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Reyes-Montes MDR, León-García AA, Frías-De-León MG, Acosta-Altamirano G, Sánchez-Saavedra EP, Victoriano-Pastelín I, Meraz-Ríos B, Duarte-Escalante E. Clinical Cases of Coccidioidomycosis in the Americas in the Period 1950-2021: Epidemiology Data, Diagnosis, and Treatment. Life (Basel) 2023; 13:2109. [PMID: 38004249 PMCID: PMC10672650 DOI: 10.3390/life13112109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/16/2023] [Accepted: 10/21/2023] [Indexed: 11/26/2023] Open
Abstract
Coccidioidomycosis, caused by Coccidioides immitis and C. posadasii, causes significant morbidity and mortality, both in immunocompetent and immunocompromised people, mainly in endemic areas. The present work analyzed its epidemiology, diagnostic methods, and treatment by reviewing clinical cases published from 1950 to 2021. Fifty-nine articles were included, corresponding to 275 clinical cases. The results showed a higher incidence of coccidioidomycosis in the male gender than the female gender. The most affected age group was 31-40 years, and the most reported clinical presentation was disseminated with greater involvement in cutaneous and subcutaneous tissue, followed by the CNS, bone system, and peritoneum. The species most frequently reported was C. immitis. The most used treatment was azoles, followed by their combination with amphotericin B, monotherapy with amphotericin B, and alternative medicine. This work shows that epidemiological data outside the USA are still scarce. Serological tests are the preferred diagnostic method in daily medical practice, and cultures remain the gold standard. The treatment for coccidioidomycosis is ketoconazole and amphotericin B, individually or in combination.
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Affiliation(s)
- María del Rocío Reyes-Montes
- Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad Nacional Autónoma de México, Ciudad Universitaria, Coyoacán, Ciudad de Mexico 04510, Mexico; (M.d.R.R.-M.); (A.A.L.-G.); (E.P.S.-S.); (I.V.-P.); (B.M.-R.)
| | - Adriana Anel León-García
- Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad Nacional Autónoma de México, Ciudad Universitaria, Coyoacán, Ciudad de Mexico 04510, Mexico; (M.d.R.R.-M.); (A.A.L.-G.); (E.P.S.-S.); (I.V.-P.); (B.M.-R.)
| | - María Guadalupe Frías-De-León
- Hospital Regional de Alta Especialidad de Ixtapaluca, Unidad de Investigación Biomédica, Pueblo de Zoquiapan, Ixtapaluca 56530, Mexico; (M.G.F.-D.-L.); (G.A.-A.)
| | - Gustavo Acosta-Altamirano
- Hospital Regional de Alta Especialidad de Ixtapaluca, Unidad de Investigación Biomédica, Pueblo de Zoquiapan, Ixtapaluca 56530, Mexico; (M.G.F.-D.-L.); (G.A.-A.)
| | - Erika Paola Sánchez-Saavedra
- Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad Nacional Autónoma de México, Ciudad Universitaria, Coyoacán, Ciudad de Mexico 04510, Mexico; (M.d.R.R.-M.); (A.A.L.-G.); (E.P.S.-S.); (I.V.-P.); (B.M.-R.)
| | - Isai Victoriano-Pastelín
- Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad Nacional Autónoma de México, Ciudad Universitaria, Coyoacán, Ciudad de Mexico 04510, Mexico; (M.d.R.R.-M.); (A.A.L.-G.); (E.P.S.-S.); (I.V.-P.); (B.M.-R.)
| | - Beatriz Meraz-Ríos
- Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad Nacional Autónoma de México, Ciudad Universitaria, Coyoacán, Ciudad de Mexico 04510, Mexico; (M.d.R.R.-M.); (A.A.L.-G.); (E.P.S.-S.); (I.V.-P.); (B.M.-R.)
| | - Esperanza Duarte-Escalante
- Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad Nacional Autónoma de México, Ciudad Universitaria, Coyoacán, Ciudad de Mexico 04510, Mexico; (M.d.R.R.-M.); (A.A.L.-G.); (E.P.S.-S.); (I.V.-P.); (B.M.-R.)
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Sharifi S, Sharma R, Heidari A, Johnson RH. Disseminated Coccidioidomycosis: Cutaneous, Soft Tissue, Osseous, and "Shotgun Intraparenchymal" Brain Disease. J Investig Med High Impact Case Rep 2022; 10:23247096221075906. [PMID: 35199591 PMCID: PMC8883362 DOI: 10.1177/23247096221075906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/05/2022] [Accepted: 01/09/2022] [Indexed: 11/25/2022] Open
Abstract
Coccidioidomycosis is a disease found in the southwestern United States and caused by inhalation of arthroconidia of Coccidioides immitis and posadasii. Although the disease is most commonly asymptomatic or respiratory, it has a propensity to disseminate to any tissue in the body with the most common being skin, bone, joints, and central nervous system. This case demonstrates the dissemination of coccidioidomycosis to several foci along with a rare form of parenchymal dissemination with an unusual neuroradiological finding.
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Affiliation(s)
| | | | - Arash Heidari
- Kern Medical, Bakersfield, CA, USA
- David Geffen School of Medicine at UCLA, USA
| | - Royce H. Johnson
- Kern Medical, Bakersfield, CA, USA
- David Geffen School of Medicine at UCLA, USA
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Kelley AJ, Stainback LB, Knowles KE, Moore TW, Plummer SB, Shoup OR. Clinical characteristics, magnetic resonance imaging features, treatment, and outcome for presumed intracranial coccidioidomycosis in 45 dogs (2009-2019). J Vet Intern Med 2021; 35:2222-2231. [PMID: 34410019 PMCID: PMC8478036 DOI: 10.1111/jvim.16243] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 12/16/2022] Open
Abstract
Background Knowledge of the clinical and magnetic resonance imaging (MRI) features of intracranial Coccidioides infection in dogs is essential for prompt diagnosis to limit disease‐associated morbidity and death. Objectives To describe the MRI appearance of intracranial coccidioidomycosis in dogs, identify associated clinical and clinicopathologic findings, and report outcomes of medical treatment. Animals Forty‐five client‐owned dogs with presumed intracranial Coccidioides infection. Methods Retrospective case series. Medical records and images were reviewed. Clinical history, examination findings, serology, imaging characteristics, treatment, and outcome were recorded. Included cases had an abnormal brain MRI and positive Coccidioides serology by agar‐gel‐immunodiffusion (AGID). Results Median age was 7‐years. Generalized tonic‐clonic seizures were the most common presenting sign (25/45). Two lesion categories were identified: a granulomatous form with 1 or more distinct, intra‐axial, contrast‐enhancing foci (37/45), and a second variation with diffuse, bilateral, symmetrical lesions of the caudate nuclei and frontal lobes (8/45). Serum IgG titers ranged from 1 : 1 to ≥ 1 : 256; 2 dogs had positive IgM titers at 1 : 2. All dogs with follow‐up serology (34/45) had a reduction in titer. Mean duration of follow‐up was 22.4 ± 20.5 months (median 16 months). Six dogs were lost to follow‐up <1‐year after diagnosis (median 9 months). Five dogs were clinically well but had yet to be followed for >1‐year. Of the remaining 34 dogs, 28 (82%) were alive ≥ 1‐year after diagnosis. Thirteen of these dogs had follow‐up times ≥ 2‐years. Conclusions and Clinical Importance The prognosis for intracranial Coccidioides infection is generally more favorable with medical treatment than in earlier reports.
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Affiliation(s)
- Ashley J Kelley
- Specialists in Companion Animal Neurology, Naples, Florida, USA
| | | | - Kim E Knowles
- Veterinary Neurological Center, Phoenix, Arizona, USA
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Abstract
PURPOSE OF REVIEW This article describes the clinical presentation, diagnostic approach (including the use of novel diagnostic platforms), and treatment of select infectious and noninfectious etiologies of chronic meningitis. RECENT FINDINGS Identification of the etiology of chronic meningitis remains challenging, with no cause identified in at least one-third of cases. Often, several serologic, CSF, and neuroimaging studies are indicated, although novel diagnostic platforms including metagenomic deep sequencing may hold promise for identifying organisms. Infectious etiologies are more common in those at risk for disseminated disease, specifically those who are immunocompromised because of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), transplantation, or immunosuppressant medications. An important step in identifying the etiology of chronic meningitis is assembling a multidisciplinary team of individuals, including those with specialized expertise in ophthalmology, dermatology, rheumatology, and infectious diseases, to provide guidance regarding diagnostic procedures. SUMMARY Chronic meningitis is defined as inflammation involving the meninges that lasts at least 4 weeks and is associated with a CSF pleocytosis. Chronic meningitis has numerous possible infectious and noninfectious etiologies, making it challenging to definitively diagnose patients. Therefore, a multifaceted approach that combines history, physical examination, neuroimaging, and laboratory analysis, including novel diagnostic platforms, is needed. This article focuses on key aspects of the evaluation of and approach to patients with chronic meningitis. Specific infectious etiologies and differential diagnoses of subacute and chronic meningitis, including noninfectious etiologies, are addressed.
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Jackson NR, Blair JE, Ampel NM. Central Nervous System Infections Due to Coccidioidomycosis. J Fungi (Basel) 2019; 5:jof5030054. [PMID: 31261704 PMCID: PMC6787616 DOI: 10.3390/jof5030054] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 06/20/2019] [Accepted: 06/26/2019] [Indexed: 12/11/2022] Open
Abstract
Coccidioidomycosis is a common infection in the western and southwestern United States as well as parts of Mexico and Central and South America and is due to the soil-dwelling fungi Coccidioides. Central nervous system (CNS) infection is an uncommon manifestation that is nearly always fatal if untreated. The presentation is subtle, commonly with headache and decreased mentation. The diagnosis should be considered in patients with these symptoms in association with a positive serum coccidioidal antibody test. The diagnosis can only be established by analysis of cerebrospinal fluid (CSF), which typically demonstrates a lymphocytic pleocytosis, hypoglycorrhachia, elevated protein, and positive CSF coccidioidal antibody. Cultures are infrequently positive but a proprietary coccidioidal antigen test has reasonable sensitivity. Current therapy usually begins with fluconazole at 800 mg daily but other triazole antifungals also have efficacy and are often used if fluconazole fails. Triazole therapy should be lifelong. Intrathecal amphotericin B, the original treatment, is now reserved for those in whom triazoles have failed. There are several distinct complications of CNS coccidioidal infection, the most common of which is hydrocephalus. This is nearly always communicating and requires mechanical shunting in addition to antifungal therapy. Other complications include cerebral vasculitis, brain abscess, and arachnoiditis. Management of these is difficult and not well established.
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Affiliation(s)
- Niki R Jackson
- Division of Infectious Diseases, Mayo Clinic in Arizona, Phoenix, AZ 85054, USA
| | - Janis E Blair
- Division of Infectious Diseases, Mayo Clinic in Arizona, Phoenix, AZ 85054, USA
| | - Neil M Ampel
- Division of Infectious Diseases, Mayo Clinic in Arizona, Phoenix, AZ 85054, USA.
- University of Arizona College of Medicine, Tucson, AZ 85724, USA.
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Sharma A, Foutz TJ, Gonzalez-Cuyar LF, Latimer CS, Longstreth WT, Tirschwell DL, Davis AP. From Herniation to Rehabilitation: A Young Woman With Rapidly Progressive Neurological Deficits. Neurohospitalist 2019; 9:215-221. [PMID: 31534611 DOI: 10.1177/1941874419832437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Akanksha Sharma
- Department of Neurology, Mayo Clinic Arizona, Phoenix, AZ, USA.,Authors share the first authorship for the article
| | - Thomas J Foutz
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA.,Authors share the first authorship for the article
| | | | - Caitlin S Latimer
- Department of Neurology, Mayo Clinic Arizona, Phoenix, AZ, USA.,Department of Neurology, University of North Carolina, Chapel Hill, NC, USA.,Department of Neuropathology, Harborview Medical Center, Seattle, WA, USA.,Department of Neurology, Harborview Medical Center, Seattle, WA, USA.,Authors share the first authorship for the article
| | - W T Longstreth
- Department of Neurology, Harborview Medical Center, Seattle, WA, USA
| | | | - Arielle P Davis
- Department of Neurology, Harborview Medical Center, Seattle, WA, USA
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Vaysman T, Villaflores S, Estrella C, Radhakrishna S, Liu A. Myelitis due to Coccidioidomycosis in an Immunocompetent Patient. Case Rep Infect Dis 2018; 2018:2176269. [PMID: 29808132 PMCID: PMC5902110 DOI: 10.1155/2018/2176269] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 02/02/2018] [Accepted: 02/25/2018] [Indexed: 01/07/2023] Open
Abstract
Myelitis of the spinal cord is an uncommon presentation of disseminated coccidioidomycosis. Most infected patients present subclinically, but patients, especially those who are immunocompromised, may progress to disseminated disease. We present a 50-year-old immunocompetent patient with no significant past medical history exhibiting symptoms of altered mental status, dizziness, headache, nausea, and quadriplegia. Upon investigation with lumbar puncture, cerebrospinal fluid (CSF) culture, and coccidioidal antibody studies, the patient was found to have acute coccidioidomycosis. Magnetic resonance imaging (MRI) of the brain demonstrated meningeal enhancements suggestive of meningitis, and further MRI study of the cervical spine revealed myelitis. Treatment with IV fluconazole for 2 weeks and IV voriconazole therapy over 3 weeks yielded limited improvement. The presentation of myelitis due to coccidioidomycosis infection is very rare and has infrequently reported in the literature. Awareness of this potentially fatal complication in immunocompetent patients can aid in faster recognition and treatment.
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Affiliation(s)
- Tetyana Vaysman
- Department of Neurology and Infectious Disease, California Hospital Medical Center, Los Angeles, CA, USA
| | - Sean Villaflores
- Department of Neurology and Infectious Disease, California Hospital Medical Center, Los Angeles, CA, USA
| | - Carlyn Estrella
- Department of Neurology and Infectious Disease, California Hospital Medical Center, Los Angeles, CA, USA
| | - Suman Radhakrishna
- Department of Neurology and Infectious Disease, California Hospital Medical Center, Los Angeles, CA, USA
| | - Antonio Liu
- Department of Neurology and Infectious Disease, California Hospital Medical Center, Los Angeles, CA, USA
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8
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Johnson R, Ho J, Fowler P, Heidari A. Coccidioidal Meningitis: A Review on Diagnosis, Treatment, and Management of Complications. Curr Neurol Neurosci Rep 2018. [DOI: 10.1007/s11910-018-0824-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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9
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Bajema KL, Dalesandro MF, Fredricks DN, Ramchandani M. Disseminated coccidioidomycosis presenting with intramedullary spinal cord abscesses: Management challenges. Med Mycol Case Rep 2016; 15:1-4. [PMID: 28053850 PMCID: PMC5198726 DOI: 10.1016/j.mmcr.2016.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 11/29/2016] [Accepted: 12/01/2016] [Indexed: 01/05/2023] Open
Abstract
Coccidioides species are endemic to the southwestern United States and typically cause a mild or asymptomatic primary infection. In some instances, infection can disseminate and involve the central nervous system with meningitis being the most common manifestation. Non-osseous spinal cord involvement is exceedingly rare. We report a case of disseminated coccidioidomycosis in an otherwise healthy 20 year old man with diffuse leptomeningeal enhancement, cerebrospinal fluid findings suggestive of meningitis, and intramedullary spinal cord abscesses. Response to treatment occurred with prolonged systemic liposomal amphotericin B and voriconazole. An extended course of steroids was needed to blunt inflammation.
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Affiliation(s)
- Kristina L Bajema
- Department of Medicine, Divison of Allergy and Infectious Diseases, University of Washington, 1959 NE Pacific Street Box 356423, Seattle, WA 98195, USA
| | | | - David N Fredricks
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Meena Ramchandani
- Department of Medicine, Divison of Allergy and Infectious Diseases, Harborview Medical Center, Seattle, WA, USA
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Galgiani JN, Ampel NM, Blair JE, Catanzaro A, Geertsma F, Hoover SE, Johnson RH, Kusne S, Lisse J, MacDonald JD, Meyerson SL, Raksin PB, Siever J, Stevens DA, Sunenshine R, Theodore N. 2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Treatment of Coccidioidomycosis. Clin Infect Dis 2016; 63:e112-46. [PMID: 27470238 DOI: 10.1093/cid/ciw360] [Citation(s) in RCA: 317] [Impact Index Per Article: 39.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 05/26/2016] [Indexed: 12/17/2022] Open
Abstract
It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. Infectious Diseases Society of America considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.Coccidioidomycosis, also known as San Joaquin Valley fever, is a systemic infection endemic to parts of the southwestern United States and elsewhere in the Western Hemisphere. Residence in and recent travel to these areas are critical elements for the accurate recognition of patients who develop this infection. In this practice guideline, we have organized our recommendations to address actionable questions concerning the entire spectrum of clinical syndromes. These can range from initial pulmonary infection, which eventually resolves whether or not antifungal therapy is administered, to a variety of pulmonary and extrapulmonary complications. Additional recommendations address management of coccidioidomycosis occurring for special at-risk populations. Finally, preemptive management strategies are outlined in certain at-risk populations and after unintentional laboratory exposure.
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Affiliation(s)
| | - Neil M Ampel
- Division of Infectious Diseases, University of Arizona, Tucson
| | - Janis E Blair
- Division of Infectious Diseases, Mayo Clinic, Scottsdale, Arizona
| | - Antonino Catanzaro
- Division of Pulmonary and Critical Care, University of California, San Diego
| | - Francesca Geertsma
- Department of Pediatrics, Infectious Diseases, Stanford University School of Medicine, California
| | | | - Royce H Johnson
- David Geffen School of Medicine at UCLA, Department of Medicine, Kern Medical Center, Bakersfield, California
| | - Shimon Kusne
- Division of Infectious Diseases, Mayo Clinic, Scottsdale, Arizona
| | - Jeffrey Lisse
- Department of Rheumatology, University of Arizona, Tucson
| | - Joel D MacDonald
- Department of Neurosurgery School of Medicine, University of Utah, Salt Lake City
| | - Shari L Meyerson
- Division of Thoracic Surgery, Northwestern University, Feinberg School of Medicine
| | - Patricia B Raksin
- Division of Neurosurgery, John H. Stroger Jr Hospital of Cook County, Chicago, Illinois
| | | | - David A Stevens
- Division of Infectious Diseases, Stanford University School of Medicine, California
| | - Rebecca Sunenshine
- Career Epidemiology Field Officer Program, Division of State and Local Readiness, Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention Maricopa County Department of Public Health
| | - Nicholas Theodore
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
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Motley BD, Grabowski M, Prayson RA. Coccidioides parenchymal cerebral abscess in the setting of lymphoma. J Clin Neurosci 2015; 22:40-1. [DOI: 10.1016/j.jocn.2014.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 06/29/2014] [Indexed: 11/26/2022]
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El Dib NA, Eldessouky NM, El Sherbini SA, Seleem HM, Algebaly HF. Disseminated coccidioidomycosis in a 5-year-old Sudanese boy. J Trop Pediatr 2014; 60:260-3. [PMID: 24457818 DOI: 10.1093/tropej/fmu002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A 5-year-old Sudanese boy not known to be immunodeficient and with no history of travelling developed septic shock from a disseminating coccidial infection. The diagnosis was delayed, as the eosinophilic hepatic abscess was initially thought to be secondary to schistosomiasis, which is endemic in Egypt and Sudan. A further survey about the existence of coccidial infection around the climatic area of the river Nile is warranted.
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Affiliation(s)
- Nadia A El Dib
- Department of Parasitology, Faculty of Medicine, Cairo University, Egypt
| | - Nabil M Eldessouky
- Department of Pediatric Surgery, Faculty of Medicine, Cairo University, EgyptDepartment of Pediatrics, Faculty of Medicine, Cairo University, Egypt
| | - Saham A El Sherbini
- Department of Pediatric Intensive Care unit, Faculty of Medicine, Cairo University, Egypt
| | - Hala M Seleem
- Department of Pediatric Intensive Care unit, Faculty of Medicine, Cairo University, Egypt
| | - HebatAllah F Algebaly
- Department of Pediatric Intensive Care unit, Faculty of Medicine, Cairo University, Egypt
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Starkey J, Moritani T, Kirby P. MRI of CNS Fungal Infections: Review of Aspergillosis to Histoplasmosis and Everything in Between. Clin Neuroradiol 2014; 24:217-30. [DOI: 10.1007/s00062-014-0305-7] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 03/26/2014] [Indexed: 11/28/2022]
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Rapidly progressive quadriparesis heralding disseminated coccidioidomycosis in an immunocompetent patient. J Clin Neurosci 2013; 21:1049-51. [PMID: 24321458 DOI: 10.1016/j.jocn.2013.07.040] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Accepted: 07/19/2013] [Indexed: 11/23/2022]
Abstract
Coccidioides species are dimorphic fungi endemic to southwestern USA and northern Mexico. Disseminated coccidioidomycosis is rare with an estimated incidence of 1% in affected individuals and usually presents as meningitis when the central nervous system is involved. Spinal involvement with coccidioidomycosis, though not uncommon, predominantly manifests as osseous involvement leading to osteomyelitis and epidural abscess formation. Progressive quadriparesis as a presenting symptom secondary to intramedullary spinal cord coccidioidomycosis is very unusual and to our knowledge has not been described. We report a patient with disseminated coccidioidomycosis who presented with rapidly progressive quadriparesis due to cervical intramedullary spinal cord involvement. The absence of known coccidioidomycosis with atypical clinical presentation made the diagnosis elusive, requiring emergent cervical laminectomies with dural biopsy for decompression of the spinal cord and confirmation of the diagnosis. The patient eventually succumbed to the progressive course of the disease. Although rare, disseminated coccidioidomycosis can present as new, rapidly progressing quadriparesis in patients who have traveled to endemic areas. A high index of suspicion in such patients with appropriately directed laboratory investigations and consideration of early biopsy might unravel the diagnosis facilitating early antifungal treatment with the potential to minimize morbidity and mortality associated with disseminated coccidioidomycosis.
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Imaging Spectrum of CNS Coccidioidomycosis: Prevalence and Significance of Concurrent Brain and Spinal Disease. AJR Am J Roentgenol 2013; 200:1334-46. [DOI: 10.2214/ajr.12.9264] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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18
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Abstract
In cases of central nervous system infection, it is crucial for the neuroradiologist to provide an accurate differential diagnosis of the possible pathogens involved so that treating physicians can be aided in the choice of empiric therapy. This approach requires the radiologist to be aware of local epidemiology and have knowledge of infectious agents that are endemic to their area of practice. This article reviews and discusses the changing epidemiology of pathogens most often observed in meningitis, brain abscess, epidural abscess, postoperative infections, and human immunodeficiency virus infection.
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Carvalho C, Ferreira I, Gaião S, Guimarães S, Costa R, Santos J, Sampaio S, Bustorff M, Oliveira G, Pestana M. Cerebral coccidioidomycosis after renal transplantation in a non-endemic area. Transpl Infect Dis 2010; 12:151-4. [DOI: 10.1111/j.1399-3062.2009.00456.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Campdelacreu J, Capurro S, Pumarola T. Varón de 52 años con inestabilidad de la marcha. Med Clin (Barc) 2010; 134:260-7. [DOI: 10.1016/j.medcli.2009.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2009] [Accepted: 05/15/2009] [Indexed: 10/20/2022]
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Blair JE. Coccidioidal meningitis: Update on epidemiology, clinical features, diagnosis, and management. Curr Infect Dis Rep 2009; 11:289-95. [DOI: 10.1007/s11908-009-0043-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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22
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Castro S, Bernardes I. Coccidioidal cerebral abscess with peripheral restricted diffusion. J Neuroradiol 2009; 36:162-4. [DOI: 10.1016/j.neurad.2008.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2008] [Revised: 12/02/2008] [Accepted: 12/09/2008] [Indexed: 10/21/2022]
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Nolt JD, Geertsma FR. Deep solitary brain mass in a four-month-old male with disseminated coccidioidomycosis: case report. Ann N Y Acad Sci 2007; 1111:385-94. [PMID: 17344521 DOI: 10.1196/annals.1406.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Parenchymal brain involvement from disseminated coccidioidomycosis occurs rarely and there are few documented pediatric cases. We report a four-month-old male infant with a cerebellar lesion seen in the brain on computed tomography (CT). Coccidioides immitis (C. immitis) grew on bronchoscopic fluid samples and serum titers to C. immitis were 1:1024. Antifungal treatment was initiated and after 3 months, CT scans demonstrated brain mass resolution and serum titers were decreased.
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Affiliation(s)
- Jennifer D Nolt
- Children's Hospital Central California, Madera, California, USA.
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25
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Abstract
Coccidioidal meningitis affects between 200 to 300 persons annually within the endemic area of the United States, with much larger numbers expected in epidemic years. Because this represents a chronic disease for survivors, several thousand patients may be under treatment at any given time. Epidemiology, background, and diagnosis are reviewed. Azole therapy has replaced intrathecal amphotericin B for induction and maintenance therapy for this disease, given its ease of administration and equivalent efficacy in controlling infection even at the cost of losing the opportunity for cure. Both itraconazole and fluconazole have demonstrated efficacy, but have not been compared in randomized human studies. One of the uses of intrathecal amphotericin B is as "add on" therapy in failing azole regimens without evidence of antagonism. Details of therapeutic approach are reviewed. Approach to diagnosis and management of the two principal potentially life threatening complications, hydrocephalus and vasculitis, is also discussed.
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Affiliation(s)
- Paul L Williams
- The Permanente Medical Group, 2651 Highland Avenue, Selma, CA 93662, USA.
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26
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Abstract
We discuss the diagnosis, treatment and prognosis of a Danish male with disseminated coccidioidomycosis. He presented with headaches and slight fever. Examination showed pulmonary, cutaneous and cerebral and cerebellar granulomas, a rare complication. He was treated with intravenously and subsequently orally administered fluconazole. Symptoms and clinical findings regressed during treatment.
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27
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Johnson RH, Einstein HE. Coccidioidal Meningitis. Clin Infect Dis 2006; 42:103-7. [PMID: 16323099 DOI: 10.1086/497596] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2005] [Accepted: 07/25/2005] [Indexed: 11/03/2022] Open
Abstract
Residents of the area now occupied by the southwestern United States and northwestern Mexico have had to deal with coccidioidomycosis and complicating meningitis for >1500 years. The hundredth anniversary of the reporting of disseminated coccidioidomycosis has just passed. This year has the dubious distinction of being the hundredth anniversary of the first description of coccidioidal meningitis. Although intrathecal amphotericin B began to be used for therapy 50 years ago, and although we have benefited from azole therapy for >10 years, the morbidity and mortality associated with this all-too-common disease remain unacceptably high. This review will endeavor to discuss the pathogenic, pathophysiologic, clinical, laboratory, radiologic, and therapeutic features of meningitis secondary to Coccidioides infection.
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Affiliation(s)
- Royce H Johnson
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA.
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28
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Foureman P, Longshore R, Plummer SB. Spinal Cord Granuloma due toCoccidioides immitisin a Cat. J Vet Intern Med 2005. [DOI: 10.1111/j.1939-1676.2005.tb02712.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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29
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Davis LE, Porter BS. Central Nervous System Coccidioides immitis Infections. Curr Treat Options Neurol 2005; 7:157-165. [PMID: 15676119 DOI: 10.1007/s11940-005-0025-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Coccidioidal meningitis occurs in healthy individuals and patients with AIDS or other immunosuppressive illnesses. The central nervous system infection results when Coccidioides immitis disseminates from a primary lung infection via a fungemia to reach the meninges. Cases develop primarily in individuals living in or traveling to the Lower Sonoran Life Zone of Southwest United States. Most cases begin as subacute granulomatous meningitis with occasional patients developing brain abscesses. Diagnosis may be challenging because C. immitis is isolated from cerebrospinal fluid in less than 50% of patients. However, a cerebrospinal fluid complement fixation test for IgG antibody to C. immitis has high sensitivity and specificity. Currently, optimal treatment is unclear. Standard therapy has been with life-long oral fluconazole or intrathecal amphotericin B followed by prolonged oral fluconazole. Liposomal amphotericin B given intravenously seems promising as an initial treatment as it has much higher brain penetration, less nephrotoxicity, and less severe infusion-related adverse effects than conventional amphotericin B. However, current comparative studies for efficacy of liposomal amphotericin B in coccidioidal meningitis are lacking.
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Affiliation(s)
- Larry E Davis
- Neurology Service, New Mexico VA Health Care System, 1501 San Pedro Drive SE, Albuquerque, NM 87108, USA.
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30
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Baddley JW, Cobbs CS, Pappas PG. Surgical treatment of multiple skull abscesses associated with coccidioidomycosis. Fallbericht. Chirurgische Behandlung multipler Schadelabszesse bei Coccidioidomykose. Mycoses 2004; 47:69-71. [PMID: 14998403 DOI: 10.1046/j.0933-7407.2003.00938.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This case emphasizes that aggressive neurosurgical management may benefit patients with disseminated coccidioidomycosis and skull abscesses. Disseminated infection due to Coccidioides immitis, the causative agent of coccidioidomycosis, is difficult to treat and often requires prolonged antifungal therapy in addition to surgical debridement. We present a case of a young woman with disseminated coccidioidomycosis who had multiple skull lesions, two of which penetrated the skull and invaded the subgaleal and epidural spaces. Despite prolonged aggressive medical management, these lesions failed to resolve until they were surgically drained.
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Affiliation(s)
- J W Baddley
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, 35294-0006, USA.
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31
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Abstract
Coccidioides, a fungus, is endemic to specific parts of the Western Hemisphere. This article examines the prevalence, pathogenesis and host defense, clinical manifestations, diagnosis, and treatment of coccidioidomycosis.
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Affiliation(s)
- Tom M Chiller
- Division of Infectious Diseases, Department of Medicine, Santa Clara Valley Medical Center, 751 South Bascom Avenue, San Jose, CA 95128-2699, USA
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32
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Abstract
The laboratory diagnosis of CNS infection is essential for optimal therapy. Acute infection requires rapid turn-around testing with high predictive values, that is, the ability of a test to accurately identify those patients who do or do not have disease caused by a specific etiology. The Gram's stain, fungal stains of direct smears, antigen testing for C. neoformans, and culture of bacteria, fungi, mycobacteria, and some viruses are important tests for the diagnosis of acute infection. The laboratory diagnosis of chronic infection necessitates discussion between the clinician and laboratory technician to allow triaging of testing. Antigen tests for bacteria, fungi, and viruses; antibody tests for multiple microorganisms; and PCR testing for bacteria, M. tuberculosis, and many viruses are all important in limited clinical situations. All testing for acute or chronic disease depends on sufficient specimen that is transported to the laboratory in a manner that will not compromise viability or chemical integrity. Sterile containers that maintain moisture content, exclude oxygen for anaerobic requests, and are stored at proper temperatures (22 degrees C room, 4 degrees C refrigeration, or -20 degrees C freezer depending on pathogen and test) are mandatory. Many laboratory issues addressing the diagnosis of CNS infection are changing or evolving. Most important is the recognition that bacterial antigen testing for the diagnosis of acute bacterial meningitis rarely impacts patient management and is not routinely needed, CSF shunt infections differ from usual meningeal infections and require rapid diagnosis, and TB meningitis remains a difficult disease to diagnosis but may be confirmed first by PCR testing of CSF. In addition, Whipple's disease of the CNS can be confirmed using PCR with CSF; CJD has a marker protein, referred to as 14-3-3 antigen, that can be detected in CSF, and the diagnosis of fungal CNS disease requires careful interpretation of direct smears, antigen and antibody testing, and culture. Most difficult to diagnose among the CNS infections are viral meningitis and encephalitis. The appearance of new etiologies, such as West Nile virus, and the common use of PCR for the herpes viruses and enteroviruses represent important advances. Evolving methods for the laboratory diagnosis of CNS infection represent significant improvements over previous testing; however, the array of tests available demands more attention for appropriate selection, is significantly more expensive, and requires new skills for performance and interpretation. The responsibility for proper use of laboratory testing lies both with the clinician and laboratory technician.
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Affiliation(s)
- R B Thomson
- Department of Pathology, Northwestern University Medical School, Evanston, Illinois, USA.
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33
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Love S. Autopsy approach to infections of the CNS. CURRENT TOPICS IN PATHOLOGY. ERGEBNISSE DER PATHOLOGIE 2001; 95:1-50. [PMID: 11545050 DOI: 10.1007/978-3-642-59554-7_1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Affiliation(s)
- S Love
- Department of Neuropathology, Institute of Clinical Neurosciences, Frenchay Hospital, Bristol BS16 1LE, UK
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34
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Hagman HM, Madnick EG, D'Agostino AN, Williams PL, Shatsky S, Mirels LF, Tucker RM, Rinaldi MG, Stevens DA, Bryant RE. Hyphal forms in the central nervous system of patients with coccidioidomycosis. Clin Infect Dis 2000; 30:349-53. [PMID: 10671340 DOI: 10.1086/313643] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Coccidioides immitis is a dimorphic fungus that grows as a filamentous mold in soil and as a spherule at human body temperature. The hyphal or soil form is found rarely in human tissue. We report 5 cases of coccidioidomycosis in which hyphae were found in brain tissue or spinal fluid. The presence of central nervous system plastic devices appears to be associated with morphological reversion to the saprophytic form. This reversion has implications for diagnosis and therapy and may increase the risk of obstruction of the device(s).
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Affiliation(s)
- H M Hagman
- Department of Medicine, Mission Viejo Community Hospital, Mission Viejo, CA, USA
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35
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Abstract
This review discusses a practical approach to the patient with possible fungal infection of the central nervous system (CNS). Difficulties in establishing the diagnosis come from the nonspecific clinical syndromes (subacute meningitis, meningoencephalitis, and brain abscess) and the low isolation rate of fungi from cerebrospinal fluid (CSF). Helpful diagnostic clues often come from knowledge of the patient's geographic travels, risk factors, evidence of systemic organ infection, and fungal serologic tests. Standard and new antifungal agents are evaluated and the initial and suppressive drug management of the common fungal infections is presented.
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Affiliation(s)
- L E Davis
- Neurology Service, Veterans Affairs Medical Center, Albuquerque, New Mexico 87108, USA
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