1
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Cunningham CA, Brown AT, Ravi SN, Bearss JJ, O’Shea MP, Elshaer AK, Biondi MV, Seddighzadeh B, Elmasry SN, Havanur A, Mahajan A, Savic J, Alozie NU, Rappaport D, Urumov A, Blair JE. Improving Coccidioidomycosis Testing for Emergency Department Patients With Suspect Community-Acquired Pneumonia: Analysis of Provider Attitudes and the Effect of a Targeted Intervention. Open Forum Infect Dis 2024; 11:ofae461. [PMID: 39192992 PMCID: PMC11347941 DOI: 10.1093/ofid/ofae461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Accepted: 08/08/2024] [Indexed: 08/29/2024] Open
Abstract
Coccidioidomycosis is a common cause of community-acquired pneumonia in endemic regions. Approximately 20 000 cases of coccidioidomycosis occur annually; however, this statistic is limited by a widespread lack of testing. Here, we analyze emergency medicine provider attitudes toward coccidioidal testing and assess the effect of an intervention to improve testing rates.
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Affiliation(s)
- Cody A Cunningham
- Department of Internal Medicine, Mayo Clinic School of Graduate Medical Education, Scottsdale, Arizona, USA
| | - Ashlyn T Brown
- Department of Internal Medicine, Mayo Clinic School of Graduate Medical Education, Scottsdale, Arizona, USA
| | - Srekar N Ravi
- Department of Internal Medicine, Mayo Clinic School of Graduate Medical Education, Scottsdale, Arizona, USA
| | - Jeremiah J Bearss
- Department of Internal Medicine, Mayo Clinic School of Graduate Medical Education, Scottsdale, Arizona, USA
| | - Michael P O’Shea
- Department of Internal Medicine, Mayo Clinic School of Graduate Medical Education, Scottsdale, Arizona, USA
| | - Amani K Elshaer
- Department of Internal Medicine, Mayo Clinic School of Graduate Medical Education, Scottsdale, Arizona, USA
| | - Matt V Biondi
- Department of Internal Medicine, Mayo Clinic School of Graduate Medical Education, Scottsdale, Arizona, USA
| | - Bobak Seddighzadeh
- Department of Internal Medicine, Mayo Clinic School of Graduate Medical Education, Scottsdale, Arizona, USA
| | - Sandra N Elmasry
- Department of Internal Medicine, Mayo Clinic School of Graduate Medical Education, Scottsdale, Arizona, USA
| | - Amogh Havanur
- Department of Internal Medicine, Mayo Clinic School of Graduate Medical Education, Scottsdale, Arizona, USA
| | - Avanika Mahajan
- Department of Internal Medicine, Mayo Clinic School of Graduate Medical Education, Scottsdale, Arizona, USA
| | - Juliana Savic
- Department of Internal Medicine, Mayo Clinic School of Graduate Medical Education, Scottsdale, Arizona, USA
| | - Nneoma U Alozie
- Department of Internal Medicine, Mayo Clinic School of Graduate Medical Education, Scottsdale, Arizona, USA
| | - Douglas Rappaport
- Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Andrej Urumov
- Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Janis E Blair
- Division of Infectious Disease, Mayo Clinic Arizona, Phoenix, Arizona, USA
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2
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Kassis C, Eric H, Nicolas B, John W, Christopher D, Cody B, Kendra C, Shanna N, Mary M, Joseph WL. Diagnosis of Coccidioidomycosis with the Second-Generation Miravista IgG and IgM Enzyme Immunoassay and the Role of Adding Miravista Coccidioides Antigen Detection to Immunodiagnostic Assays. Med Mycol 2024; 62:myae063. [PMID: 38871943 DOI: 10.1093/mmy/myae063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 04/26/2024] [Accepted: 06/12/2024] [Indexed: 06/15/2024] Open
Abstract
In the present study, we validate and compare the second-generation Miravista Coccidioides IgG and IgM enzyme immunoassays (EIA) (MiraVista Diagnostics [MVD] Ab EIA) to Meridian Diagnostics Coccidioides IgG and IgM EIA (Meridian Ab EIA), immunodiffusion (ID) and complement fixation (CF). We also evaluated whether the addition of Coccidioides antigen testing to anti-Coccidioides antibody testing increased the sensitivity for the diagnosis of currently active coccidioidomycosis. We retrospectively studied 555 patients evaluated at Valleywise Health Medical Center between January 2013 and May 2017 for whom coccidioidomycosis was suspected and samples were submitted to MVD for testing. Specimens were tested for antigen in the MVD antigen enzyme immunoassay (MVD Ag EIA) and for IgG and IgM antibodies with MVD and Meridian Diagnostics EIAs. ID and CF were obtained from medical records. Sensitivity and specificity were 83.0% and 91.1% or MVD Ab EIA, 69.3% and 99.7% for Meridian Ab EIA, 85.4% and 100% for ID and 65.5% and 100% for CF. Combined MVD antigen and antibody detection by EIA and ID resulted in increased sensitivity in disseminated and pulmonary disease (MVD Ag/MVD Ab: 100%, 88.3%; MVD Ag/Meridian Ab: 98.2%, 78.6%; and MVD Ag/ID: 100%, 91.7%). The detection of antibodies by MVD EIA was more sensitive than Meridian EIA or CF but similar to ID. This study supports the use of antigen testing in immunocompromised patients and those with suspected disseminated disease. Furthermore, the addition of antigen detection by EIA to antibody detection resulted in higher sensitivity of all serological tests.
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Affiliation(s)
| | - Holbrook Eric
- MiraVista Diagnostics, 46241, Indianapolis, Indiana, USA
| | - Barros Nicolas
- MiraVista Diagnostics, 46241, Indianapolis, Indiana, USA
- Department of Medicine, Indiana University School of Medicine, 46202, Indianapolis, Indiana
| | - Witt John
- MiraVista Diagnostics, 46241, Indianapolis, Indiana, USA
| | | | - Banks Cody
- MiraVista Diagnostics, 46241, Indianapolis, Indiana, USA
| | - Carlson Kendra
- MiraVista Diagnostics, 46241, Indianapolis, Indiana, USA
| | | | - Murlow Mary
- Valleywise Health Medical Center, 85008 Phoenix, Arizona
| | - Wheat L Joseph
- MiraVista Diagnostics, 46241, Indianapolis, Indiana, USA
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3
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Hayes JF, Nix DE. Challenges Facing Antimicrobial Stewardship Programs in the Endemic Region for Coccidioidomycosis. Open Forum Infect Dis 2024; 11:ofae041. [PMID: 38887479 PMCID: PMC11181196 DOI: 10.1093/ofid/ofae041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/23/2024] [Indexed: 06/20/2024] Open
Abstract
Coccidioidomycosis poses a significant cost and morbidity burden in the United States. Additionally, coccidioidomycosis requires constant decision-making related to prevention, diagnosis, and management. Delays in diagnosis lead to significant consequences, including unnecessary diagnostic workup and antibacterial therapy. Antifungal stewardship considerations regarding empiric, prophylactic, and targeted management of coccidioidomycosis are also complex. In this review, the problems facing antimicrobial stewardship programs (ASPs) in the endemic region for coccidioidomycosis, consequences due to delayed or missed diagnoses of coccidioidomycosis on antibacterial prescribing, and excess antifungal prescribing for prevention and treatment of coccidioidomycosis are elucidated. Finally, our recommendations and research priorities for ASPs in the endemic region for coccidioidomycosis are outlined.
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Affiliation(s)
- Justin F Hayes
- Division of Infectious Diseases, University of Arizona, Tucson, Arizona, USA
- Valley Fever Center for Excellence, University of Arizona, Tucson, Arizona, USA
| | - David E Nix
- Valley Fever Center for Excellence, University of Arizona, Tucson, Arizona, USA
- Department of Pharmacy Practice and Science, University of Arizona, Tucson, Arizona, USA
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4
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Galgiani JN, Lang A, Howard BJ, Pu J, Ruberto I, Koski L, Collins J, Rios E, Williamson T. Access to Urgent Care Practices Improves Understanding and Management of Endemic Coccidioidomycosis: Maricopa County, Arizona, 2018-2023. Am J Med 2024:S0002-9343(24)00268-7. [PMID: 38740320 DOI: 10.1016/j.amjmed.2024.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 04/22/2024] [Accepted: 04/25/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Coccidioidomycosis within endemic regions is often undiagnosed because appropriate testing is not performed. A dashboard was developed to provide information about the prevalence of coccidioidomycosis throughout the year. METHODS Banner Urgent Care Service has many clinics within Maricopa County, Arizona, a highly endemic region for coccidioidomycosis. All clinic visits and subset analyses for patients with International Classification of Diseases, Tenth Revision codes for pneumonia (J18.*) or erythema nodosum (L52) during 2018-2024 were included. Tabulated were daily frequencies of visits, pneumonia and erythema nodosum coding, coccidioidal testing, and test results. Banner Urgent Care Services' counts of monthly coccidioidomycosis diagnoses were compared with those of confirmed coccidioidomycosis cases reported to Maricopa County Department of Public Health. RESULTS Monthly frequencies of urgent care coccidioidomycosis diagnoses strongly correlated with public health coccidioidomycosis case counts (r = 0.86). Testing frequency for coccidioidomycosis correlated with overall pneumonia frequency (r = 0.52). The proportion of pneumonia due to coccidioidomycosis varied between <5% and >45% within and between years. Coccidioidomycosis was a common cause of erythema nodosum (65%; 95% confidence interval, 45%-67%) and independent of pneumonia. Over half of Banner Urgent Care Services' coccidioidomycosis diagnoses were coded for neither pneumonia nor erythema nodosum. CONCLUSION Data provided by the coccidioidomycosis dashboard can assist urgent care practitioners in knowing when coccidioidomycosis is prevalent in the community. Patients with exposure to endemic coccidioidomycosis who develop erythema nodosum or pneumonia should routinely be tested for coccidioidomycosis. Data from private health care organizations can augment surveillance of diseases important to public health.
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Affiliation(s)
- John N Galgiani
- The Valley Fever Center for Excellence, Department of Medicine, and the Department of Immunobiology, College of Medicine-Tucson, University of Arizona, Tucson; The BIO5 Institute, University of Arizona, Tucson.
| | - Anqi Lang
- Department of Data Analytics, Banner Health System, Phoenix, Ariz
| | | | - Jie Pu
- Department of Data Analytics, Banner Health System, Phoenix, Ariz
| | | | - Lia Koski
- Maricopa County Department of Public Health, Phoenix, Ariz
| | | | - Esteban Rios
- School of Osteopathic Medicine, A.T. Still University, Phoenix, Ariz
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5
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Abstract
While rare, the likelihood of encountering a case of a pulmonary endemic mycosis (PEM) in the UK is increasing. Diagnosis may be challenging, often leading to considerable delay to appropriate treatment. Clinical suspicion must be present for respiratory disease, particularly in the immunocompromised or in those not responding to empiric treatment approaches, and an extended travel history should be obtained. This article summarises the epidemiology of PEM, key clinical features, diagnostic strategies and management.
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Affiliation(s)
- Michael J Wilson
- SpR in infectious diseases and microbiology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK.
| | - Irasha Harding
- consultant microbiologist, National Infection Service, Bristol, UK
| | - Andrew M Borman
- deputy director, UKHSA National Mycology Reference Laboratory, Bristol, UK; honorary professor of medical mycology, University of Exeter, Exeter, UK
| | - Elizabeth Johnson
- honorary professor of medical mycology, University of Exeter, Exeter, UK; director, UKHSA National Mycology Reference Laboratory, Bristol, UK
| | - Robert Miller
- Associate Professor of Clinical Infection, Institute for Global Health, University College London
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6
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Krogstad P, Thompson GR, Heidari A, Kuran R, Stephens AV, Butte MJ, Johnson R. A Clinicopathological Categorization System for Clinical Research in Coccidioidomycosis. Open Forum Infect Dis 2023; 10:ofad597. [PMID: 38156047 PMCID: PMC10753911 DOI: 10.1093/ofid/ofad597] [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: 09/01/2023] [Accepted: 11/27/2023] [Indexed: 12/30/2023] Open
Abstract
A wide array of clinical manifestations follow infection with Coccidioides immitis or Coccidioides posadasii, ranging from asymptomatic infection to life-threatening pulmonary disease or extrapulmonary dissemination and meningitis. Epidemiological studies require consistent definitions of cases and their comparative clinical features. Understanding host and pathogen determinants of the severity of coccidioidomycosis also requires that specific clinical features (such as coccidioidal meningitis) and their overlap be precisely defined and quantified. Here we propose a system for categorization of outcomes of coccidioidomycosis in individuals who are not overtly immunocompromised that harmonizes clinical assessments during translational research of this increasingly common disease.
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Affiliation(s)
- Paul Krogstad
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - George R Thompson
- Division of Infectious Diseases, UC Davis School of Medicine, Sacramento California, USA
| | - Arash Heidari
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Dignity Health, Bakersfield Memorial Hospital, Bakersfield, California, USA
| | - Rasha Kuran
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Department of Medicine, Kern Medical, Bakersfield, California, USA
| | - Alexis V Stephens
- Institute of Precision Health, University of California, Los Angeles, California, USA
| | - Manish J Butte
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Department of Microbiology, Immunology, and Molecular Genetics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Royce Johnson
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Department of Medicine, Kern Medical, Bakersfield, California, USA
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7
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Grill FJ, Svarovsky S, Gonzalez-Moa M, Kaleta E, Blair JE, Lovato L, Grant R, Ross K, Linnehan BK, Meegan J, Reilly KS, Brown A, Williams S, Chung Y, Magee DM, Grys TE, Lake DF. Development of a rapid lateral flow assay for detection of anti-coccidioidal antibodies. J Clin Microbiol 2023; 61:e0063123. [PMID: 37655868 PMCID: PMC10512788 DOI: 10.1128/jcm.00631-23] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/10/2023] [Indexed: 09/02/2023] Open
Abstract
Coccidioides spp. are dimorphic fungi that are capable of infecting human and non-human mammals and can cause diverse manifestations of coccidioidomycosis or Valley fever (VF). In combination with clinical symptoms and radiographic findings, antibody-based diagnostic tests are often used to diagnose and monitor patients with VF. Chitinase 1 (CTS1) has previously been identified as the seroreactive antigen used in these diagnostic assays to detect anticoccidial IgG. Here, an indirect enzyme-linked immunosorbent assay to detect IgG to CTS1 demonstrated 165 of 178 (92.7%) patients with a positive result by immunodiffusion (ID) and/or complement fixation (CF) had antibodies to the single antigen CTS1. We then developed a rapid antibody lateral flow assay (LFA) to detect anti-CTS1 antibodies. Out of 143 samples tested, the LFA showed 92.9% positive percent agreement [95% confidence interval (CI), 84.3%-96.9%] and 97.7% negative percent agreement (95% CI, 87.9%-99.6%) with ID and CF assays. Serum or plasma from canines, macaques, and dolphins was also tested by the CTS1 LFA. Test line densities of the CTS1 LFA correlated in a linear manner with the reported CF and ID titers for human and non-human samples, respectively. This 10-min point-of-care test for the rapid detection of anti-coccidioidal antibodies could help to inform healthcare providers in real-time, potentially improving the efficiency of healthcare delivery.
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Affiliation(s)
| | | | | | - Erin Kaleta
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, Arizona, USA
| | - Janis E. Blair
- Division of Infectious Diseases, Mayo Clinic, Phoenix, Arizona, USA
| | - Lydia Lovato
- Veterinary Neurological Center, Phoenix, Arizona, USA
| | - Richard Grant
- Washington National Primate Research Center, Seattle, Washington, USA
| | - Kyle Ross
- National Marine Mammal Foundation, San Diego, California, USA
| | | | - Jenny Meegan
- National Marine Mammal Foundation, San Diego, California, USA
| | - Kenta S. Reilly
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, Arizona, USA
| | - Ashlyn Brown
- Division of Infectious Diseases, Mayo Clinic, Phoenix, Arizona, USA
| | - Stacy Williams
- Center for Personalized Diagnostics, Biodesign Institute, Arizona State University, Tempe, Arizona, USA
| | - Yunro Chung
- Center for Personalized Diagnostics, Biodesign Institute, Arizona State University, Tempe, Arizona, USA
- College of Health Solutions, Arizona State University, Phoenix, Arizona, USA
| | - D. Mitchell Magee
- Center for Personalized Diagnostics, Biodesign Institute, Arizona State University, Tempe, Arizona, USA
| | - Thomas E. Grys
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, Arizona, USA
| | - Douglas F. Lake
- School of Life Sciences, Arizona State University, Tempe, Arizona, USA
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8
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Lucero-Obusan C, Deka R, Schirmer P, Oda G, Holodniy M. Epidemiology of Coccidioidomycosis in the Veterans Health Administration, 2013-2022. J Fungi (Basel) 2023; 9:731. [PMID: 37504720 PMCID: PMC10381299 DOI: 10.3390/jof9070731] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/29/2023] [Accepted: 07/05/2023] [Indexed: 07/29/2023] Open
Abstract
We describe the epidemiology of coccidioidomycosis among a national cohort of Veterans. Using electronic health record data from adults tested for coccidioidomycosis between 1 January 2013 and 31 December 2022, we analyzed differences in baseline demographics (age, sex, race/ethnicity, birth country, comorbidities, residence, and Charlson Comorbidity Index score) between 4204 coccidioidomycosis-test-positive and 63,322 test-negative Veterans. Log-binomial regression models with adjusted risk ratios (aRRs) were used to evaluate risk factors associated with coccidioidomycosis including dissemination, hospitalization, and mortality. Case counts and incidence rates were highest in select counties in Arizona and California where Coccidioides is endemic. Coccidioidomycosis-positive Veterans were younger, more likely to be male, and Philippine-born. The risk factors most highly associated with being coccidioidomycosis-positive included Native Hawaiian/Pacific Islander (aRR 1.068 [95%CI: 1.039-1.098]), Asian (aRR 1.060 [95%CI: 1.037-1.083]), Black (aRR 1.029 [95%CI: 1.022-1.036]), American Indian/Alaska Native (aRR 1.026 [95%CI: 1.004-1.048]) race, and Hispanic/Latino ethnicity (aRR 1.021 [95%CI: 1.013-1.028]). Black race (aRR: 1.058 [95%CI: 1.037-1.081]) and Hispanic/Latino ethnicity (aRR 1.018 [95%CI: 1.0003-1.036]) were also associated with disseminated coccidioidomycosis, strengthening the evidence for the association of coccidioidomycosis, including severe infections, with specific racial and ethnic groups. There were no statistically significant differences in hospitalization within 45 days of testing or 30-day all-cause mortality. Improving our understanding of coccidioidomycosis risk factors is important for targeted prevention strategies and to reduce delays in diagnosis and ineffective treatment.
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Affiliation(s)
- Cynthia Lucero-Obusan
- Public Health National Program Office, Department of Veterans Affairs, Washington, DC 20420, USA
| | - Rishi Deka
- Public Health National Program Office, Department of Veterans Affairs, Washington, DC 20420, USA
| | - Patricia Schirmer
- Public Health National Program Office, Department of Veterans Affairs, Washington, DC 20420, USA
| | - Gina Oda
- Public Health National Program Office, Department of Veterans Affairs, Washington, DC 20420, USA
| | - Mark Holodniy
- Public Health National Program Office, Department of Veterans Affairs, Washington, DC 20420, USA
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA 94305, USA
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9
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Caceres DH, Rodriguez-Barradas MC, Whitaker M, Jackson BR, Kim L, Surie D, Cikesh B, Lindsley MD, McCotter OZ, Berkow EL, Toda M. Fungal Pathogens as Causes of Acute Respiratory Illness in Hospitalized Veterans: Frequency of Fungal Positive Test Results Using Rapid Immunodiagnostic Assays. J Fungi (Basel) 2023; 9:jof9040456. [PMID: 37108910 PMCID: PMC10145596 DOI: 10.3390/jof9040456] [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: 02/13/2023] [Revised: 04/01/2023] [Accepted: 04/03/2023] [Indexed: 04/29/2023] Open
Abstract
Fungal respiratory illnesses caused by endemic mycoses can be nonspecific and are often mistaken for viral or bacterial infections. We performed fungal testing on serum specimens from patients hospitalized with acute respiratory illness (ARI) to assess the possible role of endemic fungi as etiologic agents. Patients hospitalized with ARI at a Veterans Affairs hospital in Houston, Texas, during November 2016-August 2017 were enrolled. Epidemiologic and clinical data, nasopharyngeal and oropharyngeal samples for viral testing (PCR), and serum specimens were collected at admission. We retrospectively tested remnant sera from a subset of patients with negative initial viral testing using immunoassays for the detection of Coccidioides and Histoplasma antibodies (Ab) and Cryptococcus, Aspergillus, and Histoplasma antigens (Ag). Of 224 patient serum specimens tested, 49 (22%) had positive results for fungal pathogens, including 30 (13%) by Coccidioides immunodiagnostic assays, 19 (8%) by Histoplasma immunodiagnostic assays, 2 (1%) by Aspergillus Ag, and none by Cryptococcus Ag testing. A high proportion of veterans hospitalized with ARI had positive serological results for fungal pathogens, primarily endemic mycoses, which cause fungal pneumonia. The high proportion of Coccidioides positivity is unexpected as this fungus is not thought to be common in southeastern Texas or metropolitan Houston, though is known to be endemic in southwestern Texas. Although serological testing suffers from low specificity, these results suggest that these fungi may be more common causes of ARI in southeast Texas than commonly appreciated and more increased clinical evaluation may be warranted.
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Affiliation(s)
- Diego H Caceres
- Centers for Disease Control and Prevention (CDC), Atlanta, GA 30329, USA
- Center of Expertise in Mycology Radboudumc, Canisius Wilhelmina Hospital, 6532 SZ Nijmegen, The Netherlands
- Studies in Translational Microbiology and Emerging Diseases (MICROS) Research Group, School of Medicine and Health Sciences, Universidad del Rosario, Bogota 111221, Colombia
| | | | - Michael Whitaker
- Centers for Disease Control and Prevention (CDC), Atlanta, GA 30329, USA
| | - Brendan R Jackson
- Centers for Disease Control and Prevention (CDC), Atlanta, GA 30329, USA
- US Public Health Service, Rockville, MD 20852, USA
| | - Lindsay Kim
- Centers for Disease Control and Prevention (CDC), Atlanta, GA 30329, USA
- US Public Health Service, Rockville, MD 20852, USA
| | - Diya Surie
- Centers for Disease Control and Prevention (CDC), Atlanta, GA 30329, USA
- US Public Health Service, Rockville, MD 20852, USA
| | - Bryanna Cikesh
- Centers for Disease Control and Prevention (CDC), Atlanta, GA 30329, USA
| | - Mark D Lindsley
- Centers for Disease Control and Prevention (CDC), Atlanta, GA 30329, USA
| | - Orion Z McCotter
- Centers for Disease Control and Prevention (CDC), Atlanta, GA 30329, USA
- Oregon Health Authority, Portland, OR 97232, USA
| | - Elizabeth L Berkow
- Centers for Disease Control and Prevention (CDC), Atlanta, GA 30329, USA
| | - Mitsuru Toda
- Centers for Disease Control and Prevention (CDC), Atlanta, GA 30329, USA
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10
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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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11
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Ashcherkin N, Gupta S, Huff DA, Vikram HR, Ampel NM, Fischer KM, Blair JE. Impact of COVID-19 on diagnosis of primary pulmonary coccidioidomycosis. Medicine (Baltimore) 2022; 101:e30361. [PMID: 36107584 PMCID: PMC9439624 DOI: 10.1097/md.0000000000030361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
The COVID-19 pandemic has disrupted medical care worldwide and caused delays in care for many illnesses and procedures unrelated to COVID-19; however, less clear is how it may have affected diagnosis of conditions that present with similar symptoms, such as primary pulmonary coccidioidomycosis (PPC). We conducted an observational cohort study of patients diagnosed with PPC between March 1 and December 1 in 2 years: 2019 (before COVID-19) and in 2020 (after COVID-19) to compare the time from symptom onset to PPC diagnosis. Relevant demographic and clinical variables were collected, and statistical analyses were performed with the χ2 test, Wilcoxon rank sum test, and Cox proportional hazards regression analysis. During 2019, 83 patients were diagnosed with PPC. During 2020, 113 patients were diagnosed with PPC. For both groups, the median time from symptom onset to diagnosis of PPC was 14 days (P = .13). No significant differences in time to diagnosis existed between the 2 years for location of diagnosis (outpatient clinic, emergency department, or in hospital), for computed tomographic imaging performed before diagnosis, or for number of COVID-19 tests received before PPC diagnosis. In addition, there were no differences in the 2 years between the total number of clinical visits before diagnosis. However, patients in the post-COVID-19 group who had fever were diagnosed with PPC earlier than those without fever (hazard ratio, 1.77; 95% confidence interval, 1.15-2.73; P = .01). Contrary to what we expected, no significant delay in diagnosis of PPC occurred during the COVID-19 pandemic.
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Affiliation(s)
- Nikita Ashcherkin
- Department of Internal Medicine, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Scottsdale, Arizona, USA
| | - Simran Gupta
- Department of Internal Medicine, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Scottsdale, Arizona, USA
| | - Daniel A. Huff
- Department of Internal Medicine, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Scottsdale, Arizona, USA
| | | | - Neil M. Ampel
- Division of Infectious Diseases, Mayo Clinic, Phoenix, Arizona, USA
| | - Karen M. Fischer
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Janis E. Blair
- Division of Infectious Diseases, Mayo Clinic, Phoenix, Arizona, USA
- *Correspondence: Janis E. Blair, Division of Infectious Diseases, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA (e-mail: )
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12
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Coccidioidomycosis in Northern Arizona: an Investigation of the Host, Pathogen, and Environment Using a Disease Triangle Approach. mSphere 2022; 7:e0035222. [PMID: 35972134 PMCID: PMC9599602 DOI: 10.1128/msphere.00352-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Coccidioides immitis and Coccidioides posadasii are the etiological agents of coccidioidomycosis (Valley fever [VF]). Disease manifestation ranges from mild pneumonia to chronic or extrapulmonary infection. If diagnosis is delayed, the risk of severe disease increases. In this report, we investigated the intersection of pathogen, host, and environment for VF cases in Northern Arizona (NAZ), where the risk of acquiring the disease is much lower than in Southern Arizona. We investigated reported cases and assessed pathogen origin by comparing genomes of NAZ clinical isolates to isolates from other regions. Lastly, we surveyed regional soils for presence of Coccidioides. We found that cases of VF increased in NAZ in 2019, and Coccidioides NAZ isolates are assigned to Arizona populations using phylogenetic inference. Importantly, we detected Coccidioides DNA in NAZ soil. Given recent climate modeling of the disease that predicts that cases will continue to increase throughout the region, and the evidence presented in this report, we propose that disease awareness outreach to clinicians throughout the western United States is crucial for improving patient outcomes, and further environmental sampling across the western U.S. is warranted. IMPORTANCE Our work is the first description of the Valley fever disease triangle in Northern Arizona, which addresses the host, the pathogen, and the environmental source in the region. Our data suggest that the prevalence of diagnosed cases rose in 2019 in this region, and some severe cases necessitate hospitalization. We present the first evidence of Coccidioides spp. in Northern Arizona soils, suggesting that the pathogen is maintained in the local environment. Until disease prevention is an achievable option via vaccination, we predict that incidence of Valley fever will rise in the area. Therefore, enhanced awareness of and surveillance for coccidioidomycosis is vital to community health in Northern Arizona.
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13
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Vaccines to Prevent Coccidioidomycosis: A Gene-Deletion Mutant of Coccidioides Posadasii as a Viable Candidate for Human Trials. J Fungi (Basel) 2022; 8:jof8080838. [PMID: 36012826 PMCID: PMC9410110 DOI: 10.3390/jof8080838] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/05/2022] [Accepted: 08/07/2022] [Indexed: 11/19/2022] Open
Abstract
Coccidioidomycosis is an endemic fungal infection that is reported in up to 20,000 persons per year and has an economic impact close to $1.5 billion. Natural infection virtually always confers protection from future exposure, and this suggests that a preventative vaccine strategy is likely to succeed. We here review progress toward that objective. There has been ongoing research to discover a coccidioidal vaccine over the past seven decades, including one phase III clinical trial, but for reasons of either efficacy or feasibility, a safe and effective vaccine has not yet been developed. This review first summarizes the past research to develop a coccidioidal vaccine. It then details the evidence that supports a live, gene-deletion vaccine candidate as suitable for further development as both a veterinary and a human clinical product. Finally, a plausible vaccine development plan is described which would be applicable to this vaccine candidate and also useful to other future candidates. The public health and economic impact of coccidioidomycosis fully justifies a public private partnership for vaccine development, and the development of a vaccine for this orphan disease will likely require some degree of public funding.
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14
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Caceres DH, Lindsley MD. Comparison of Immunodiagnostic Assays for the Rapid Diagnosis of Coccidioidomycosis in Dogs. J Fungi (Basel) 2022; 8:jof8070728. [PMID: 35887483 PMCID: PMC9317878 DOI: 10.3390/jof8070728] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 07/04/2022] [Accepted: 07/11/2022] [Indexed: 02/05/2023] Open
Abstract
Coccidioidomycosis is a disease caused by the dimorphic fungi Coccidioides spp., which affects humans and a variety of animal species, including domestic dogs. In dogs, accurate diagnosis could provide a substantial improvement on the quality of canine life, as well as an advancement in the mapping of regions endemic for coccidioidomycosis. The purpose of this study was to compare immunodiagnostic assays for anti-Coccidioides antibody (Ab) detection in dogs’ serum. Three commercially available immunodiagnostic assays (IMMY®; Norman, OK, USA) were evaluated, including the sōna Coccidioides Ab Lateral Flow Assay (LFA), Coccidioides IDCF immunodiffusion assay (IDCF), and the Clarus Coccidioides Ab Enzyme Immunoassay (EIA). Assays were evaluated using 98 dog serum samples: 29 from dogs with coccidioidomycosis, 15 from dogs diagnosed with histoplasmosis, 10 from dogs diagnosed with blastomycosis, and 44 from dogs without a fungal disease. Using specimens from dogs with coccidioidomycosis, the IDCF had an accuracy of 92% (95% confidence interval [95% CI] = 85–96%), the EIA had an accuracy of 91% (95% CI = 83–96%), and the LFA displayed an accuracy of 82% (95% CI = 73–89%). Using Kappa analysis, the agreement between LFA and EIA was 0.59 (95% CI = 0.42–0.75), that between LFA and IDCF was 0.64 (95% CI = 0.48–0.79), and that between EIA and IDCF was 0.79 (95% CI = 0.64–0.90). Most cross-reactions were observed in dogs with histoplasmosis. Compared with EIA and IDCF, the LFA requires substantially less laboratory equipment and infrastructure and rapidly produces results, offering a substantial improvement for the initial screening of coccidioidomycosis in dogs.
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Affiliation(s)
- Diego H. Caceres
- Mycotic Diseases Branch, Centers for Disease Control and Prevention (CDC), Atlanta, GA 30333, USA
- Center of Expertise in Mycology Radboudumc/CWZ, 6525GA Nijmegen, The Netherlands
- Studies in Translational Microbiology and Emerging Diseases (MICROS) Research Group, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 1653, Colombia
- Correspondence: (D.H.C.); (M.D.L.)
| | - Mark D. Lindsley
- Mycotic Diseases Branch, Centers for Disease Control and Prevention (CDC), Atlanta, GA 30333, USA
- Correspondence: (D.H.C.); (M.D.L.)
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15
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Williams SL, Chiller T. Update on the Epidemiology, Diagnosis, and Treatment of Coccidioidomycosis. J Fungi (Basel) 2022; 8:666. [PMID: 35887423 PMCID: PMC9316141 DOI: 10.3390/jof8070666] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/17/2022] [Accepted: 06/20/2022] [Indexed: 11/16/2022] Open
Abstract
Coccidioidomycosis is a fungal infection caused by Coccidioides immitis and Coccidioides posadasii. The dimorphic fungi live in the soils of arid and semi-arid regions of the western United States, as well as parts of Mexico, Central America, and South America. Incidence of disease has risen consistently in recent years, and the geographic distribution of Coccidioides spp. appears to be expanding beyond previously known areas of endemicity. Climate factors are predicted to further extend the range of environments suitable for the growth and dispersal of Coccidioides species. Most infections are asymptomatic, though a small proportion result in severe or life-threatening forms of disease. Primary pulmonary coccidioidomycosis is commonly mistaken for community-acquired pneumonia, often leading to inappropriate antibacterial treatment and unnecessary healthcare costs. Diagnosis of coccidioidomycosis is challenging and often relies on clinician suspicion to pursue laboratory testing. Advancements in diagnostic tools and antifungal therapy developments seek to improve the early detection and effective management of infection. This review will highlight recent updates and summarize the current understanding of the epidemiology, diagnosis, and treatment of coccidioidomycosis.
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Affiliation(s)
- Samantha L. Williams
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA 30329, USA;
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16
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Ramadan FA, Ellingson KD, Canales RA, Bedrick EJ, Galgiani JN, Donovan FM. Cross-Sectional Study of Clinical Predictors of Coccidioidomycosis, Arizona, USA. Emerg Infect Dis 2022; 28:1091-1100. [PMID: 35608552 PMCID: PMC9155888 DOI: 10.3201/eid2806.212311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Demographic and clinical indicators have been described to support identification of coccidioidomycosis; however, the interplay of these conditions has not been explored in a clinical setting. In 2019, we enrolled 392 participants in a cross-sectional study for suspected coccidioidomycosis in emergency departments and inpatient units in Coccidioides-endemic regions. We aimed to develop a predictive model among participants with suspected coccidioidomycosis. We applied a least absolute shrinkage and selection operator to specific coccidioidomycosis predictors and developed univariable and multivariable logistic regression models. Univariable models identified elevated eosinophil count as a statistically significant predictive feature of coccidioidomycosis in both inpatient and outpatient settings. Our multivariable outpatient model also identified rash (adjusted odds ratio 9.74 [95% CI 1.03–92.24]; p = 0.047) as a predictor. Our results suggest preliminary support for developing a coccidioidomycosis prediction model for use in clinical settings.
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17
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Amoth H, Kemp WL. Coccidioides immitis: A Rare Form of the Disease Process Presenting in an Even Rarer Location. Am J Forensic Med Pathol 2022; 43:90-92. [PMID: 34935695 DOI: 10.1097/paf.0000000000000736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Coccidioides immitis is a dimorphic fungus, growing as a fungus in the soil and as a yeast in the human body, that is geographically limited in the United States, being most commonly associated with the San Joaquin Valley and found in California and Arizona. In most individuals, infection with C. immitis causes an asymptomatic, self-limited pulmonary infection; however, in a small percentage of individuals, the infection is disseminated and can involve any organ. We present the case of a 50-year-old man who was found unresponsive in his home in the northern portion of the United States. Autopsy revealed a 2163-g spleen. The initial differential diagnosis for the splenomegaly was an infection or a neoplastic process, such as leukemia. Because of the geographic location where the body was found, C. immitis was not initially considered; however, microscopic examination confirmed the presence of C. immitis spherules, which were found in the spleen and other organs. Granulomatous inflammation, often associated with spherules, was also present in a kidney, the pancreas, the thyroid gland, a parathyroid gland, and the heart. Additional investigation after the autopsy revealed that the decedent had spent time in the past in California, which would have allowed for exposure to C. immitis. The decedent had a rare form of a disease process not normally associated with the geographic location in which he was found, which highlights the need for continued diligence in death investigation so as to not allow a first impression to impair the correct final determination.
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Affiliation(s)
- Haley Amoth
- From the University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND
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18
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Duttke SH, Beyhan S, Singh R, Neal S, Viriyakosol S, Fierer J, Kirkland TN, Stajich JE, Benner C, Carlin AF. Decoding Transcription Regulatory Mechanisms Associated with Coccidioides immitis Phase Transition Using Total RNA. mSystems 2022; 7:e0140421. [PMID: 35076277 PMCID: PMC8788335 DOI: 10.1128/msystems.01404-21] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/04/2022] [Indexed: 01/07/2023] Open
Abstract
New or emerging infectious diseases are commonly caused by pathogens that cannot be readily manipulated or studied under common laboratory conditions. These limitations hinder standard experimental approaches and our abilities to define the fundamental molecular mechanisms underlying pathogenesis. The advance of capped small RNA sequencing (csRNA-seq) now enables genome-wide mapping of actively initiated transcripts from genes and other regulatory transcribed start regions (TSRs) such as enhancers at a precise moment from total RNA. As RNA is nonpathogenic and can be readily isolated from inactivated infectious samples, csRNA-seq can detect acute changes in gene regulation within or in response to a pathogen with remarkable sensitivity under common laboratory conditions. Studying valley fever (coccidioidomycosis), an emerging endemic fungal infection that increasingly impacts livestock, pet, and human health, we show how csRNA-seq can unravel transcriptional programs driving pathogenesis. Performing csRNA-seq on RNA isolated from different stages of the valley fever pathogen Coccidioides immitis revealed alternative promoter usage, connected cis-regulatory domains, and a WOPR family transcription factor, which are known regulators of virulence in other fungi, as being critical for pathogenic growth. We further demonstrate that a C. immitis WOPR homologue, CIMG_02671, activates transcription in a WOPR motif-dependent manner. Collectively, these findings provide novel insights into valley fever pathogenesis and provide a proof of principle for csRNA-seq as a powerful means to determine the genes, regulatory mechanisms, and transcription factors that control the pathogenesis of highly infectious agents. IMPORTANCE Infectious pathogens like airborne viruses or fungal spores are difficult to study; they require high-containment facilities, special equipment, and expertise. As such, establishing approaches such as genome editing or other means to identify the factors and mechanisms underlying caused diseases, and, thus, promising drug targets, is costly and time-intensive. These obstacles particularly hinder the analysis of new, emerging, or rare infectious diseases. We recently developed a method termed capped small RNA sequencing (csRNA-seq) that enables capturing acute changes in active gene expression from total RNA. Prior to csRNA-seq, such an analysis was possible only by using living cells or nuclei, in which pathogens are highly infectious. The process of RNA purification, however, inactivates pathogens and thus enables the analysis of gene expression during disease progression under standard laboratory conditions. As a proof of principle, here, we use csRNA-seq to unravel the gene regulatory programs and factors likely critical for the pathogenesis of valley fever, an emerging endemic fungal infection that increasingly impacts livestock, pet, and human health.
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Affiliation(s)
- Sascha H. Duttke
- Department of Medicine, Division of Endocrinology, UC San Diego School of Medicine, La Jolla, California, USA
| | - Sinem Beyhan
- Department of Medicine, Division of Infectious Disease, UC San Diego School of Medicine, La Jolla, California, USA
- J. Craig Venter Institute, Department of Infectious Diseases, La Jolla, California, USA
| | - Rajendra Singh
- Department of Medicine, Division of Infectious Disease, UC San Diego School of Medicine, La Jolla, California, USA
| | - Sonya Neal
- Section of Cell and Developmental Biology, Division of Biological Sciences, University of California, San Diego, La Jolla, California, USA
| | - Suganya Viriyakosol
- Department of Medicine, Division of Infectious Disease, UC San Diego School of Medicine, La Jolla, California, USA
| | - Joshua Fierer
- Department of Medicine, Division of Infectious Disease, UC San Diego School of Medicine, La Jolla, California, USA
- Infectious Diseases Section, VA Healthcare San Diego, San Diego, California, USA
- Department of Pathology, UC San Diego School of Medicine, La Jolla, California, USA
| | - Theo N. Kirkland
- Department of Medicine, Division of Infectious Disease, UC San Diego School of Medicine, La Jolla, California, USA
- Department of Pathology, UC San Diego School of Medicine, La Jolla, California, USA
| | - Jason E. Stajich
- Department of Microbiology and Plant Pathology, Institute for Integrative Genome Biology, University of California—Riverside, Riverside, California, USA
| | - Christopher Benner
- Department of Medicine, Division of Endocrinology, UC San Diego School of Medicine, La Jolla, California, USA
| | - Aaron F. Carlin
- Department of Medicine, Division of Infectious Disease, UC San Diego School of Medicine, La Jolla, California, USA
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19
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Gastélum-Cano JM, Dautt-Castro M, García-Galaz A, Felix-Murray K, Rascón-Careaga A, Cano-Rangel MA, Islas-Osuna MA. The clinical laboratory evolution in coccidioidomycosis detection: Future perspectives. J Mycol Med 2021; 31:101159. [PMID: 34157512 DOI: 10.1016/j.mycmed.2021.101159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 05/22/2021] [Accepted: 05/25/2021] [Indexed: 11/18/2022]
Abstract
Coccidioidomycosis is a systemic disease caused by the fungi Coccidioides immitis and C. posadasii. It is a prevalent disease in arid regions with high temperatures and low precipitations in America. Coccidioidomycosis is a highly endemic disease of US-Mexico border states but commonly underdiagnosed. The diagnosis of coccidiomycosis is not easy due to the lack of specific symptoms; it is usually an integral approach, including clinical laboratory tests as an essential part of the diagnosis. Nevertheless, despite various laboratory tests available, affordability can be a limitation, mainly in developing countries. This review's objectives are 1) to learn the different laboratory approaches that arose and their application for clinical diagnosis; 2) to discuss their advantages and weaknesses, and finally, 3) propose what is on the horizon for future advances in clinical laboratory diagnosis of coccidioidomycosis. It has been a long way in laboratory tests evolution to detect coccidioidomycosis from tissue microscopy to Real-Time PCR. However, there is a delay in technology adoption for Coccidioides spp. detection in the clinical laboratory. The molecular Point of Care Testing (POCT) technology has reached us in our trench while research in PCR variants stills on-going. None of the currently existing scientific literature in coccidioidomycosis research has mentioned it. However, this trend in infectious and non-infectious disease diagnosis will continue in that way in order to offer better options for an easy and fast diagnosis. Undoubtedly, the implementation of molecular POCT for Coccidioides spp. would save resources in health care attention and improve access to diagnostic tools.
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Affiliation(s)
- José María Gastélum-Cano
- Lab. de Genética y Biología Molecular, Centro de Investigación en Alimentación y Desarrollo A.C. (CIAD, A.C.) Gustavo Enrique Astiazarán Rosas No. 46. La Victoria, Hermosillo, Sonora 83304, Mexico
| | - Mitzuko Dautt-Castro
- Instituto Potosino de Investigación Científica y Tecnológica A.C. (IPICYT). Camino a la Presa de San José No. 2055. Lomas 4ta Sección, San Luis Potosí, S.L.P. 78216, Mexico
| | - Alfonso García-Galaz
- Lab. de Microbiología Molecular, Centro de Investigación en Alimentación y Desarrollo A.C. (CIAD, A.C.) Gustavo Enrique Astiazarán Rosas No. 46. La Victoria, Hermosillo, Sonora 83304, Mexico
| | - Katya Felix-Murray
- Universidad de Sonora. Blvd. Luis Encinas y Rosales S/N. Col. Centro, Hermosillo, Sonora 83000, Mexico
| | - Antonio Rascón-Careaga
- Universidad de Sonora. Blvd. Luis Encinas y Rosales S/N. Col. Centro, Hermosillo, Sonora 83000, Mexico
| | - Manuel A Cano-Rangel
- Hospital Infantil del Estado de Sonora (HIES), Reforma 355. Ley 57, Hermosillo, Sonora 83100, Mexico
| | - María A Islas-Osuna
- Lab. de Genética y Biología Molecular, Centro de Investigación en Alimentación y Desarrollo A.C. (CIAD, A.C.) Gustavo Enrique Astiazarán Rosas No. 46. La Victoria, Hermosillo, Sonora 83304, Mexico.
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20
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Trainor M, Henkel E, Diaz LZ, Carrasco R. Disseminated coccidioidomycosis in a patient with juvenile idiopathic arthritis receiving infliximab. Pediatr Rheumatol Online J 2021; 19:63. [PMID: 33933122 PMCID: PMC8088673 DOI: 10.1186/s12969-021-00549-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 04/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Coccidioides immitis is a dimorphic fungus endemic to the arid climates of the Southwest United States, Mexico and parts of Central and South America. Human infection occurs through inhalation of spores with less than half of exposures progressing to a symptomatic state that primarily consists of pulmonary manifestations. Disseminated coccidioidomycosis is exceedingly rare, occurring in fewer than 1 % of symptomatic infections. Through hematogenous spread, the fungus can infect most organ systems and may be fatal without systemic antifungal treatment. Individuals with impaired cell-mediated immunity either from primary immunodeficiency disorders or secondary to immunosuppression with medications such as tumor necrosis factor alpha (TNF-α) inhibitors have increased risk of disseminated coccidioidomycosis and previous cases of coccidioidomycosis have been reported with biologic therapy. CASE PRESENTATION We present a case of disseminated coccidioidomycosis in a 16-year-old female with polyarticular juvenile idiopathic arthritis (JIA) being treated with prednisone, methotrexate, and infliximab. The patient presented with symptoms of meningeal irritation, bilateral choroidal lesions, and necrotizing peripheral pneumonia. Her infection was thought to be a reactivation of coccidioidomycosis given her history of resolved pneumonia that occurred after traveling to Arizona, New Mexico, and El Paso one year prior to presentation. Following diagnosis, she improved with discontinuation of her immunosuppressive medications and two weeks of intravenous amphotericin B and fluconazole with plans for lifetime treatment with fluconazole while immunosuppressed. Due to worsening arthritis, she will begin tofacitinib and continue close monitoring of chest x-rays and coccidioides antibody. CONCLUSIONS Patients undergoing immunosuppressive therapy for rheumatological conditions are at increased risk of disseminated coccidioidomycosis and should be evaluated with high suspicion when presenting with atypical symptoms and history of travel to endemic regions.
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Affiliation(s)
- Megan Trainor
- Division of Dermatology, Dell Medical School, University of Texas at Austin, 601 E 15th St, CEC C2.470 , Austin, TX, 78701 , USA.
| | - Emily Henkel
- grid.267309.90000 0001 0629 5880Long School of Medicine, University of Texas Health Science Center at San Antonio, Texas San Antonio, USA
| | - Lucia Z. Diaz
- grid.89336.370000 0004 1936 9924Division of Dermatology, Dell Medical School, University of Texas at Austin, 601 E 15th St, CEC C2.470 , Austin, TX 78701 USA ,grid.413578.c0000 0004 0637 322XDell Children’s Medical Center, Texas Austin, USA ,grid.89336.370000 0004 1936 9924Department of Pediatrics, Dell Medical School, University of Texas at Austin, Austin, Texas USA
| | - Ruy Carrasco
- grid.487005.e0000 0004 0368 0216Presbyterian Healthcare Services, New Mexico Albuquerque, USA
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21
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Chan H, Nematollahi S, Manesh R, Geha RM, Minter DJ. More Is Less. J Hosp Med 2021; 16:239-243. [PMID: 32966193 DOI: 10.12788/jhm.3488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 06/10/2020] [Indexed: 11/20/2022]
Affiliation(s)
- Hilary Chan
- Department of Medicine, University of California, San Francisco, California
| | - Saman Nematollahi
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Reza Manesh
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rabih M Geha
- Department of Medicine, University of California, San Francisco, California
- Medical Service, San Francisco VA Medical Center, San Francisco, California
| | - Daniel J Minter
- Department of Medicine, University of California, San Francisco, California
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22
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Heaney AK, Head JR, Broen K, Click K, Taylor J, Balmes JR, Zelner J, Remais JV. Coccidioidomycosis and COVID-19 Co-Infection, United States, 2020. Emerg Infect Dis 2021; 27:1266-1273. [PMID: 33755007 PMCID: PMC8084485 DOI: 10.3201/eid2705.204661] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
We review the interaction between coronavirus disease (COVID-19) and coccidioidomycosis, a respiratory infection caused by inhalation of Coccidioides fungal spores in dust. We examine risk for co-infection among construction and agricultural workers, incarcerated persons, Black and Latino populations, and persons living in high dust areas. We further identify common risk factors for co-infection, including older age, diabetes, immunosuppression, racial or ethnic minority status, and smoking. Because these diseases cause similar symptoms, the COVID-19 pandemic might exacerbate delays in coccidioidomycosis diagnosis, potentially interfering with prompt administration of antifungal therapies. Finally, we examine the clinical implications of co-infection, including severe COVID-19 and reactivation of latent coccidioidomycosis. Physicians should consider coccidioidomycosis as a possible diagnosis when treating patients with respiratory symptoms. Preventive measures such as wearing face masks might mitigate exposure to dust and severe acute respiratory syndrome coronavirus 2, thereby protecting against both infections.
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23
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Gade L, McCotter OZ, Bowers JR, Waddell V, Brady S, Carvajal JA, Sunenshine R, Komatsu KK, Engelthaler DM, Chiller T, Litvintseva AP. The detection of Coccidioides from ambient air in Phoenix, Arizona: Evidence of uneven distribution and seasonality. Med Mycol 2021; 58:552-559. [PMID: 31506673 DOI: 10.1093/mmy/myz093] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 08/15/2019] [Accepted: 08/23/2019] [Indexed: 11/12/2022] Open
Abstract
Coccidioidomycosis is a debilitating fungal disease caused by inhalation of arthroconidia. We developed a novel approach for detection of airborne Coccidioides and used it to investigate the distribution of arthroconidia across the Phoenix, Arizona, metropolitan area. Air filters were collected daily from 21 stationary air-sampling units across the area: the first set collected before, during and after a large dust storm on August 25, 2015, and the second over the 45-day period September 25-November 8, 2016. Analysis of DNA extracted from the filters demonstrated that the day of the dust storm was not associated with increase of Coccidioides in air samples, although evidence of the low-level polymerase chain reaction (PCR) inhibition was observed in DNA extracted from samples collected on the day of the dust storm. Testing over 45 days identified uneven geographic distribution suggesting Coccidioides hot spots. In 2016, highest daily concentration of arthroconidia was observed between September 25-October 20, and only sporadic low levels were detected after that. These results provide evidence of seasonality and uneven spatial distribution of Coccidioides in the air. Our results demonstrate that routine air monitoring for arthroconidia is possible and provides an important tool for Coccidioides surveillance, which can address important questions about environmental exposure and human infection.
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Affiliation(s)
- Lalitha Gade
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Orion Z McCotter
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jolene R Bowers
- Pathogen and Microbiome Division, Translational Genomics Research Institute (TGen-North), Flagstaff, Arizona, USA
| | - Victor Waddell
- Arizona Department of Health Services, Phoenix, Arizona, USA
| | - Shane Brady
- Arizona Department of Health Services, Phoenix, Arizona, USA
| | | | - Rebecca Sunenshine
- Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,Maricopa County Department of Public Health, Phoenix, Arizona, USA
| | | | - David M Engelthaler
- Pathogen and Microbiome Division, Translational Genomics Research Institute (TGen-North), Flagstaff, Arizona, USA
| | - Tom Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Grizzle AJ, Wilson L, Nix DE, Galgiani JN. Clinical and Economic Burden of Valley Fever in Arizona: An Incidence-Based Cost-of-Illness Analysis. Open Forum Infect Dis 2021; 8:ofaa623. [PMID: 33575419 PMCID: PMC7863867 DOI: 10.1093/ofid/ofaa623] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 12/11/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Coccidioidomycosis, ie, Valley fever, is an important fungal infection in the Southwest, with half to two thirds of all cases occurring in Arizona. This endemic respiratory disease can range from primary uncomplicated pneumonia to disseminated infection such as meningitis with chronic pulmonary complications. Valley fever diagnoses have risen over recent years and cause substantial morbidity and economic burden in Arizona. METHODS We estimated the lifetime cost-of-illness associated with all cases of Valley fever diagnosed in 2019 in Arizona. Natural history of the disease was determined from literature and expert opinion and assigned costs from national data sources to determine lifetime direct and indirect costs (work loss). RESULTS Total lifetime costs of $736 million were estimated for the 10 359 cases of Valley fever diagnosed in Arizona in 2019. Direct costs of $671 million accounted for over 90% of expenditures, with $65 million in indirect costs. Disseminated infection produces the highest economic burden at $1.26 million direct and $137 400 indirect costs per person. The lowest Valley fever lifetime costs were for cases of primary uncomplicated pneumonia with $23 200 in direct costs and $1300 in lost wages. The average lifetime direct costs across all Valley fever manifestations are $64 800 per person diagnosed in Arizona in 2019 and $6300 for indirect costs. CONCLUSIONS Valley fever is responsible for substantial economic burden in Arizona. Our estimates underscore the value of supporting research into developing more rapid diagnostic tests, better therapies, and ultimately a preventative vaccine to address this important public health problem in Arizona.
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Affiliation(s)
- Amy J Grizzle
- Center for Health Outcomes & PharmacoEconomic Research, University of Arizona College of Pharmacy, Tucson, Arizona, USA
| | - Leslie Wilson
- Department of Clinical Pharmacy, University of California, San Francisco, California, USA
| | - David E Nix
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona, USA
- Department of Medicine, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA
| | - John N Galgiani
- Department of Medicine, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA
- Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA
- Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona, USA
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Galgiani JN, Blair JE, Ampel NM, Thompson GR. Treatment for Early, Uncomplicated Coccidioidomycosis: What Is Success? Clin Infect Dis 2021; 70:2008-2012. [PMID: 31544210 DOI: 10.1093/cid/ciz933] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 09/19/2019] [Indexed: 12/13/2022] Open
Abstract
The care of primary pulmonary coccidioidomycosis remains challenging. Such infections produce a variety of signs, symptoms, and serologic responses that cause morbidity in patients and concern in treating clinicians for the possibility of extrapulmonary dissemination. Illness may be due to ongoing fungal growth that produces acute inflammatory responses, resulting in tissue damage and necrosis, and for this, administering an antifungal drug may be of benefit. In contrast, convalescence may be prolonged by other immunologic reactions to infection, even after fungal replication has been arrested, and in those situations, antifungal therapy is unlikely to yield clinical improvement. In this presentation, we discuss what findings are clinical indicators of fungal growth and what other sequelae are not. Understanding these differences provides a rational management strategy for deciding when to continue, discontinue, or reinstitute antifungal treatments.
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Affiliation(s)
- 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
| | - Janis E Blair
- Division of Infectious Diseases, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Neil M Ampel
- 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.,Division of Infectious Diseases, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - George R Thompson
- Division of Infectious Diseases, Department of Internal Medicine, University of California, Davis Medical Center, Sacramento, California, USA
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Donovan FM, Ramadan FA, Khan SA, Bhaskara A, Lainhart WD, Narang AT, Mosier JM, Ellingson KD, Bedrick EJ, Saubolle MA, Galgiani JN. Comparison of a Novel Rapid Lateral Flow Assay to Enzyme Immunoassay Results for Early Diagnosis of Coccidioidomycosis. Clin Infect Dis 2020; 73:e2746-e2753. [PMID: 32818956 DOI: 10.1093/cid/ciaa1205] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 08/13/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Coccidioidomycosis (CM) is a common cause of community acquired pneumonia (CAP) where CM is endemic. Manifestations include self-limited pulmonary infection, chronic fibrocavitary pulmonary disease, and disseminated coccidioidomycosis (DCM). Most infections are identified by serological assays including enzyme-linked immunoassay (EIA), complement fixation (CF) and immunodiffusion (IMDF). These are time-consuming and take days to result, impeding early diagnosis. A new lateral flow assay (LFA, Sōna, IMMY, Norman OK) improves time-to-result to one hour. METHODS We prospectively enrolled 392 suspected CM patients, compared the LFA to standard EIA and included procalcitonin evaluation. RESULTS Compared to standard EIA, LFA demonstrates 31% sensitivity (95% CI of 20%-44%) and 92% specificity (95% CI of 88%-95%). Acute pulmonary disease (74%) was the most common clinical syndrome. Hospitalized patients constituted 75% of subjects, and compared to outpatients, they more frequently had ≥ 3 previous healthcare facility visits (p = 0.05), received antibacterials (p & 0.01) and had > 3 antibacterial courses (p & 0.01). Procalcitonin (PCT) was &0.25 ng/ml in 52 (83%) EIA+ patients, suggesting infection was not bacterial. CONCLUSIONS When CM is a possible diagnosis, LFA identified nearly a third of EIA+ infections. Combined with PCT &0.25 ng/ml, LFA could reduce unnecessary antibacterial use by 77%.
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Affiliation(s)
- Fariba M Donovan
- The Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, Arizona.,The University of Arizona College of Medicine-Tucson, Tucson, Arizona
| | - Ferris A Ramadan
- Department of Epidemiology and Biostatistics, University of Arizona College of Public Health, Tucson, Arizona
| | - Sher A Khan
- Department of Epidemiology and Biostatistics, University of Arizona College of Public Health, Tucson, Arizona
| | - Apoorva Bhaskara
- The University of Arizona College of Medicine-Tucson, Tucson, Arizona
| | - William D Lainhart
- The University of Arizona College of Medicine-Tucson, Tucson, Arizona.,Department of Pathology, University of Arizona College of Medicine-Tucson, Tucson Arizona
| | - Aneesh T Narang
- University of Arizona College of Medicine-Phoenix, and Banner-University Medical Center Phoenix, Phoenix, Arizona
| | - Jarrod M Mosier
- The University of Arizona College of Medicine-Tucson, Tucson, Arizona
| | - Katherine D Ellingson
- Department of Epidemiology and Biostatistics, University of Arizona College of Public Health, Tucson, Arizona
| | - Edward J Bedrick
- Department of Epidemiology and Biostatistics, University of Arizona College of Public Health, Tucson, Arizona
| | - Michael A Saubolle
- University of Arizona College of Medicine-Phoenix, and Banner-University Medical Center Phoenix, Phoenix, Arizona
| | - John N Galgiani
- The Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, Arizona.,The University of Arizona College of Medicine-Tucson, Tucson, Arizona
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Pu J, Donovan FM, Ellingson K, Leroy G, Stone J, Bedrick E, Galgiani JN. Clinician Practice Patterns That Result in the Diagnosis of Coccidioidomycosis Before or During Hospitalization. Clin Infect Dis 2020; 73:e1587-e1593. [PMID: 32511677 DOI: 10.1093/cid/ciaa739] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/04/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Coccidioidomycosis (CM) is common and important within endemic regions, requiring specific testing for diagnosis. Long delays in diagnosis have been ascribed to ambulatory clinicians. However, how their testing practices have impacted patient care has not been systematically unexplored. METHODS We analyzed practice patterns for CM diagnoses over 3 years within a large Arizona healthcare system, including diagnosis location, patient characteristics, and care-seeking patterns associated with missed diagnosis. RESULTS For 2043 CM diagnoses, 72.9% were made during hospital admission, 21.7% in ambulatory clinics, 3.2% in emergency units, and only 0.5% in urgent care units. A 40.6% subgroup of hospitalized patients required neither intensive care unit or hospital-requiring procedures, had a median length of stay of only 3 days, but still incurred both substantial costs ($27.0 million) and unnecessary antibiotic administrations. Prior to hospital diagnosis (median of 32 days), 45.1% of patients had 1 or more visits with symptoms consistent with CM. During those visits, 71.3% were not tested for CM. Diagnoses were delayed a median of 27 days. CONCLUSIONS Lack of testing for CM in ambulatory care settings within a region endemic for CM resulted in a large number of hospital admissions, attendant costs, and unneeded antibacterial drug use, much of which would otherwise be unnecessary. Improving this practice is challenging since many clinicians did not train where CM is common, resulting in significant inertia to change. Determining the best way to retrain clinicians to diagnose CM earlier is an opportunity to explore which strategies might be the most effective.
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Affiliation(s)
- Jie Pu
- Division of Data Analytics, Banner Health Corporation, Phoenix, Arizona, USA
| | - Fariba M Donovan
- Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA.,Department of Medicine, University Arizona College of Medicine-Tucson, Tucson, Arizona, USA
| | - Kate Ellingson
- Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA.,Department of Epidemiology and Biostatistics, University of Arizona College of Public Health, Tucson, Arizona, USA
| | - Gondy Leroy
- Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA.,Management Information Systems, University of Arizona Eller College of Business, Tucson, Arizona, USA
| | - Jeff Stone
- Department of Medicine, University Arizona College of Medicine-Tucson, Tucson, Arizona, USA.,Arizona Cancer Center, University of Arizona-Tucson, Tucson, Arizona, USA
| | - Edward Bedrick
- Department of Epidemiology and Biostatistics, University of Arizona College of Public Health, Tucson, Arizona, USA
| | - John N Galgiani
- Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA.,Department of Medicine, University Arizona College of Medicine-Tucson, Tucson, Arizona, USA.,Department of Medicine, University Arizona College of Medicine-Phoenix, Phoenix, Arizona, USA
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Donovan FM, Wightman P, Zong Y, Gabe L, Majeed A, Ynosencio T, Bedrick EJ, Galgiani JN. Delays in Coccidioidomycosis Diagnosis and Associated Healthcare Utilization, Tucson, Arizona, USA. Emerg Infect Dis 2020; 25:1745-1747. [PMID: 31441755 PMCID: PMC6711243 DOI: 10.3201/eid2509.190023] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Tucson, Arizona, USA, is a highly coccidioidomycosis-endemic area. We conducted a retrospective review of 815 patients in Tucson over 2.7 years. Of 276 patients with coccidioidomycosis, 246 had a delay in diagnosis; median delay was 23 days. Diagnosis delay was associated with coccidioidomycosis-related costs totaling $589,053 and included extensive antibacterial drug use.
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Krogstad P, Johnson R, Garcia-Lloret MI, Heidari A, Butte MJ. Host-Pathogen Interactions in Coccidioidomycosis: Prognostic Clues and Opportunities for Novel Therapies. Clin Ther 2019; 41:1939-1954.e1. [PMID: 31648806 PMCID: PMC10482146 DOI: 10.1016/j.clinthera.2019.08.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 08/16/2019] [Accepted: 08/19/2019] [Indexed: 01/09/2023]
Abstract
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.
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Affiliation(s)
- Paul Krogstad
- Department of Pediatrics, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA, USA; Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA, USA.
| | - Royce Johnson
- Department of Medicine, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA, USA
| | - Maria I Garcia-Lloret
- Department of Pediatrics, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA, USA
| | - Arash Heidari
- Department of Medicine, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA, USA
| | - Manish J Butte
- Department of Pediatrics, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA, USA; Department of Microbiology, Immunology, and Molecular Genetics, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA, USA
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Gorris ME, Treseder KK, Zender CS, Randerson JT. Expansion of Coccidioidomycosis Endemic Regions in the United States in Response to Climate Change. GEOHEALTH 2019; 3:308-327. [PMID: 32159021 PMCID: PMC7007157 DOI: 10.1029/2019gh000209] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 08/16/2019] [Accepted: 08/20/2019] [Indexed: 05/21/2023]
Abstract
Coccidioidomycosis (Valley fever) is a fungal disease endemic to the southwestern United States. Across this region, temperature and precipitation influence the extent of the endemic region and number of Valley fever cases. Climate projections for the western United States indicate that temperatures will increase and precipitation patterns will shift, which may alter disease dynamics. We estimated the area potentially endemic to Valley fever using a climate niche model derived from contemporary climate and disease incidence data. We then used our model with projections of climate from Earth system models to assess how endemic areas will change during the 21st century. By 2100 in a high warming scenario, our model predicts that the area of climate-limited endemicity will more than double, the number of affected states will increase from 12 to 17, and the number of Valley fever cases will increase by 50%. The Valley fever endemic region will expand north into dry western states, including Idaho, Wyoming, Montana, Nebraska, South Dakota, and North Dakota. Precipitation will limit the disease from spreading into states farther east and along the central and northern Pacific coast. This is the first quantitative estimate of how climate change may influence Valley fever in the United States. Our predictive model of Valley fever endemicity may provide guidance to public health officials to establish disease surveillance programs and design mitigation efforts to limit the impacts of this disease.
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Affiliation(s)
- Morgan E. Gorris
- Department of Earth System ScienceUniversity of CaliforniaIrvineCAUSA
| | - Kathleen K. Treseder
- Department of Ecology and Evolutionary BiologyUniversity of CaliforniaIrvineCAUSA
| | - Charles S. Zender
- Department of Earth System ScienceUniversity of CaliforniaIrvineCAUSA
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Ginn R, Mohty R, Bollmann K, Goodsell J, Mendez G, Bradley B, Galgiani JN. Delays in Coccidioidomycosis Diagnosis and Relationship to Healthcare Utilization, Phoenix, Arizona, USA 1. Emerg Infect Dis 2019; 25:1742-1744. [PMID: 31228403 PMCID: PMC6711213 DOI: 10.3201/eid2509.190019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
We developed an electronic records methodology to programmatically estimate the date of first appearance of coccidioidomycosis symptoms in patients. We compared the diagnostic delay with overall healthcare utilization charges. Many patients (46%) had delays in diagnosis of >1 month. Billed healthcare charges before diagnosis increased with length of delay.
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Hage CA, Carmona EM, Epelbaum O, Evans SE, Gabe LM, Haydour Q, Knox KS, Kolls JK, Murad MH, Wengenack NL, Limper AH. Microbiological Laboratory Testing in the Diagnosis of Fungal Infections in Pulmonary and Critical Care Practice. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2019; 200:535-550. [PMID: 31469325 PMCID: PMC6727169 DOI: 10.1164/rccm.201906-1185st] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background: Fungal infections are of increasing incidence and importance in immunocompromised and immunocompetent patients. Timely diagnosis relies on appropriate use of laboratory testing in susceptible patients.Methods: The relevant literature related to diagnosis of invasive pulmonary aspergillosis, invasive candidiasis, and the common endemic mycoses was systematically reviewed. Meta-analysis was performed when appropriate. Recommendations were developed using the Grading of Recommendations Assessment, Development, and Evaluation approach.Results: This guideline includes specific recommendations on the use of galactomannan testing in serum and BAL and for the diagnosis of invasive pulmonary aspergillosis, the role of PCR in the diagnosis of invasive pulmonary aspergillosis, the role of β-d-glucan assays in the diagnosis of invasive candidiasis, and the application of serology and antigen testing in the diagnosis of the endemic mycoses.Conclusions: Rapid, accurate diagnosis of fungal infections relies on appropriate application of laboratory testing, including antigen testing, serological testing, and PCR-based assays.
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Oltean HN, Etienne KA, Roe CC, Gade L, McCotter OZ, Engelthaler DM, Litvintseva AP. Utility of Whole-Genome Sequencing to Ascertain Locally Acquired Cases of Coccidioidomycosis, Washington, USA. Emerg Infect Dis 2019; 25:501-506. [PMID: 30789132 PMCID: PMC6390764 DOI: 10.3201/eid2503.181155] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Coccidioidomycosis is an emerging fungal infection in Washington, USA, and the epidemiology of the disease in this state is poorly understood. We used whole-genome sequencing to differentiate locally acquired cases in Washington on the basis of the previously identified phylogeographic population structure of Coccidioides spp. Clinical isolates from coccidioidomycosis cases involving possible Washington soil exposure were included. Of 17 human infections with epidemiologic evidence of possible local acquisition, 4 were likely locally acquired infections and 13 were likely acquired outside Washington. Isolates from locally acquired cases clustered within the previously established Washington clade of C. immitis. Genetic differences among these strains suggest multiple environmental reservoirs of C. immitis in the state.
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Ginn R, Mohty R, Bollmann K, Goodsell J, Mendez G, Bradley B, Galgiani JN. Delays in Coccidioidomycosis Diagnosis and Relationship to Healthcare Utilization, Phoenix, Arizona, USA1. Emerg Infect Dis 2019. [DOI: 10.3201/eid2508.190019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Donovan FM, Wightman P, Zong Y, Gabe L, Majeed A, Ynosencio T, Bedrick EJ, Galgiani JN. Delays in Coccidioidomycosis Diagnosis and Associated Healthcare Utilization, Tucson, Arizona, USA. Emerg Infect Dis 2019. [DOI: 10.3201/eid2508.190023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Jasbi P, Mitchell NM, Shi X, Grys TE, Wei Y, Liu L, Lake DF, Gu H. Coccidioidomycosis Detection Using Targeted Plasma and Urine Metabolic Profiling. J Proteome Res 2019; 18:2791-2802. [DOI: 10.1021/acs.jproteome.9b00100] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Paniz Jasbi
- Arizona Metabolomics Laboratory, College of Health Solutions, Arizona State University, Scottsdale, Arizona 85259, United States
| | - Natalie M. Mitchell
- School of Life Sciences, Mayo Clinic Collaborative Research Building, Arizona State University, Scottsdale, Arizona 85259, United States
| | - Xiaojian Shi
- Arizona Metabolomics Laboratory, College of Health Solutions, Arizona State University, Scottsdale, Arizona 85259, United States
| | - Thomas E. Grys
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, Arizona 85054, United States
| | - Yiping Wei
- Arizona Metabolomics Laboratory, College of Health Solutions, Arizona State University, Scottsdale, Arizona 85259, United States
| | - Li Liu
- Department of Biomedical Informatics, Arizona State University, Tempe, Arizona 85259, United States
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona 85259, United States
| | - Douglas F. Lake
- School of Life Sciences, Mayo Clinic Collaborative Research Building, Arizona State University, Scottsdale, Arizona 85259, United States
| | - Haiwei Gu
- Arizona Metabolomics Laboratory, College of Health Solutions, Arizona State University, Scottsdale, Arizona 85259, United States
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McCotter OZ, Benedict K, Engelthaler DM, Komatsu K, Lucas KD, Mohle-Boetani JC, Oltean H, Vugia D, Chiller TM, Sondermeyer Cooksey GL, Nguyen A, Roe CC, Wheeler C, Sunenshine R. Update on the Epidemiology of coccidioidomycosis in the United States. Med Mycol 2019; 57:S30-S40. [PMID: 30690599 DOI: 10.1093/mmy/myy095] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 10/18/2018] [Indexed: 01/25/2023] Open
Abstract
The incidence of reported coccidioidomycosis in the past two decades has increased greatly; monitoring its changing epidemiology is essential for understanding its burden on patients and the healthcare system and for identifying opportunities for prevention and education. We provide an update on recent coccidioidomycosis trends and public health efforts nationally and in Arizona, California, and Washington State. In Arizona, enhanced surveillance shows that coccidioidomycosis continues to be associated with substantial morbidity. California reported its highest yearly number of cases ever in 2016 and has implemented interventions to reduce coccidioidomycosis in the prison population by excluding certain inmates from residing in prisons in high-risk areas. Coccidioidomycosis is emerging in Washington State, where phylogenetic analyses confirm the existence of a unique Coccidioides clade. Additional studies of the molecular epidemiology of Coccidioides will improve understanding its expanding endemic range. Ongoing public health collaborations and future research priorities are focused on characterizing geographic risk, particularly in the context of environmental change; identifying further risk reduction strategies for high-risk groups; and improving reporting of cases to public health agencies.
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Affiliation(s)
- Orion Z McCotter
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Kaitlin Benedict
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Ken Komatsu
- Arizona Department of Health Services, Phoenix, Arizona, USA
| | - Kimberley D Lucas
- California Correctional Healthcare Services, Elk Grove, California, USA
| | | | - Hanna Oltean
- Washington State Department of Health, Shoreline, Washington, USA
| | - Duc Vugia
- California Department of Public Health, Richmond and Sacramento, California, USA
| | - Tom M Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Alyssa Nguyen
- California Department of Public Health, Richmond and Sacramento, California, USA
| | - Chandler C Roe
- Translational Genomics Research Institute, Flagstaff, Arizona, USA.,Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, Arizona, USA
| | - Charlotte Wheeler
- California Correctional Healthcare Services, Elk Grove, California, USA
| | - Rebecca Sunenshine
- Maricopa County Department of Public Health, Phoenix, Arizona, USA.,Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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The Rise of Valley Fever: Prevalence and Cost Burden of Coccidioidomycosis Infection in California. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16071113. [PMID: 30925716 PMCID: PMC6480346 DOI: 10.3390/ijerph16071113] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 03/20/2019] [Accepted: 03/25/2019] [Indexed: 11/23/2022]
Abstract
Coccidioidomycosis (CM) is a fungal infection endemic in the southwestern United States (US). In California, CM incidence increased more than 213% (from 6.0/100,000 (2014) to 18.8/100,000 (2017)) and continues to increase as rates in the first half of 2018 are double that of 2017 during the same period. This cost-of-illness study provides essential information to be used in health planning and funding as CM infections continue to surge. We used a “bottom-up” approach to determine lifetime costs of 2017 reported incident CM cases in California. We defined CM natural history and used a societal approach to determine direct and discounted indirect costs using literature, national datasets, and expert interviews. The total lifetime cost burden of CM cases reported in 2017 in California is just under $700 million US dollars, with $429 million in direct costs and $271 million in indirect costs. Per person direct costs were highest for disseminated disease ($1,023,730), while per person direct costs were lowest for uncomplicated CM pneumonia ($22,039). Cost burden varied by county. This is the first study to estimate total costs of CM, demonstrating its huge cost burden for California.
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McCotter O, Kennedy J, McCollum J, Bartholomew M, Iralu J, Jackson BR, Haberling D, Benedict K. Coccidioidomycosis Among American Indians and Alaska Natives, 2001-2014. Open Forum Infect Dis 2019; 6:ofz052. [PMID: 30882015 DOI: 10.1093/ofid/ofz052] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 01/25/2019] [Accepted: 02/01/2019] [Indexed: 11/15/2022] Open
Abstract
Background American Indians and Alaska Natives (AI/ANs) may be uniquely vulnerable to coccidioidomycosis given the large population residing in the Southwestern United States. We describe coccidioidomycosis-associated hospitalizations and outpatient visits during 2001-2014 in the Indian Health Service (IHS) system and compare hospitalizations with data from the Agency for Healthcare Research and Quality's National (Nationwide) Inpatient Sample (NIS). Methods We identified hospitalizations in the IHS and the NIS and outpatient visits in the IHS using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes 114.0-114.9. We calculated average annual hospitalization and outpatient visit rates per 1 000 000 population and used Poisson regression to calculate rate ratios (RRs) and 95% confidence intervals (CIs). We used multivariable logistic regression to assess factors associated with IHS hospitalization. Results AI/ANs had the highest average annual hospitalization rate (58.0; 95% CI, 49.5-66.6) of any racial/ethnic group in the NIS, compared with 13.4 (95% CI, 12.7-14.2) for non-Hispanic whites. IHS data showed a hospitalization rate of 37.0; the median length of stay (interquartile range) was 6 (3-10) days. The average annual outpatient visit rate in IHS was 764.2, and it increased from 529.9 in 2001 to 845.9 in 2014. Male sex, age ≥65 years, diabetes, and extrapulmonary or progressive coccidioidomycosis were independently associated with increased risk for hospitalization. Twenty-four percent of patients had ICD-9-CM codes for community-acquired pneumonia in the 3 months before coccidioidomycosis diagnosis. Conclusions AI/ANs experience high coccidioidomycosis-associated hospitalization rates, high morbidity, and possible missed opportunities for earlier diagnosis. Yearly trends in IHS data were similar to the general increase in hospitalizations and reported cases nationwide in the same period.
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Affiliation(s)
- Orion McCotter
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jordan Kennedy
- Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | | | - Brendan R Jackson
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Dana Haberling
- Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kaitlin Benedict
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
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Tartof SY, Benedict K, Xie F, Rieg GK, Yu KC, Contreras R, Truong J, Fong K, Tseng HF, Jacobsen SJ, Mody RK. Testing for Coccidioidomycosis among Community-Acquired Pneumonia Patients, Southern California, USA 1. Emerg Infect Dis 2019; 24:779-781. [PMID: 29553315 PMCID: PMC5875278 DOI: 10.3201/eid2404.161568] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
We conducted a cohort study to identify characteristics associated with testing for, and testing positive for, coccidioidomycosis among patients with community-acquired pneumonia in southern California, USA. Limited and delayed testing probably leads to underdiagnosis among non-Hispanic black, Filipino, or Hispanic patients and among high-risk groups, including persons in whom antimicrobial drug therapy has failed.
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Benedict K, Ireland M, Weinberg MP, Gruninger RJ, Weigand J, Chen L, Perez-Lockett K, Bledsoe C, Denny L, Cibulskas K, Gibbons-Burgener S, Kocharian A, DeBess E, Miller TK, Lepp A, Cronquist L, Warren K, Serrano JA, Loveland C, Turabelidze G, McCotter O, Jackson BR. Enhanced Surveillance for Coccidioidomycosis, 14 US States, 2016. Emerg Infect Dis 2019; 24:1444-1452. [PMID: 30014837 PMCID: PMC6056093 DOI: 10.3201/eid2408.171595] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Although coccidioidomycosis in Arizona and California has been well-characterized, much remains unknown about its epidemiology in states where it is not highly endemic. We conducted enhanced surveillance in 14 such states in 2016 by identifying cases according to the Council of State and Territorial Epidemiologists case definition and interviewing patients about their demographic characteristics, clinical features, and exposures. Among 186 patients, median time from seeking healthcare to diagnosis was 38 days (range 1–1,654 days); 70% had another condition diagnosed before coccidioidomycosis testing occurred (of whom 83% were prescribed antibacterial medications); 43% were hospitalized; and 29% had culture-positive coccidioidomycosis. Most (83%) patients from nonendemic states had traveled to a coccidioidomycosis-endemic area. Coccidioidomycosis can cause severe disease in residents of non–highly endemic states, a finding consistent with previous studies in Arizona, and less severe cases likely go undiagnosed or unreported. Improved coccidioidomycosis awareness in non–highly endemic areas is needed.
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Khan MA, Brady S, Komatsu KK. Testing for coccidioidomycosis in emergency departments in Arizona. Med Mycol 2018; 56:900-902. [PMID: 29228363 DOI: 10.1093/mmy/myx112] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 10/07/2017] [Indexed: 01/12/2023] Open
Abstract
Testing practices for coccidioidomycosis in the emergency department are poorly understood. We described characteristics of patients tested for coccidioidomycosis in emergency departments in Arizona and examined coccidioidomycosis testing among community-acquired pneumonia (CAP) patients. Emergency department visit records for patients tested for coccidioidomycosis and CAP patients were extracted from the Arizona hospital discharge database. In sum, 2.8% of CAP patients were tested for coccidioidomycosis. The proportion of patients tested varied substantially by healthcare facility and provider.
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Affiliation(s)
- Mohammed A Khan
- Arizona Department of Health Services, Phoenix, AZ, USA.,Department of Epidemiology and Laney Graduate School, Emory University, Atlanta, GA, USA
| | - Shane Brady
- Arizona Department of Health Services, Phoenix, AZ, USA
| | - Ken K Komatsu
- Arizona Department of Health Services, Phoenix, AZ, USA
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Stoney RJ, Esposito DH, Kozarsky P, Hamer DH, Grobusch MP, Gkrania-Klotsas E, Libman M, Gautret P, Lian Lim P, Leder K, Schwartz E, Sotir MJ, Licitra C. Infectious diseases acquired by international travellers visiting the USA. J Travel Med 2018; 25:5075537. [PMID: 30124885 PMCID: PMC6638561 DOI: 10.1093/jtm/tay053] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 07/26/2018] [Indexed: 11/14/2022]
Abstract
BACKGROUND Estimates of travel-related illness have focused predominantly on populations from highly developed countries visiting low- or middle-income countries, yet travel to and within high-income countries is very frequent. Despite being a top international tourist destination, few sources describe the spectrum of infectious diseases acquired among travellers to the USA. METHODS We performed a descriptive analysis summarizing demographic and travel characteristics, and clinical diagnoses among non-US-resident international travellers seen during or after travel to the USA at a GeoSentinel clinic from 1 January 1997 through 31 December 2016. RESULTS There were 1222 ill non-US-resident travellers with 1393 diagnoses recorded during the 20-year analysis period. Median age was 40 (range 0-86 years); 52% were female. Patients visited from 63 countries and territories, most commonly Canada (31%), Germany (14%), France (9%) and Japan (7%). Travellers presented with a range of illnesses; skin and soft tissue infections of unspecified aetiology were the most frequently reported during travel (29 diagnoses, 14% of during-travel diagnoses); arthropod bite/sting was the most frequently reported after travel (173 diagnoses, 15% after-travel diagnoses). Lyme disease was the most frequently reported arthropod-borne disease after travel (42, 4%). Nonspecific respiratory, gastrointestinal and systemic infections were also among the most frequently reported diagnoses overall. Low-frequency illnesses (<2% of cases) made up over half of diagnoses during travel and 41% of diagnoses after travel, including 13 cases of coccidioidomycosis and mosquito-borne infections like West Nile, dengue and Zika virus diseases. CONCLUSIONS International travellers to the USA acquired a diverse array of mostly cosmopolitan infectious diseases, including nonspecific respiratory, gastrointestinal, dermatologic and systemic infections comparable to what has been reported among travellers to low- and middle-income countries. Clinicians should consider the specific health risks when preparing visitors to the USA and when evaluating and treating those who become ill.
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Affiliation(s)
- Rhett J. Stoney
- Travelers’ Health Branch, Division of Global Migration and Quarantine, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Douglas H. Esposito
- Travelers’ Health Branch, Division of Global Migration and Quarantine, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Phyllis Kozarsky
- Travelers’ Health Branch, Division of Global Migration and Quarantine, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
- Department of Medicine, Emory University, Atlanta, GA, USA
| | - Davidson H. Hamer
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Martin P. Grobusch
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, The Netherlands
| | | | - Michael Libman
- Centre for Tropical Diseases, McGill University Health Centre, Montreal, Canada
| | - Philippe Gautret
- Aix Marseille Univ, IRD, AP-HM, SSA, VITROME, IHU-Méditerranée Infection, Marseille, France
| | - Poh Lian Lim
- Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Karin Leder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Victorian Infectious Disease Service, Royal Melbourne Hospital at the Doherty Institute, Melbourne, Australia
| | - Eli Schwartz
- Institute of Geographic Medicine and Tropical Diseases, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mark J. Sotir
- Travelers’ Health Branch, Division of Global Migration and Quarantine, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Carmelo Licitra
- Orlando Health Infectious Disease, University of Central Florida College of Medicine, Orlando, FL, USA
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Multicenter Clinical Validation of a Cartridge-Based Real-Time PCR System for Detection of Coccidioides spp. in Lower Respiratory Specimens. J Clin Microbiol 2018; 56:JCM.01277-17. [PMID: 29212702 PMCID: PMC5786707 DOI: 10.1128/jcm.01277-17] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 11/28/2017] [Indexed: 11/30/2022] Open
Abstract
Available methods for the diagnosis of coccidioidomycosis have significant shortcomings relative to accuracy and timeliness. We retrospectively and prospectively evaluated the diagnostic performance and reproducibility of a new cartridge-based real-time PCR assay for Coccidioides spp. directly in lower respiratory secretions and compared them to today's “gold standard,” fungal culture. The GeneSTAT Coccidioides assay uses a 106-bp target sequence repeated multiple times (∼60×) per genome, thus lowering the limit of detection (LOD) for extracted DNA to 10 genome equivalents/ml. A total of 332 prospective and retrospective individual patient specimens were tested. The retrospective samples consisted of 100 bronchoalveolar lavage or bronchial wash (BAL/BW) (51 positive and 49 negative by culture) specimens that had been collected previously and stored at −70°C. These samples were tested by the GeneSTAT Coccidioides assay across three clinical test sites. The sensitivity was 100%, and the specificity ranged between 93.8% and 100%. There was minimal variance in the percent agreement across the three sites, 95.6% to 100%. Additionally, a total of 232 fresh (prospective) deidentified BAL/BW specimens were tested across the three clinical sites, which included a number of specimens from Southern California to provide a diversity of isolates. Specimens were tested by fungal culture, with any isolates of Coccidioides, except for one, being confirmed by molecular means (AccuProbe). The sensitivity of the GeneSTAT Coccidioides assay across the three sites was 100% (4/4) for positive fresh specimens, and the overall specificity of the assay was 99.6% (227/228), ranging from 98.1% to 100%. In testing for cross-reactivity, the assay was 100% specific when screened against 47 different bacterial, viral, and fungal species.
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Diaz JH. Travel-related risk factors for coccidioidomycosis. J Travel Med 2018; 25:5001358. [PMID: 29796604 DOI: 10.1093/jtm/tay027] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 03/25/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Coccidioidomycosis is a regionally endemic systemic mycosis with unique risk factors. Since people travel for business or pleasure, and often in conjunction with their avocations or hobbies, the objectives of this review were to describe these and other risk factors for coccidioidomycosis; to alert travel medicine clinicians to the different presenting manifestations of coccidioidomycosis; and to recommend effective treatment, disease control and prevention strategies. METHODS To meet the objectives of this review, Internet search engines were queried with the keywords as medical subject headings over the study period, 1970-2017. RESULTS The principle transmission mechanism of coccidioidomycosis is by deep inhalation of aerosolized arthroconidia with resulting symptomatic pulmonary infections ranging from febrile influenza-like illnesses to fatal disseminated mycoses. In addition to residency or travel in endemic areas, persons immunocompromised by advancing age, pregnancy, cancer, corticosteroid therapy, diabetes, organ transplantation and human immunodeficiency virus infection are at significantly increased risks of contracting coccidioidomycosis. Persons of African, Asian, Filipino and Hispanic descent are also at increased risks of contracting coccidioidomycosis. Hobbies associated with coccidioidomycosis have included armadillo hunting, model airplane flying and archaeological digging. Occupational risk factors for coccidioidomycosis include endemic exposures during military maneuvers, outdoor track and field events, road construction, solar-power and wind-power farm construction, archaeological excavation and prison work. CONCLUSIONS Coccidioidomycosis is more common in endemic and non-endemic areas than previously recognized and can result in considerable morbidity and mortality. Coccidioidomycosis is increasingly imported from endemic areas in the Western Hemisphere to non-endemic areas worldwide. Increased awareness of disease risk factors among the public and the international healthcare community will improve the timely diagnosis and treatment of coccidioidomycosis and prevent disease progression, dissemination and deaths in residents in and in travellers returning from endemic regions. A vaccine for the primary prevention of coccidioidomycosis would be cost-effective.
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Affiliation(s)
- James H Diaz
- Environmental and Occupational Health Sciences, School of Public Health and School of Medicine, Louisiana State University Health Sciences Center (LSUHSC), Office 2020 Gravier Street, Third Floor, New Orleans, LA 70112, USA
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Enhanced Antibody Detection and Diagnosis of Coccidioidomycosis with the MiraVista IgG and IgM Detection Enzyme Immunoassay. J Clin Microbiol 2017; 55:893-901. [PMID: 28053216 DOI: 10.1128/jcm.01880-16] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 12/16/2016] [Indexed: 11/20/2022] Open
Abstract
Coccidioidomycosis is a common cause of community-acquired pneumonia in areas of the southwestern United States in which the disease is endemic. Clinical presentations range from self-limited disease to severe disseminated disease. Therefore, early and accurate diagnosis is essential to ensure appropriate treatment and monitoring. Currently available diagnostic tests have variable accuracy, particularly in certain patient populations, and new tests may offer improved accuracy for the diagnosis of coccidioidomycosis. Serum samples from 103 cases of coccidioidomycosis and 373 controls were tested for IgG and IgM antibodies using the MVista anti-Coccidioides antibody enzyme immunoassay. Serum specimens from 170 controls from areas in which the disease is endemic and 44 cases were tested by immunodiffusion at MiraVista Diagnostics. The sensitivity of the MVista antibody assay was 88.3%, and the specificity was 90%. The sensitivity was maintained in the presence of immunocompromising conditions or immunosuppressive therapies. The sensitivity of immunodiffusion was 60.2%, and the specificity was 98.8%. The sensitivity of complement fixation (62 cases) was 66.1%, but the specificity could not be determined. The MVista anti-Coccidioides antibody enzyme immunoassay offers improved sensitivity, compared with immunodiffusion and complement fixation, is not impaired in immunocompromised patients, and permits highly reproducible semiquantification.
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Community-Acquired Pneumonia. Infect Dis (Lond) 2017. [PMCID: PMC7149822 DOI: 10.1016/b978-0-7020-6285-8.00028-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Community-acquired pneumonia (CAP) is the most common cause of admission of adults in the USA. Diagnosis of community-acquired pneumonia is relatively easy in previously healthy patients but may be challenging in those with underlying cardiopulmonary disease or in the elderly. The highest yield for diagnostic testing for CAP etiology is in the critically ill and those with risk factors for drug-resistant pathogens. The majority of hospitalized CAP patients can be treated with either a respiratory fluoroquinolone or cephalosporin/macrolide combination. Alternative antibiotic treatment should be based on presence of multiple risk factors for drug-resistant pathogens (i.e. healthcare-associated pneumonia), specific risks (e.g. travel or zoonotic risks), or unique syndromes (e.g. toxin-mediated community-acquired MRSA syndrome). Decisions regarding initial placement in an intensive care unit (ICU) of tenuous CAP patients should be based on the number of minor physiologic factors and laboratory abnormalities associated with risk of subsequent deterioration. Number of deaths by pneumonia is decreasing in the world linked to child vaccination of pneumococcus and large-scale use of antibiotics in India/China.
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Forrester JD, Guo HH, Weiser TG. Coccidioidomycosis: Surgical Issues and Implications. Surg Infect (Larchmt) 2016; 17:645-655. [PMID: 27740893 DOI: 10.1089/sur.2016.148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Coccidioidomycosis, commonly called "valley fever," "San Joaquin fever," "desert fever," or "desert rheumatism," is a multi-system illness caused by infection with Coccidioides fungi (C. immitis or C. posadasii). This organism is endemic to the desert Southwest regions of the United States and Mexico and to parts of South America. The manifestations of infection occur along a spectrum from asymptomatic to mild self-limited fever to severe disseminated disease. METHODS Review of the English-language literature. RESULTS There are five broad indications for surgical intervention in patients with coccidioidomycosis: Tissue diagnosis in patients at risk for co-existing pathology, perforation, bleeding, impingement on critical organs, and failure to resolve with medical management. As part of a multidisciplinary team, surgeons may be responsible for the care of infected patients, particularly those with severe disease. CONCLUSION This review discusses the history, microbiology, epidemiology, pathology, diagnosis, and treatment of coccidioidomycosis, focusing on situations that may be encountered by surgeons.
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Affiliation(s)
| | - Haiwei Henry Guo
- 2 Department of Radiology, Stanford University , Stanford, California
| | - Thomas G Weiser
- 1 Department of Surgery, Stanford University , Stanford, California
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Hartmann CA, Aye WT, Blair JE. Treatment considerations in pulmonary coccidioidomycosis. Expert Rev Respir Med 2016; 10:1079-91. [PMID: 27635942 DOI: 10.1080/17476348.2017.1234378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Carlos A Hartmann
- a Division of Infectious Diseases , Mayo Clinic Hospital , Phoenix , AZ , USA
| | - Wint T Aye
- b Department of Internal Medicine , Mayo Clinic , Scottsdale , AZ , USA
| | - Janis E Blair
- a Division of Infectious Diseases , Mayo Clinic Hospital , Phoenix , AZ , USA
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