidomycosis is more severe in patients with depressed cellular immunity, such as organ transplant recipients. We retrospectively reviewed charts of 391 liver transplant recipients (mean follow-up, 38.7 months; range, 2-105 months). Before transplantation, 12 patients had a history of coccidioidomycosis and 13 patients had asymptomatic seropositivity. Of these 25 patients, 23 had no active coccidioidomycosis posttransplantation and 2 had reactivated infection. One of 5 patients with indeterminate serology before transplantation died of disseminated coccidioidomycosis shortly after transplantation. De novo coccidioidomycosis developed in 12 patients (3%) who had no evidence of coccidioidomycosis pretransplantation. Of 15 total episodes of posttransplantation coccidioidomycosis, 10 (66%) occurred during the first year. Dissemination was noted in 33% of active coccidioidomycosis after transplantation; two patients (13%) died of coccidioidomycosis. Because most coccidioidal infections occurred in the first posttransplantation year despite targeted antifungal prophylaxis, we recommend a new strategy of universal antifungal prophylaxis for 6-12 months for liver transplant recipients who reside in the endemic area.

Treatment of endemic mycoses

The endemic mycoses are a diverse group of diseases caused by thermally dimorphic fungi. While they share many characteristics, each has unique aspects with regards to their clinical course, diagnosis and management. Diagnosis may be difficult and delayed owing to the varied manifestations and wide differential diagnosis. Historically, treatment has been with amphotericin B, which has been limited by its significant toxicity. The advent of the azole class of medications has allowed for safer alternatives to amphotericin B. The azoles have become the mainstay of treatment for many, if not most, forms of these diseases. Guidelines have been released for the management of each of the North American endemic mycoses; however, many questions remain as to the best strategies for the diagnosis and management of various manifestations of these diseases.

Epidemiology of invasive mycoses in North America

The incidence of invasive mycoses is increasing, especially among patients who are immunocompromised or hospitalized with serious underlying diseases. Such infections may be broken into two broad categories: opportunistic and endemic. The most important agents of the opportunistic mycoses are Candida spp., Cryptococcus neoformans, Pneumocystis jirovecii, and Aspergillus spp. (although the list of potential pathogens is ever expanding); while the most commonly encountered endemic mycoses are due to Histoplasma capsulatum, Coccidioides immitis/posadasii, and Blastomyces dermatitidis. This review discusses the epidemiologic profiles of these invasive mycoses in North America, as well as risk factors for infection, and the pathogens' antifungal susceptibility.

Rare mycoses of the oral cavity: a literature epidemiologic review

Stomatologic fungal infections display different etiologies, pathogenesis, and clinical presentations. The incidence of rare mycoses of oral cavity is very low. These infections can involve both immunocompromised and immmunocompetent patients with common predisposing factors, such as diabetes or suffering from diseases causing immune system impairment. Oral mycoses can cause acute, chronic, and mucocutaneous lesions. Candidiasis is the most common mouth mycosis. Although occasionally primary mouth pathogens, Cryptococcus spp. or filamentous fungi (Aspergillus spp. and zygomycetes) can cause oral mycoses, with the oral localization more commonly secondary to a more serious systemic infection. The diagnosis of oral mycoses is based on clinical examination; for yeasts, culture is necessary to identify the etiologic agents; for filamentous fungi, in particular for zygomycetes and dimorphic, a definitive diagnosis can be made by histologic examination and pertinent stains with or without isolation of the fungus from the same site.

Current status and future perspectives on molecular and serological methods in diagnostic mycology

Invasive fungal infections are an important cause of infectious morbidity. Nonculture-based methods are increasingly used for rapid, accurate diagnosis to improve patient outcomes. New and existing DNA amplification platforms have high sensitivity and specificity for direct detection and identification of fungi in clinical specimens. Since laboratories are increasingly reliant on DNA sequencing for fungal identification, measures to improve sequence interpretation should support validation of reference isolates and quality control in public gene repositories. Novel technologies (e.g., isothermal and PNA FISH methods), platforms enabling high-throughput analyses (e.g., DNA microarrays and Luminex® xMAP™) and/or commercial PCR assays warrant further evaluation for routine diagnostic use. Notwithstanding the advantages of molecular tests, serological assays remain clinically useful for patient management. The serum Aspergillus galactomannan test has been incorporated into diagnostic algorithms of invasive aspergillosis. Both the galactomannan and the serum β-D-glucan test have value for diagnosing infection and monitoring therapeutic response.

Coccidioides immitis meningitis in a patient with hyperimmunoglobulin E syndrome due to a novel mutation in signal transducer and activator of transcription

Hyperimmunoglobulin E syndrome (HIES) is a rare primary immunodeficiency characterized by recurrent skin and lung infections. We report the first case of Coccidioides immitis meningitis in a patient with HIES. Coccidioides should be included in the differential diagnosis for central nervous system infections in HIES patients.

Fungal Infections

Older adults are at increased risk of developing opportunistic fungal infections because organ transplantation, intensive cancer chemotherapy regimens, and anti-tumor necrosis factor agents are now used more commonly, and because admission to an intensive care unit, which carries many risk factors for fungal infection, has become commonplace in this group.

Candida species are the most common cause of opportunistic fungal infections, and bloodstream infections are usually treated with fluconazole or an echinocandin antifungal agent.

Invasive mold infections are mostly caused by Aspergillus species; in older adults, they cause primarily pulmonary and sinus infections, and they are associated with a high mortality rate.

The endemic fungi, Histoplasma capsulatum, Coccidioides species, and Blastomyces dermatitidis, cause infection when the mold form is dispersed and inhaled from the environment in those specific areas of the country in which these organisms flourish.

Amphotericin B is used for initial treatment of severe histoplasmosis, coccidioi­domycosis, and blastomycosis; itraconazole is the therapy of choice for most mild to moderate infections due to these endemic mycoses.

[Immigration and HIV: pulmonary, cutaneous and genitourinary syndromes. Eosinophilia]

Infectious diseases are the leading cause of mortality in less developed countries, many of which are located in tropical areas. These diseases have particular features than can hamper diagnosis unless clinicians are familiar with their characteristics. The present article describes the clinical pattern of pulmonary, cutaneous and genitourinary tropical diseases and the main principles of their diagnosis. Emphasis is placed on their geographical distribution and the influence of HIV infection.

[Bacterial, mycobacterial and fungal opportunistic infections in HIV-infected immigrants: diagnosis and treatment]

The number of HIV infected immigrants has increased sharply in Spain. These patients are prone to contracting several different types of opportunistic infections, including bacterial, mycobacterial, fungal and parasitic infections. The present article provides an in-depth review of bacterial and fungal infections, with particular emphasis on those not endemic in our country.

An unusual case of coccidioidomycosis presenting with skin lesions

A 42-year-old white male without prior skin disease presented 8 months ago with chest pain, fever, and coughing to his primary physician. At that point, he had no skin lesions. The diagnosis was made by standard blood tests. The patient completed treatment and was symptom free for 8 months until he presented to his physician again with skin lesions on his right cheek and extremities. The patient was referred to our dermatology clinic for further evaluation. A complete skin examination revealed lesions on his face, extremities, and back. The lesions on his right face were 8 x 10-mm erythematous papules and nodules coalescing into a plaque. A biopsy was taken from his right cheek lesions.

Expanding understanding of epidemiology of coccidioidomycosis in the Western hemisphere

Coccidioidomycosis is a disease of both national and worldwide importance that is most often diagnosed in nonendemic regions. The endemic region for Coccidioides spp. lies exclusively in the Western Hemisphere. Coccidioides spp. has long been identified in semiarid areas of the United States and Mexico, and endemic foci have been described in areas of Central and South America. Infection is usually the result of activities that cause the fungus to become airborne and inhaled by a susceptible host. Underlying medical diseases that affect T cell function are known to increase the risk of disseminated disease and include human immunodeficiency virus, cancer, and disease processes requiring transplantation and its subsequent immunosuppressive agents. In recent years the incidence of the coccidioidomycosis has increased in California and Arizona, which may be partially due to the massive migration of Americans to the Sunbelt states. To date the highest number of cases reported in Arizona was in 2004, when a total of 3,665 cases of coccidioidomycosis was reported, representing a 281% increase since 1997. Statistics on the prevalence and incidence of coccidioidomycosis in Latin America either are fragmentary or simply are not available.

Coccidioidomycosis in persons infected with HIV-1

Coccidioidomycosis is a recognized opportunistic infection in those with HIV-1 infection. The major risk factor is immunodeficiency, particularly when the peripheral blood CD4 T lymphocyte count is below 250/muL. There are many manifestations of coccidioidomycosis during HIV-1 infection, including diffuse, reticulonodular pneumonia, focal primary pneumonia, and disease disseminated beyond the thoracic cavity. Diagnosis is based on serology, culture and histopathologic identification. Two therapeutic modalities are currently available, the polyene antifungal amphotericin B and the triazole antifungals. Of the latter, the most experience is with the triazoles fluconazole and itraconazole. There are increasing data regarding drug interactions between triazoles and antiretroviral agents. The duration of treatment of coccidioidomycosis in those with HIV-1 infection is not established and in many patients it is either prolonged or life-long. Adherence to antiretroviral therapy is important in preventing recurrence.

The public health need and present status of a vaccine for the prevention of coccidioidomycosis

Although the epidemiology of coccidioidomycosis has been well described, there is a paucity of recent data on the public health burden associated with this disease. Accordingly, California's Inpatient Hospital Discharge Data Set from 1997 to 2002 was used to calculate the incidence of hospitalization for coccidioidomycosis by county, year, age, race, ethnicity, and gender. The overall finding that coccidioidomycosis has a significant impact in endemic areas supports the conclusion that the need for a preventive vaccine is great. Investigators of the Valley Fever Vaccine Project (VFVP) have successfully identified a number of recombinant coccidioidal protein antigens and two attenuated mutant strains that have been evaluated as vaccines, demonstrating protective responses in murine models. Efforts to select and develop a vaccine for human clinical trials are in progress.

Diagnosis of coccidioidomycosis by antigen detection using cross-reaction with a Histoplasma antigen

BACKGROUND

In 2005, patients with coccidioidomycosis were observed to have positive Histoplasma antigen test results.

METHODS

We performed a review of the records of patients with coccidioidomycosis who were under our care who underwent testing for Histoplasma antigen to determine the value of this test in the diagnosis of coccidioidomycosis. Many of the patients were immunosuppressed and critically ill.

RESULTS

The Histoplasma antigen test had positive results when urine samples from 11 (58%) of 19 patients who had acute or chronic coccidioidomycosis were tested. The sensitivity was highest for patients who had acute coccidioidomycosis, and antigenuria was detected in 11 (79%) of 14 patients. One patient who had chronic coccidioidomycosis but who had a negative result when a urine sample was tested had antigen detected in bronchoalveolar lavage fluid.

CONCLUSIONS

Physicians should be alerted that infections with Coccidioides species may cause positive Histoplasma antigen test results. There is potential for the use of this test in the diagnosis of coccidioidomycosis by taking advantage of this observed cross-reactivity. The greatest benefit appears to be in the population of seriously ill patients with acute pneumonia who live in areas that are endemic for Coccidioides infection.

Fungal infections and their treatment in the intensive care unit

PURPOSE OF REVIEW

To describe and bring together recent development in the diagnosis and treatment of both community-acquired and opportunistic fungal infections in the intensive care unit.

RECENT FINDINGS

The past few years have brought major advances to both the diagnosis and treatment of fungal infections. The development of newer therapeutic modalities to supplement existing treatment options includes a new class of antifungal agents, the echinocandins. Newer and improved agents of the azole class have arrived as well as better delineation for the role of liposomal amphotericins. Newer, nonculture-based diagnostic tests have allowed earlier, more timely diagnosis of opportunistic fungal infections, allowing more rapid initiation of therapy.

SUMMARY

Improved diagnostic tests and newer antifungal agents have been introduced, leading to earlier diagnosis and treatment.

Coccidioidomycosis: a review and update

Coccidioidomycosis occurs in arid and semi-arid regions of the New World from the western United States to Argentina. Highly endemic areas are present in the southwest United States. Coccidioides species live in the soil and produce pulmonary infection via airborne arthroconidia. The skin may be involved by dissemination of the infection, or by reactive eruptions, such as a generalized exanthem or erythema nodosum. Interstitial granulomatous dermatitis and Sweet's syndrome have recently been recognized as additional reactive signs of the infection. Coccidioidomycosis is a "great imitator" with protean manifestations. Cutaneous findings may be helpful clues in the diagnosis of this increasingly important disease.

Iritis presumed as secondary to disseminated coccidioidomycosis

BACKGROUND

Coccidioidomycosis is a systemic disease caused by a fungus found in soil and transmitted through inhalation. It is prevalent in western and southwestern United States, Mexico, and South and Central America. Results of skin testing, serologic testing, and tissue cultures confirm the diagnosis. Coccidioidomycosis can manifest in various ways: the infected individual may present asymptomatically, with an acute respiratory infection, or, in more severe or chronic cases, with a multiorgan presentation. Ocular involvement may include anterior segment, posterior segment, or extraorbital involvement.

CASE REPORT

A case concerning a patient with iritis presumed as secondary to disseminated coccidioidomycosis is discussed. The patient initially presented to our clinic with signs and symptoms of acute, unilateral iritis and a recent history of iritis in the contralateral eye. The active inflammation was treated topically with Pred Forte and cyclopentolate and resolved without sequelae. Because the presentation was bilateral with an asymmetric timecourse, laboratory tests were ordered to rule out systemic association. Because all tests yielded negative results, the known history of disseminated coccidioidomycosis was presumed to be the etiology of this iritis.

CONCLUSION

Although eye findings are rare, disseminated coccidioidomycosis is an important differential to consider when a patient presents with uveitis. For this reason, awareness and recognition of ocular signs and symptoms of this disease is significant in proper patient care and management.

Coccidioidomycosis

The difficulties in managing this potentially horrific disease, with its myriad manifestations, are immense, because host factors dramatically impact outcome. Coccidioidomycosis should warrant great respect among clinicians, because, even with dramatic improvements in therapies, outcomes remain poor. Although there have been outstanding successes with these new therapies, tragic losses after years of immense patient suffering still occur. Coccidioidomycosis is a geographically restricted fungus but is one that inflicts tremendous suffering on affected patients. In addition, because of travel and the influx of susceptible hosts, dramatic increases in patients at risk for infection are seen throughout the southwest United States. The extended-spectrum azoles, such as posaconazole and voriconazole, may prove to be more efficacious in the treatment of coccidioidomycosis than prior agents, including amphotericin B, fluconazole, and itraconazole. Additional resources are needed to conduct randomised, controlled clinical trials for the treatment of this disease.