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Pu J, Miranda V, Minior D, Reynolds S, Rayhorn B, Ellingson KD, Galgiani JN. Improving Early Recognition of Coccidioidomycosis in Urgent Care Clinics: Analysis of an Implemented Education Program. Open Forum Infect Dis 2023; 10:ofac654. [PMID: 36733697 PMCID: PMC9887936 DOI: 10.1093/ofid/ofac654] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 12/05/2022] [Indexed: 02/03/2023] Open
Abstract
Background Only 0.2% of coccidioidomycosis (CM) diagnoses were made in patients (pts) with pneumonia (PNA) in urgent care (UC), because they were not being tested for CM. Our objective in this study was to improve CM testing rates. Methods This was a time series of clinician practice before and after an intervention that occurred at UC clinics in Phoenix and Tucson Arizona. All patients in UC were >18 years old. We included information about CM in periodic educational activities for clinicians. Coccidioidal serologic testing (CST), CST results, and their relation to International Classification of Diseases, Tenth Revision (ICD-10) codes were extracted from medical records. Results Urgent care received 2.1 million visits from 1.5 million patients. The CST orders per 104 visits increased from 5.5 to 19.8 (P < .0001). Percentage positive CSTs were highest for August, November, and December (17.0%) versus other months (10.6%). Positive CSTs were associated with PNA ICD-10 codes, and, independently, for Erythema nodosum (EN) which had the highest positivity rate (61.4%). Testing of PNA pts increased on first visits and on second visits when the first CST was negative. Yearly rates of PNA due to CM ranged from 17.3% to 26.0%. Despite this improvement, CST was still not done for over three quarters of pts with PNA. This was a noncomparative study. Conclusions Routine quality improvement activities have significantly but only partially improved rates of testing pts with PNA for CM in UC clinics located in a highly endemic area. Innovative strategies may be needed to improve current practice. Also in our region, EN, independent of PNA, is a strong predictor of CM.
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Affiliation(s)
- Jie Pu
- Banner Health Corporation, Phoenix, Arizona, USA
| | | | - Devin Minior
- Banner Urgent Care Services, Phoenix, Arizona, USA
| | | | | | - Katherine D Ellingson
- Department of Epidemiology and Biostatistics, College of Public Health, University of Arizona, Tucson, Arizona, USA
| | - John N Galgiani
- Correspondence: John N. Galgiani, MD, University of Arizona, PO Box 245215, Tucson, AZ 85724 ()
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6
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Hsu AP, Korzeniowska A, Aguilar CC, Gu J, Karlins E, Oler AJ, Chen G, Reynoso GV, Davis J, Chaput A, Peng T, Sun L, Lack JB, Bays DJ, Stewart ER, Waldman SE, Powell DA, Donovan FM, Desai JV, Pouladi N, Long Priel DA, Yamanaka D, Rosenzweig SD, Niemela JE, Stoddard J, Freeman AF, Zerbe CS, Kuhns DB, Lussier YA, Olivier KN, Boucher RC, Hickman HD, Frelinger J, Fierer J, Shubitz LF, Leto TL, Thompson GR, Galgiani JN, Lionakis MS, Holland SM. Immunogenetics associated with severe coccidioidomycosis. JCI Insight 2022; 7:159491. [PMID: 36166305 PMCID: PMC9746810 DOI: 10.1172/jci.insight.159491] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 09/21/2022] [Indexed: 12/15/2022] Open
Abstract
Disseminated coccidioidomycosis (DCM) is caused by Coccidioides, pathogenic fungi endemic to the southwestern United States and Mexico. Illness occurs in approximately 30% of those infected, less than 1% of whom develop disseminated disease. To address why some individuals allow dissemination, we enrolled patients with DCM and performed whole-exome sequencing. In an exploratory set of 67 patients with DCM, 2 had haploinsufficient STAT3 mutations, and defects in β-glucan sensing and response were seen in 34 of 67 cases. Damaging CLEC7A and PLCG2 variants were associated with impaired production of β-glucan-stimulated TNF-α from PBMCs compared with healthy controls. Using ancestry-matched controls, damaging CLEC7A and PLCG2 variants were overrepresented in DCM, including CLEC7A Y238* and PLCG2 R268W. A validation cohort of 111 patients with DCM confirmed the PLCG2 R268W, CLEC7A I223S, and CLEC7A Y238* variants. Stimulation with a DECTIN-1 agonist induced DUOX1/DUOXA1-derived hydrogen peroxide [H2O2] in transfected cells. Heterozygous DUOX1 or DUOXA1 variants that impaired H2O2 production were overrepresented in discovery and validation cohorts. Patients with DCM have impaired β-glucan sensing or response affecting TNF-α and H2O2 production. Impaired Coccidioides recognition and decreased cellular response are associated with disseminated coccidioidomycosis.
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Affiliation(s)
- Amy P Hsu
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA.,Department of Cell Biology and Molecular Genetics, University of Maryland, College Park, Maryland, USA
| | - Agnieszka Korzeniowska
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
| | - Cynthia C Aguilar
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
| | - Jingwen Gu
- Bioinformatics and Computational Biosciences Branch, Office of Cyber Infrastructure and Computational Biology, NIAID, NIH, Bethesda, Maryland, USA
| | - Eric Karlins
- Bioinformatics and Computational Biosciences Branch, Office of Cyber Infrastructure and Computational Biology, NIAID, NIH, Bethesda, Maryland, USA
| | - Andrew J Oler
- Bioinformatics and Computational Biosciences Branch, Office of Cyber Infrastructure and Computational Biology, NIAID, NIH, Bethesda, Maryland, USA
| | - Gang Chen
- Marsico Lung Institute and Cystic Fibrosis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Glennys V Reynoso
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
| | - Joie Davis
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
| | - Alexandria Chaput
- Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA
| | - Tao Peng
- Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA
| | - Ling Sun
- Marsico Lung Institute and Cystic Fibrosis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Department of Respiratory and Critical Care Medicine, Laboratory of Pulmonary Immunology and Inflammation, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Justin B Lack
- NIAID Collaborative Bioinformatics Resource, NIAID, NIH, Bethesda, Maryland, USA.,Advanced Biomedical Computational Science, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research, Inc., Frederick, Maryland, USA
| | - Derek J Bays
- Department of Internal Medicine, Division of Infectious Diseases, UC Davis Health, Sacramento, California, USA
| | - Ethan R Stewart
- Department of Internal Medicine, Division of Infectious Diseases, UC Davis Health, Sacramento, California, USA
| | - Sarah E Waldman
- Department of Internal Medicine, Division of Infectious Diseases, UC Davis Health, Sacramento, California, USA
| | - Daniel A Powell
- Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA.,Department of Immunobiology, University of Arizona, Tucson, Arizona, USA
| | - Fariba M Donovan
- Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA.,Department of Medicine, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA
| | - Jigar V Desai
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
| | - Nima Pouladi
- Center for Biomedical Informatics and Biostatistics and.,The Center for Applied Genetics and Genomic Medicine, Department of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Debra A Long Priel
- Neutrophil Monitoring Laboratory, Applied/Developmental Research Directorate, Leidos Biomedical Research, Inc, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Daisuke Yamanaka
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA.,Laboratory for Immunopharmacology of Microbial Products, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, Hachioji, Tokyo, Japan
| | | | - Julie E Niemela
- Immunology Service, Department of Laboratory Medicine, Clinical Center and
| | - Jennifer Stoddard
- Immunology Service, Department of Laboratory Medicine, Clinical Center and
| | - Alexandra F Freeman
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
| | - Christa S Zerbe
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
| | - Douglas B Kuhns
- Neutrophil Monitoring Laboratory, Applied/Developmental Research Directorate, Leidos Biomedical Research, Inc, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Yves A Lussier
- Center for Biomedical Informatics and Biostatistics and.,The Center for Applied Genetics and Genomic Medicine, Department of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Kenneth N Olivier
- Laboratory of Chronic Airway Infection, Pulmonary Branch, National Heart, Lung, and Blood Institute, NIH, Bethesda, Maryland, USA
| | - Richard C Boucher
- Marsico Lung Institute and Cystic Fibrosis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Heather D Hickman
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
| | - Jeffrey Frelinger
- Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA.,Department of Immunobiology, University of Arizona, Tucson, Arizona, USA
| | - Joshua Fierer
- VA HealthCare San Diego, San Diego, California, USA.,Division of Infectious Diseases, Departments of Pathology and Medicine, School of Medicine, University of California San Diego, La Jolla, California, USA
| | - Lisa F Shubitz
- Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA
| | - Thomas L Leto
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
| | - George R Thompson
- Department of Internal Medicine, Division of Infectious Diseases, UC Davis Health, Sacramento, California, USA.,Department of Medical Microbiology and Immunology, University of California Davis, Davis, California, USA
| | - John N Galgiani
- Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA.,Department of Medicine, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA
| | - Michail S Lionakis
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
| | - Steven M Holland
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
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7
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Shemuel J, Bays DJ, Thompson GR, Reef S, Snyder L, Freifeld AJ, Huppert M, Salkin D, Wilson MD, Galgiani JN. Natural history of pulmonary coccidioidomycosis: Further examination of the VA-Armed Forces Database. Med Mycol 2022; 60:myac054. [PMID: 36166843 PMCID: PMC9614921 DOI: 10.1093/mmy/myac054] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 07/08/2022] [Accepted: 07/19/2022] [Indexed: 02/02/2023] Open
Abstract
There are still many limitations related to the understanding of the natural history of differing forms of coccidioidomycosis (CM), including characterizing the spectrum of pulmonary disease. The historical Veterans Administration-Armed Forces database, recorded primarily before the advent of antifungal therapy, presents an opportunity to characterize the natural history of pulmonary CM. We performed a retrospective cohort study of 342 armed forces service members who were diagnosed with pulmonary CM at VA facilities between 1955 to 1958, followed through 1966, who did not receive antifungal therapy. Patients were grouped by predominant pulmonary finding on chest radiographs. The all-cause mortality was low for all patients (4.6%). Cavities had a median size of 3-3.9 cm (IQR: 2-2.9-4-4.9 cm), with heterogeneous wall thickness and no fluid level, while nodules had a median size of 1-1.19 cm (Interquartile range [IQR] 1-1.9-2-2.9 cm) and sharp borders. The majority of cavities were chronic (85.6%), and just under half were found incidentally. Median complement fixation titers in both the nodular and cavitary groups were negative, with higher titers in the cavitary group overall. This retrospective cohort study of non-disseminated coccidioidomycosis, the largest to date, sheds light on the natural history, serologic markers, and radiologic characteristics of this understudied disease. These findings have implications for the evaluation and management of CM.
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Affiliation(s)
- Joseph Shemuel
- School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Derek J Bays
- Department of Internal Medicine, Division of Infectious Diseases, University of California, Davis Health, Sacramento, California, USA
| | - George R Thompson
- Department of Internal Medicine, Division of Infectious Diseases, University of California, Davis Health, Sacramento, California, USA
- Medical Microbiology and Immunology, University of California, Davis, Davis, California, USA
| | - Susan Reef
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Linda Snyder
- Department of Internal Medicine, Division of Pulmonary/Critical Care and Palliative Medicine, University of Arizona-Tucson, Tucson, Arizona, USA
| | - Alana J Freifeld
- Department of Internal Medicine, University of Colorado, Boulder, Colorado, USA
| | | | | | - Machelle D Wilson
- Department of Public Health Sciences, Division of Biostatistics, Clinical and Translational Science Center, University of California Davis, Sacramento, California, USA
| | - John N Galgiani
- Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA
- Department of Internal Medicine, Division of Infectious Diseases, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA
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12
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Abstract
Coccidioidomycosis, colloquially known as Valley Fever, is an invasive dimorphic fungal infection caused by Coccidioides immitis and C. posadasii. The fungi are found in the arid desert soils of the southwestern US, as well as in parts of Mexico and Central and South America. Acquisition is typically via inhalation of arthroconidia which become airborne after both natural (e.g., earthquakes, dust storms, and fires) and human-related events (e.g., military maneuvers, recreational activities, agriculture, and construction). The incidence of infection in increasing likely a result of both climatic and populational changes. Further, the recognized geographic distribution of Coccidioides spp. is expanding, as cases are being diagnosed in new areas (e.g., eastern Washington, Oregon, and Utah). Most coccidioidal infections are asymptomatic (60%); however, approximately one-third develop a pulmonary illness which is a leading cause of community-acquired pneumonia in highly endemic areas. Uncommonly (0.5–2% of cases), the infection disseminates to extrapulmonary locations (e.g., skin, bones/joints, and the central nervous system), and is most commonly seen among persons with cellular immunodeficiencies (e.g., transplant recipients, HIV, and pregnancy) and non-Caucasian races (especially African Americans and Filipinos). The diagnosis of coccidioidomycosis requires astute clinical suspicion and laboratory findings, including positive serology, cultures, and/or histopathology results. Treatment is warranted among persons with pneumonia who have risk factors for complicated disease and among those with extrapulmonary disease. Novel antifungals with improved fungicidal activity and rapidity of action with fewer side effects and drug interactions are needed. Preventive strategies (e.g., education regarding the disease, dust avoidance, mask wearing, including among select groups, antifungal prophylaxis, and surveillance laboratory testing) are advised for residents and travelers to endemic areas. Currently, no preventive vaccine is available. Coccidioidomycosis has been recognized for over a century, and an expanding wealth of knowledge has been gained regarding this emerging infectious disease which will be reviewed here.
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Affiliation(s)
- Nancy F Crum
- Infectious Diseases Department, Scripps Health System, San Diego, CA, USA.
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