Coccidioides immitis infection of the neonate: two routes of infection

Clinical Cases of Coccidioidomycosis in the Americas in the Period 1950-2021: Epidemiology Data, Diagnosis, and Treatment

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.

Neonatal Coccidioidomycosis: A Single-center Experience and Review of the Literature

BACKGROUND

Coccidioidomycosis is common in adult and pediatric populations living in endemic areas of the United States but has rarely been reported in neonates. We reviewed recent cases of neonatal coccidioidomycosis treated at a tertiary care children's hospital in an endemic area and compared them with previously reported cases in the literature.

METHODS

We performed a retrospective chart review of infants 1 month old or less hospitalized with a diagnosis of coccidioidomycosis from January 1, 2014, to December 31, 2019. Additionally, we performed a literature review of all reported cases of neonatal coccidioidomycosis over the past 7 decades through PubMed. Infants born to mothers with confirmed or suspected active coccidioidomycosis were excluded.

RESULTS

Three cases of neonatal coccidioidomycosis were identified at our institution. Each presented in a unique manner and had an alternative diagnosis at the time of initial presentation. Two patients had negative coccidioidal screening tests upon admission but later seroconverted. All patients had extrapulmonary involvement, and all recovered after appropriate treatment. A review of the literature reveals that the presentations and outcomes of neonatal coccidioidomycosis vary widely.

CONCLUSIONS

There is significant variability in the presentation of coccidioidomycosis in the neonatal period, and diagnosis may be challenging. In endemic regions, healthcare providers should consider coccidioidomycosis in their differential diagnoses of ill-appearing neonates that do not respond to treatment.

Invasive fungal infections in neonates: a review

Invasive fungal infections remain the leading causes of morbidity and mortality in neonates, especially preterm and very low birth weight infants. Most invasive fungal infections are due to Candida or Aspergillus species, and other fungi are increasingly reported and described. Appropriate identification and treatment are required to augment activity and reduce the toxicity of antifungal drugs. Successful use of antifungals in the vulnerable neonatal population is important for both prevention and treatment of infection. Strategies for prevention, including prophylactic antifungal therapy as well as reducing exposure to modifiable risk factors, like limiting antibiotic exposure, discontinuation of central catheters, and hand hygiene are key techniques to prevent and decrease rates of invasive fungal infections. In conclusion, this is a review of the most common causes, prevention strategies, prophylaxis, and treatment of invasive fungal infections in neonates.

Congenital Coccidioidomycosis: A Case Report and Review of the Literature

Coccidioidomycosis in neonates is rare and the acquisition of disease in this age group is not well understood. Congenital coccidioidomycosis is very rare, usually associated with coccidioidal placentitis. Only a handful of cases of congenital coccidioidomycosis have been described in the literature. We describe an infant with congenital coccidioidomycosis delivered by cesarean section to a mother who was diagnosed with disseminated disease in the second trimester and summarize the available literature on congenital coccidioidomycosis.

Coccidioidomycosis during pregnancy: a review and recommendations for management

Pregnancy is an established risk factor for the development of severe and disseminated coccidioidomycosis, particularly when infection is acquired during the later stages of gestation. Although recent studies suggest that the incidence of symptomatic coccidioidomycosis during pregnancy is decreasing and that outcome has improved, management is complicated by the observations that azole antifungal agents can be teratogenic when given to some women, particularly at high doses, early in pregnancy. This article summarizes the data on these issues and offers guidance on the management of coccidioidomycosis during pregnancy.

Disseminated Coccidioidomycosis in Pregnancy

Coccidioidomycosis is a fungal infection contracted through the inhalation of airborne spores, which are most frequently present in desert areas of the southwestern United States and Mexico. Primary immune response to infection is by TH1, a subset of helper T cells. Although pulmonary symptoms are most common, hematogenous systemic spread can also occur. Pregnancy is a well-noted risk factor for disseminated Coccidioides infection. The objective of this review is to provide an overview of coccidioidomycosis and to review immunologic and hormonal factors that increase risk of dissemination in pregnancy. Dissemination may occur more frequently in pregnant patients than in nonpregnant women because of shifts in T-cell immunity, changes in cytokine production, and increased hormone levels. There is disagreement regarding the precise incidence of systemic spread in pregnancy, but most sources agree that risk is substantially increased and vigilance must be high in patients with exposures in endemic areas.

Coccidioidomycosis and pregnancy: a review

Coccidioidomycosis (CM) is a fungal infection endemic to the southwestern United States, northwestern Mexico, and parts of Central and South America. CM has been recognized as a complicating factor in pregnancy since at least the 1940s, and seems to be a relatively uncommon infection during pregnancy. The disease presentation during pregnancy includes a wide clinical spectrum that ranges from mild influenza-like illness and pneumonia, especially in the first two trimesters of pregnancy. The third trimester of pregnancy is a time of high risk for dissemination. Immunologic and hormonal changes during pregnancy and the postpartum period may account for any increased frequency and severity of disease observed during pregnancy. Early diagnosis and appropriate aggressive therapeutic intervention with careful monitoring usually result in good outcome.

Coccidioidomycosis in pregnancy: case report and review of the literature

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A vaccine against coccidioidomycosis is justified and attainable

Coccidioides is a fungal pathogen of humans which can cause a life-threatening respiratory disease in immunocompetent individuals. Recurrent epidemics of coccidioidal infections in Southwestern United States has raised the specter of awareness of this soil-borne microbe, particularly among residents of Arizona and Southern California, and has galvanized research efforts to develop a human vaccine against coccidioidomycosis. In this review, we discuss the rationale for such a vaccine, examine the features of host innate and acquired immune response to Coccidioides infection, describe strategies used to identify and evaluate vaccine candidates, and provide an update on progress toward development of a vaccine against this endemic pathogen.

Pulmonary coccidioidomycosis in a neonatal foal

A 13-day-old foal with profound tachypnoea and respiratory distress was examined. Thoracic radiographs revealed a severe, diffuse miliary pattern, and the foal was markedly hypoxaemic. It failed to improve with empirical treatment, and was euthanased. Lesions associated with Coccidioides immitis infection were identified at postmortem examination, and were limited to the lower respiratory tract.

Exotic pulmonary infections

Pulmonary infections are the commonest type of illnesses seen in everyday practice. Although most infections are caused by a few familiar pathogens, an increase in global travel has led to the occurrence of rare and exotic diseases that often do not manifest until after the traveller returns home. Previously innocuous organisms may also be the cause of exotic infections in patients undergoing transplantation, or very aggressive immunosupression. Such treatment regimes may reactivate quiescent organisms acquired years previously, for example melioidosis and strongyloides stercoralis. In most developed countries there is also an increasing incidence of zoonotic infections, with a number of these presenting with mainly pulmonary symptoms. A carefully taken history of recent travel, exposure to wild or domestic animals or the presence of immunosuppression, is extremely helpful in identifying problematic infections that fall into the realm of the exotic. This review discusses some of the respiratory infections in each of these groups with an emphasis on imported infections.