Characteristics of patients with mild to moderate primary pulmonary coccidioidomycosis

Hypoxemic Respiratory Failure and Coccidioidomycosis-Associated Acute Respiratory Distress Syndrome

Background

Severe coccidioidomycosis presenting with respiratory failure is an uncommon manifestation of disease. Current knowledge of this condition is limited to case reports and small case series.

Methods

A retrospective multicenter review of patients with coccidioidomycosis-associated acute respiratory distress syndrome (CA-ARDS) was conducted. It assessed clinical and laboratory variables at the time of presentation, reviewed the treatment course, and compared this cohort with a national database of patients with noncoccidioidomycosis ARDS. Survivors and nonsurvivors of coccidioidomycosis were also compared to determine prognostic factors.

Results

In this study, CA-ARDS (n = 54) was most common in males, those of Hispanic ethnicity, and those with concurrent diabetes mellitus. As compared with the PETAL network database (Prevention and Early Treatment of Acute Lung Injury; n = 1006), patients with coccidioidomycosis were younger, had fewer comorbid conditions, and were less acidemic. The 90-day mortality was 15.4% for patients with coccidioidomycosis, as opposed to 42.6% (P < .0001) for patients with noncoccidioidomycosis ARDS. Patients with coccidioidomycosis who died, as compared with those who survived, were older, had higher APACHE II scores (Acute Physiology and Chronic Health Evaluation), and did not receive corticosteroid therapy.

Conclusions

CA-ARDS is an uncommon but morbid manifestation of infection. When compared with a national database, the overall mortality appears favorable vs other causes of ARDS. Patients with CA-ARDS had a low overall mortality but required prolonged antifungal therapy. The utility of corticosteroids in this condition remains unconfirmed.

Endemic mycoses - are we making progress in management?

PURPOSE OF REVIEW

The endemic fungi are a significant cause of morbidity and mortality in effected patients. The range of endemicity for these are expanding with infections observed outside of traditional locations. Enhanced diagnostic and treatment practices may significantly alter patient outcomes.

RECENT FINDINGS

Recently completed clinical trials have focused on an assessment of improving efficacy while minimizing patient toxicity. Practice changing trials have been completed in histoplasmosis showing the utility of a single up-front liposomal amphotericin B dose followed by standard itraconazole dosing. The recent evaluation of several antifungal options including isauvconazole in the treatment of coccidioidomycosis also show promise for additional therapeutic agents. A recently conducted trial has also shown the superiority of amphotericin B therapy over itraconazole in the treatment of talaromycosis.

SUMMARY

The increased range of endemic mycoses coupled with the growing immunocompromised patient population mandates continued investigation of improved diagnostic and therapeutic options. Advances in these areas have led to more rapid diagnosis and more efficacious antifungal therapy.

Development of a rapid lateral flow assay for detection of anti-coccidioidal antibodies

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.

Isavuconazole in the Treatment of Chronic Forms of Coccidioidomycosis

Coccidioidomycosis is a fungal infection with a range of clinical manifestations. Currently used antifungal agents exhibit variable efficacy and toxicity profiles that necessitate evaluation of additional therapeutic options. Improvement was observed in the majority of patients treated with isavuconazole, with clinical failures observed only in those with coccidioidal meningitis.

Review of Clinical and Laboratory Diagnostics for Coccidioidomycosis

Coccidioidomycosis is a fungal disease associated with soil exposure that frequently goes undiagnosed due at least in part to its nonspecific presentation and the lack of clinical suspicion by health care providers. Currently available diagnostics for coccidioidomycosis offer qualitative results that can suffer from low specificity, while semiquantitative assays are labor-intensive and complex and can require multiple days to complete. Furthermore, significant confusion exists regarding the optimal diagnostic algorithms and appropriate usage of available diagnostic tests. This review aims to inform clinical laboratorians and treating clinicians about the current diagnostic landscape, appropriate diagnostic strategies, and future diagnostic directions for coccidioidomycosis, which is expected to become more prevalent due to increased migration into areas of endemicity and climate changes.

Diagnosis and Treatment of Pulmonary Coccidioidomycosis and Paracoccidioidomycosis

Coccidioidomycosis (CM) and paracoccidioidomycosis (PCM) are systemic mycoses that are highly endemic in Latin America and have recently been included on the World Health Organization (WHO) Fungal Priority Pathogens List. Coccidioides immitis and Coccidioides posadasii are recognized as etiological agents of CM, with peculiarities in their geographic distribution. The genus Paracoccidioides now includes Paracoccidioides lutzii and the Paracoccidioides brasiliensis complex, which encompasses four phylogenetic species. In both diseases, pulmonary signs and symptoms are the main reasons for patients to seek medical assistance, and they are frequently misdiagnosed as tuberculosis. In this paper, we present a critical view of the strategies for diagnosis and clinical management of CM and PCM. Over the past few decades, there has been an increase in the number of reports of endemic fungal infections in areas previously thought to be "non-endemic" due to climate change and increased travel, among other factors. Learning to recognize their main epidemiological aspects and clinical manifestations is crucial so that clinicians can include them in the differential diagnosis of lung disease and avoid late diagnosis.

Systemic Antifungal Therapy for Invasive Pulmonary Infections

Antifungal therapy for pulmonary fungal diseases is in a state of flux. Amphotericin B, the time-honored standard of care for many years, has been replaced by agents demonstrating superior efficacy and safety, including extended-spectrum triazoles and liposomal amphotericin B. Voriconazole, which became the treatment of choice for most pulmonary mold diseases, has been compared with posaconazole and itraconazole, both of which have shown clinical efficacy similar to that of voriconazole, with fewer adverse events. With the worldwide expansion of azole-resistant Aspergillus fumigatus and infections with intrinsically resistant non-Aspergillus molds, the need for newer antifungals with novel mechanisms of action becomes ever more pressing.

Invasive Fungal Diseases in Africa: A Critical Literature Review

Invasive fungal diseases (IFDs) are of huge concern in resource-limited settings, particularly in Africa, due to the unavailability of diagnostic armamentarium for IFDs, thus making definitive diagnosis challenging. IFDs have non-specific systemic manifestations overlapping with more frequent illnesses, such as tuberculosis, HIV, and HIV-related opportunistic infections and malignancies. Consequently, IFDs are often undiagnosed or misdiagnosed. We critically reviewed the available literature on IFDs in Africa to provide a better understanding of their epidemiology, disease burden to guide future research and interventions. Cryptococcosis is the most encountered IFD in Africa, accounting for most of the HIV-related deaths in sub-Saharan Africa. Invasive aspergillosis, though somewhat underdiagnosed and/or misdiagnosed as tuberculosis, is increasingly being reported with a similar predilection towards people living with HIV. More cases of histoplasmosis are also being reported with recent epidemiological studies, particularly from Western Africa, showing high prevalence rates amongst presumptive tuberculosis patients and patients living with HIV. The burden of pneumocystis pneumonia has reduced significantly probably due to increased uptake of anti-retroviral therapy among people living with HIV both in Africa, and globally. Mucormycosis, talaromycosis, emergomycosis, blastomycosis, and coccidiomycosis have also been reported but with very few studies from the literature. The emergence of resistance to most of the available antifungal drugs in Africa is yet of huge concern as reported in other regions. IFDs in Africa is much more common than it appears and contributes significantly to morbidity and mortality. Huge investment is needed to drive awareness and fungi related research especially in diagnostics and antifungal therapy.

Impact of COVID-19 on diagnosis of primary pulmonary coccidioidomycosis

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.

Coccidioidomycosis: A Contemporary Review

Coccidioidomycosis, colloquially known as Valley Fever, is an invasive dimorphic fungal infection caused by Coccidioides immitis and C. posadasii. The fungi are found in the arid desert soils of the southwestern US, as well as in parts of Mexico and Central and South America. Acquisition is typically via inhalation of arthroconidia which become airborne after both natural (e.g., earthquakes, dust storms, and fires) and human-related events (e.g., military maneuvers, recreational activities, agriculture, and construction). The incidence of infection in increasing likely a result of both climatic and populational changes. Further, the recognized geographic distribution of Coccidioides spp. is expanding, as cases are being diagnosed in new areas (e.g., eastern Washington, Oregon, and Utah). Most coccidioidal infections are asymptomatic (60%); however, approximately one-third develop a pulmonary illness which is a leading cause of community-acquired pneumonia in highly endemic areas. Uncommonly (0.5–2% of cases), the infection disseminates to extrapulmonary locations (e.g., skin, bones/joints, and the central nervous system), and is most commonly seen among persons with cellular immunodeficiencies (e.g., transplant recipients, HIV, and pregnancy) and non-Caucasian races (especially African Americans and Filipinos). The diagnosis of coccidioidomycosis requires astute clinical suspicion and laboratory findings, including positive serology, cultures, and/or histopathology results. Treatment is warranted among persons with pneumonia who have risk factors for complicated disease and among those with extrapulmonary disease. Novel antifungals with improved fungicidal activity and rapidity of action with fewer side effects and drug interactions are needed. Preventive strategies (e.g., education regarding the disease, dust avoidance, mask wearing, including among select groups, antifungal prophylaxis, and surveillance laboratory testing) are advised for residents and travelers to endemic areas. Currently, no preventive vaccine is available. Coccidioidomycosis has been recognized for over a century, and an expanding wealth of knowledge has been gained regarding this emerging infectious disease which will be reviewed here.

Global guideline for the diagnosis and management of the endemic mycoses: an initiative of the European Confederation of Medical Mycology in cooperation with the International Society for Human and Animal Mycology

The global burden of the endemic mycoses (blastomycosis, coccidioidomycosis, emergomycosis, histoplasmosis, paracoccidioidomycosis, sporotrichosis, and talaromycosis) continues to rise yearly and these infectious diseases remain a leading cause of patient morbidity and mortality worldwide. Management of the associated pathogens requires a thorough understanding of the epidemiology, risk factors, diagnostic methods and performance characteristics in different patient populations, and treatment options unique to each infection. Guidance on the management of these infections has the potential to improve prognosis. The recommendations outlined in this Review are part of the "One World, One Guideline" initiative of the European Confederation of Medical Mycology. Experts from 23 countries contributed to the development of these guidelines. The aim of this Review is to provide an up-to-date consensus and practical guidance in clinical decision making, by engaging physicians and scientists involved in various aspects of clinical management.

A randomized, double-blind, placebo-controlled clinical trial of fluconazole as early empiric treatment of coccidioidomycosis pneumonia (Valley Fever) in adults presenting with community-acquired pneumonia in endemic areas (FLEET-Valley Fever)

Introduction

Coccidioidomycosis is a fungal infection endemic in the southwestern United States (US). Primary pulmonary coccidioidomycosis (PPC) is a leading cause of community-acquired pneumonia (CAP) in this region, although its diagnosis is often delayed, leading to lag in antifungal treatment and subsequent morbidity. The impact of early empiric antifungal therapy as part of treatment for CAP in endemic areas on clinical outcomes is unknown.

Methods

Phase IV randomized, double-blind, placebo-controlled trial in individuals aged 18 years or older with CAP who met all eligibility criteria in Coccidioides endemic regions in the US. Eligible participants with CAP were randomized to receive either fluconazole (400 mg daily) or matching placebo for 42 days and were subsequently monitored for clinical resolution of their illness.

Objectives

The primary objective was to assess the clinical response of early empiric antifungal therapy with fluconazole through Day 22 in subjects with PPC who were adherent to the study intervention. Secondary objectives included: assessments of the impact of early empiric antifungal therapy with fluconazole through Day 22 and 43 in subjects with PPC regardless of adherence, comparisons of the clinical response and its individual components over time by treatment group in subjects with PPC, assessments of days lost from work or school, hospitalization, and all-cause mortality.

Discussion

This trial was halted early due to slow enrollment (72 participants in one year, 33 received fluconazole and 39 received placebo). Of those enrolled, eight (11%) met the study definition of PPC. The study design and challenges are discussed.

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Clinical impact of early antifungal therapy for pneumonia in Coccidioides endemic regions is unknown.

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We designed a phase IV trial in adults with community-acquired pneumonia in regions endemic for Coccidioides.

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Trial was halted early due to slow enrollment and low prevalence of coccidioidomycosis in the enrollment population.

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Lost to follow-up and treatment discontinuation were common in this trial.

Disseminated Coccidioidomycosis Presenting as Fever of Unknown Origin and Erythema Nodosum in a 3-Year-Old Child

Disseminated coccidioidomycosis is a disease caused by Coccidioides species, fungi endemic to the southwestern United States. We present here an uncommon case of a young child with erythema nodosum and fever of unknown origin, found to have the infection. While more common in adults, coccidioidomycosis should be considered in all patients with erythema nodosum.

Disseminated Coccidioidomycosis With Orbital Osteomyelitis and Periorbital Abscess

Coccidioidomycosis osteomyelitis involving the orbital bones is exceedingly rare and is often misdiagnosed initially as other inflammatory or infectious conditions. No clear guidelines currently exist regarding appropriate management. The authors present an atypical presentation of disseminated coccidioidomycosis in an immunocompetent child with frontal bone superotemporal orbital rim osteomyelitis and associated periorbital abscess, successfully managed with surgical debridement through an upper eyelid crease incision.

A Review of Coccidioides Research, Outstanding Questions in the Field, and Contributions by Women Scientists

Purpose of Review

Coccidioidomycosis is an infectious disease that gained clinical significance in the early 20th century. Many of the foundational contributions to coccidioidomycosis research, including the discovery of the fungal disease agent, Coccidioides spp., were made by women. We review recent progress in Coccidioides research and big questions remaining in the field, while highlighting some of the contributions from women.

Recent Findings

New molecular-based techniques provide a promising method for detecting Coccidioides, which can help determine the dominate reservoir host and ideal environmental conditions for growth. Genetic and genomic analyses have allowed an understanding of population structure, species level diversity, and evolutionary histories. We present a current, comprehensive genome list, where women contributed many of these entries. Several efforts to develop a coccidioidomycosis vaccine are underway.

Summary

Women continue to pioneer research on Coccidioides, including the relationships between the fungi and the environment, genetics, and clinical observations. Significant questions remain in the field of Coccidioides, including the main host reservoir, the relationships between genotypic and phenotypic variation, and the underlying cause for chronic clinical coccidioidomycosis cases.

Development of a Quantitative Antigen Assay to Detect Coccidioidal Chitinase-1 (CTS1) in Human Serum

Background

Coccidioidomycosis is often diagnosed with a collection of tests that rely on the patient's ability to mount an immune response to the fungus (antibody-based diagnostics), making diagnosis of this infection challenging. Here we present an antigen-based assay that detects and quantifies coccidioidal chitinase-1 (CTS1) in human serum.

Methods

An inhibition-based enzyme-linked immunoassay (ELISA) was developed that utilizes a monoclonal antibody specific for coccidioidal CTS1. CTS1 was quantified in commercial antigen preparations using recombinant CTS1 as a standard. Sera from 192 individuals from an endemic area were tested, which included 78 patients (40.6%) with proven or probable coccidioidomycosis.

Results

The quantity of CTS1 in diagnostic commercial antigen preparations from different suppliers varied. CTS1 antigenemia was detected in 87.2% of patients with proven or probable coccidioidomycosis. Specificity was determined to be 96.94% using serum from individuals who reside in the Phoenix, Arizona area who did not have coccidioidomycosis. Levels of CTS1 correlated with low- and high-titer serology from patients with a coccidioidomycosis diagnosis.

Conclusions

Since the CTS1 inhibition ELISA described in this report does not depend on the host immune response, it is a promising diagnostic tool to aid in diagnosis and disease monitoring of coccidioidomycosis.

Coccidioidomycosis and COVID-19 Co-Infection, United States, 2020

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.

Treatment for Early, Uncomplicated Coccidioidomycosis: What Is Success?

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.

Pathogenesis and Classification of Paracocidioidomycosis: New Insights From Old Good Stuff

Different classifications of paracoccidioidomycosis emerged since its discovery in 1908, culminating in the proposition of a simplified and consensual one in 1987. However, by revisiting these classifications, case reports, or case series from which the authors based their own, we found many patients who did not fit in either the 1987 classification or in the correspondent natural history/pathogenesis view. In this report, the concepts of paracoccidioidomycosis infection, primary pulmonary paracoccidioidomycosis (PP-PCM), and other subclinical forms of PCM are reassessed. A classification is proposed to encompass all these subtle but distinct outcomes. I suggest a continuum between the PP-PCM and the overt chronic form of disease, and not the current view of quiescent foci, frozen in time and suddenly reactivated for unknown reasons. Failure to fully resolve the infection in its initial stages is a conceivable hypothesis for the chronic form. The proposed clinical classification might offer new insights to better characterize and manage PCM patients.

Coccidioidomycosis: Changing Concepts and Knowledge Gaps

Although first described more than 120 years ago, much remains unknown about coccidioidomycosis. In this review, new information that has led to changing concepts will be reviewed and remaining gaps in our knowledge will be discussed. In particular, new ideas regarding ecology and epidemiology, problems and promises of diagnosis, controversies over management, and the possibility of a vaccine will be covered.

Natural History of Disseminated Coccidioidomycosis: Examination of the VA-Armed Forces Database

BACKGROUND

The natural history of non-central nervous system (CNS) disseminated coccidioidomycosis (DCM) has not been previously characterized. The historical VA-Armed Forces coccidioidomycosis patient group provides a unique cohort of patients not treated with standard antifungal therapy allowing for characterization of the natural history of coccidioidomycosis.

METHODS

We conducted a retrospective study of 531 VA-Armed Forces coccidioidomycosis patients diagnosed between 1955-1958 and followed to 1966. Groups were identified as non-disseminated coccidioidomycosis (non-DCM, 462 patients), DCM (44 patients), and CNS (25 patients). The duration of initial infection, fate of primary infection, all-cause mortality and mortality secondary to coccidioidomycosis were assessed and compared between groups.

RESULTS

Mortality due to coccidioidomycosis at last known follow up was significantly different across the groups: 0.65% in non-DCM, 25% in DCM, and 88% in CNS (P<0.001). The primary fate of pulmonary infection demonstrated key differences with pulmonary nodules observed in 39.61% in non-DCM, 13.64% in DCM, and 20% in CNS (P<0.001). There were differences in cavity formation with 34.20% in non-DCM, 9.09% DCM, and 8 % in CNS (P <0.001). Forty-one percent and 56% of patients in the non-CNS DCM and CNS groups, respectively, developed dissemination as the presenting manifestation or concurrent with initial infection.

CONCLUSIONS

This large retrospective cohort study helps characterize the natural history of DCM, provides insight into the host immunologic response, and has direct clinical implications for the management and follow-up of patients.

Tolerability of long-term fluconazole therapy

BACKGROUND

Fluconazole is a commonly prescribed first-generation triazole antifungal. Although the toxicity profile of fluconazole has been evaluated in clinical trials, there are scant data regarding its tolerability with long-term therapy. Treatment guidelines for coccidioidomycosis recommend fluconazole therapy and severe or disseminated infections can require lifelong treatment.

OBJECTIVES

To assess the prevalence of long-term fluconazole adverse effects, their consequences for antifungal therapy, time to adverse effects and the association between dosing regimen or fluconazole serum level and adverse effect status.

METHODS

We conducted a single-centre, retrospective study of adult patients (≥18 years) with proven or probable coccidioidomycosis receiving long-term fluconazole therapy for an intended duration of ≥28 days.

RESULTS

Out of 124 patients included, 64 (51.6%) experienced adverse effects. The most common adverse effects were xerosis (16.9%), alopecia (16.1%) and fatigue (11.3%). Of the 64 patients experiencing adverse effects, 42 (65.6%) required a therapeutic intervention such as dose reduction, discontinuation or switch to a new antifungal. Patients experiencing adverse effects were prescribed higher total daily fluconazole doses (6.7 versus 5.7 mg/kg; P < 0.01). The median therapeutic drug levels did not differ significantly between patients who experienced adverse effects and those who did not (36.1 versus 28.1 mg/L; P = 0.35).

CONCLUSIONS

A significant number of patients receiving long-term fluconazole therapy for coccidioidomycosis experienced adverse effects. Of these, around two-thirds required a therapeutic change. We believe these findings are representative of the adverse effect profile of long-term fluconazole therapy as it is used in clinical practice for coccidioidomycosis as opposed to use in clinical trials.

Early Events in Coccidioidomycosis

Since its description nearly 130 years ago, hundreds of studies have deepened our understanding of coccidioidomycosis, also known as valley fever (VF), and provided useful diagnostic tests and treatments for the disease caused by the dimorphic fungi Coccidioides spp. In general, most of the literature has addressed well-established infections and has described patients who have experienced major complications. In contrast, little attention has been given to the earliest consequences of the pathogen-host interaction and its implications for disease manifestation, progression, and resolution. The purpose of this review is to highlight published studies on early coccidioidomycosis, identify gaps in our knowledge, and suggest new or former research areas that might be or remain fertile ground for insight into the early stages of this invasive fungal disease.

The Rise of Coccidioides: Forces Against the Dust Devil Unleashed

Coccidioidomycosis (Valley fever) is a fungal disease caused by the inhalation of Coccidioides posadasii or C. immitis. This neglected disease occurs in the desert areas of the western United States, most notably in California and Arizona, where infections continue to rise. Clinically, coccidioidomycosis ranges from asymptomatic to severe pulmonary disease and can disseminate to the brain, skin, bones, and elsewhere. New estimates suggest as many as 350,000 new cases of coccidioidomycosis occur in the United States each year. Thus, there is an urgent need for the development of a vaccine and new therapeutic drugs against Coccidioides infection. In this review, we discuss the battle against Coccidioides including the development of potential vaccines, the quest for new therapeutic drugs, and our current understanding of the protective host immune response to Coccidioides infection.

Microbiological Laboratory Testing in the Diagnosis of Fungal Infections in Pulmonary and Critical Care Practice. An Official American Thoracic Society Clinical Practice Guideline

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.

Coccidioidomycosis: Epidemiology, Fungal Pathogenesis, and Therapeutic Development

Purpose of Review

Coccidioidomycosis can result from the inhalation of infectious spores of Coccidioides species (spp.) immitis or posadasii. Clinical manifestations range from mild flu-like disease to severe disseminated infection that can require life-long therapy. Burden of this mycosis is high in the southwest region of the USA where it is well characterized, and in many areas of Mexico and Latin America where it is inadequately characterized. Here, we provide historical data and current knowledge on Coccidioides spp. pathogenesis as well as recent progress in therapeutic and vaccine development against coccidioidomycosis.

Recent Findings

The virulence mechanisms of Coccidioides spp. are largely unknown; however, production and regulation of a spherule glycoprotein, ammonium production, and melanization have all been proposed as integral factors in Coccidioides spp.' pathogenesis. Therapeutic options are limited and not 100% effective, but individualized treatment with triazoles or amphotericin B over the course of pulmonary or disseminated infection can be effective in resolution of coccidioidomycosis. Human immunization has not been achieved but efforts are ongoing.

Summary

Advances in therapeutic and vaccine development are imperative for the prevention and treatment of coccidioidomycosis, especially for those individuals at risk either living or traveling to or from endemic areas.

Current Concepts and Future Directions in the Pharmacology and Treatment of Coccidioidomycosis

Coccidioidomycosis remains a significant clinical problem with substantial morbidity and mortality. The vast majority of infections are asymptomatic and the need for early primary therapy remains controversial. The use of triazole antifungals has improved tolerability of therapy but concerns about acute and long-term toxicities among available agents limit their use. In addition, recent findings of decreased in vitro fluconazole susceptibility to as many as 37% of Coccidioides spp. isolates raises concerns regarding optimal therapy for these infections as fluconazole is commonly used for therapy including central nervous system disease. Thus, new agents from novel antifungal classes are currently in preclinical and clinical development aimed at reducing toxicity and improving outcomes of these serious infections.

Enhanced Surveillance for Coccidioidomycosis, 14 US States, 2016

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.

Top Questions in the Diagnosis and Treatment of Coccidioidomycosis

Revised and greatly expanded treatment guidelines for coccidioidomycosis were published last year by the Infectious Diseases Society of America. We have selected 4 questions that commonly arise in the management of patients suspected of this disease and for which there remain divided opinions.

Divergence in the approach to tumor necrosis factor α-inhibitor recipients with coccidioidomycosis

BACKGROUND

Tumor necrosis factor α-inhibitors (TNFIs) have been associated with increased risk of certain fungal infections, including coccidioidomycosis. The optimal treatment approach to coccidioidomycosis in TNFI recipients is unknown.

METHODS

We constructed an anonymous, voluntary survey for practicing pulmonary and infectious disease physicians in the state of Arizona regarding approach to TNFI patients with coccidioidomycosis.

RESULTS

There is no current consensus on managing these patients.

CONCLUSIONS

Further research is necessary to determine the optimal approach to TNFI recipients with coccidioidomycosis.

Enhanced Antibody Detection and Diagnosis of Coccidioidomycosis with the MiraVista IgG and IgM Detection Enzyme Immunoassay

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.

Coccidioidomycosis: Surgical Issues and Implications

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.

Treatment considerations in pulmonary coccidioidomycosis

INTRODUCTION

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

AREAS COVERED

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

Integrative Medicine Preferences Among Coccidioidomycosis (Valley Fever) Patients

OBJECTIVES

To understand the extent and modalities of integrative medicine strategies that patients with coccidioidomycosis (valley fever) have incorporated into their treatment regimens.

DESIGN

A direct patient survey was distributed, with 100 unique responses, at a single infectious diseases clinic at an academic medical center in Arizona. Eligible patients, defined as those with confirmed coccidioidomycosis or currently under evaluation, were polled on their personal use of 36 integrative medicine modalities. Patients were also asked to indicate their level of fatigue on a 10-point scale in an attempt to correlate levels of fatigue to use of specific integrative medicine modalities.

RESULTS

Of the patients surveyed, 64% had used at least one integrative medicine modality, and 53% used two or more, along with conventional medical therapy. The top three modalities were nutrition (39%), massage (27%), and breathing exercises (26%). The mean reported fatigue level was 4.7 on a 10-point scale, with a standard deviation of 3.0. There was no statistically significant association between use of a specific modality and reported level of fatigue.

CONCLUSIONS

Nearly two thirds of patients (64%) surveyed had used at least one integrative medicine modality throughout the course of their therapy. Clinicians are probably unaware of the extent to which many patients, including this population, have embraced integrative medicine. Awareness of patients' goal and preferences is valuable in shared clinical decision making.

2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Treatment of Coccidioidomycosis

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. Infectious Diseases Society of America considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.Coccidioidomycosis, also known as San Joaquin Valley fever, is a systemic infection endemic to parts of the southwestern United States and elsewhere in the Western Hemisphere. Residence in and recent travel to these areas are critical elements for the accurate recognition of patients who develop this infection. In this practice guideline, we have organized our recommendations to address actionable questions concerning the entire spectrum of clinical syndromes. These can range from initial pulmonary infection, which eventually resolves whether or not antifungal therapy is administered, to a variety of pulmonary and extrapulmonary complications. Additional recommendations address management of coccidioidomycosis occurring for special at-risk populations. Finally, preemptive management strategies are outlined in certain at-risk populations and after unintentional laboratory exposure.

THE TREATMENT OF COCCIDIOIDOMYCOSIS

Therapy of coccidioidomycosis continues to evolve. For primary pulmonary disease, antifungal therapy is frequently not required while prolonged courses of antifungals are generally needed for those in whom extrathoracic disseminated has occurred. Intravenous amphotericin B should be reserved for those with severe disease. Oral triazole antifungals have had a great impact on the management of coccidioidomycosis. Both fluconazole and itraconazole at 400 mg daily have been effective for various forms of coccidioidomycosis, including meningitis, although relapse after therapy is discontinued is a problem. Individuals with suppressed cellular immunity are at increased risk for symptomatic coccidioidomycosis and they include those with HIV infection, those on immunosuppressive medications, and those who have received a solid organ transplant. Pregnant women and African-American men have been identified as two other groups who are at an increased risk for symptomatic and severe infection.

Epidemiology of Pediatric Coccidioidomycosis in California, 2000-2012

BACKGROUND

Reported coccidioidomycosis cases have increased in the southwestern US since 2000. However, there are few publications on pediatric coccidioidomycosis. We sought to describe the epidemiology of coccidioidomycosis in the California pediatric population during 2000-2012.

METHODS

We reviewed surveillance and hospitalization datasets for years 2000-2012 and death datasets for years 2000-2010 to identify coccidioidomycosis-associated cases, hospitalizations and deaths in pediatric (≤17 years old) California residents. We calculated rates and described demographic characteristics of cases and hospitalized patients and, using Poisson regression, calculated bivariate relative risks to identify potential demographic risk factors. We identified immunocompromising conditions associated with hospitalization and death and calculated hospitalization charges.

RESULTS

We identified 3453 cases, 1301 hospitalizations and 11 deaths associated with coccidioidomycosis in the California pediatric population. During 2000-2012, annual case and hospitalized patient rates increased and were highest in males, those in the 12-17 age group, and residents of the California endemic region. Compared with White children, African-American children were significantly more likely to be hospitalized (relative risk = 1.4, P = 0.01). Approximately 12.0% of those hospitalized and 27% of those who died had an immunocompromising condition. Hospitalized patients accrued $149 million in total hospital charges.

CONCLUSIONS

Similar to recent increases among adults, reported pediatric coccidioidomycosis cases and hospitalizations have increased in California since 2000, disproportionately affecting certain demographic groups. The burden of coccidioidomycosis among California children emphasizes the need for more awareness and research into this reemerging fungal disease in endemic and nonendemic areas.

Uphill both ways: Fatigue and quality of life in valley fever

Primary pulmonary coccidioidomycosis is characterized by prolonged respiratory and systemic symptoms and fatigue. We prospectively administered the fatigue severity scale (FSS) and Short Form-36 Health Status Questionnaire (SF-36) to patients with proven or probable primary pulmonary coccidioidomycosis to quantify disease effect on quality of life (QOL). The 24-week observational study did not specify whether antifungal treatment would be provided; the treating physician made treatment decisions. FSS and SF-36 were completed at 4-week intervals. Thirty-six patients participated, of whom 20 received antifungal treatment. At onset of coccidioidal illness, mean FSS score was higher (ie, more fatigue) in the treatment group. However, in early illness, both groups had higher fatigue levels than reference populations with other diseases (eg, multiple sclerosis). FSS scores gradually improved, and scores in each group were below the severe fatigue level at week 12 and week 16 in the nontreatment and treatment groups, respectively. By week 24, mean FSS score of the nontreatment group equaled the general population. SF-36 component and profile scores were lower (with more symptoms) in the treatment group at each time point than the nontreatment group; both groups showed similar improvement. Mental and emotional health SF-36 scores were not as severely affected as physical scores. Most patients reached a physical functioning level similar to the general population at week 12. Pulmonary coccidioidomycosis causes severe fatigue and substantially affects physical abilities. Fatigue was found to be prolonged, with gradual improvement in QOL, regardless of antifungal administration.

Serum procalcitonin levels in patients with primary pulmonary coccidioidomycosis

RATIONALE

The serum procalcitonin assay has emerged as a promising biomarker to distinguish between bacterial and viral respiratory tract infections but has not been used to differentiate coccidioidomycosis from bacterial infection. A correlation between procalcitonin serum levels and coccidioidomycosis has never been reported.

OBJECTIVE

To determine any association between serum procalcitonin levels and primary pulmonary coccidioidomycosis.

METHODS

We identified and enrolled 20 immunocompetent patients with symptomatic primary pulmonary coccidioidomycosis of < 8 weeks' duration and performed a one-time procalcitonin assay, with a cutoff of < 0.25 μg/L indicating a nonbacterial infection.

MEASUREMENTS AND MAIN RESULTS

Nineteen of 20 patients (95%) had serum procalcitonin of < 0.25 μg/L. The median procalcitonin level was 0.05 μg/L (range, < 0.05-0.87 μg/L; interquartile range, 0.05-0.05 μg/L). Sixteen of 20 patients (80%) had undetectable procalcitonin of < 0.05 μg/L. The four patients with detectable procalcitonin had a median value of 0.2 μg/L (range, 0.09-0.87 μg/L).

CONCLUSIONS

In this pilot study, procalcitonin was not elevated in immunocompetent patients with primary pulmonary coccidioidomycosis at a median of 32 days after symptom onset. Larger prospective studies are needed to confirm this finding.