The Rise of Valley Fever: Prevalence and Cost Burden of Coccidioidomycosis Infection in California

Antifungal therapy patterns, healthcare utilization, costs, and mortality in central nervous system and non-central nervous system disseminated coccidioidomycosis across the continuum-of-care

OBJECTIVES

This study aims to describe baseline characteristics, antifungal treatment patterns, healthcare utilization, costs, and mortality in patients with central nervous system (CNS) and non-CNS disseminated coccidioidomycosis.

METHODS

A retrospective study using IQVIA claims data was conducted to identify adults with disseminated coccidioidomycosis in two mutually exclusive cohorts: those with CNS and those with non-CNS disease. Patients had to have ≥1 medical claim for disseminated coccidioidomycosis from October 2015 to November 2022. Antifungal treatment patterns were assessed, as were all-cause healthcare utilization, costs, and mortality during follow-up.

RESULTS

In total, 2218 patients were identified, 28.2% (626/2218) with CNS and 71.8% (1592/2218) with non-CNS disease. In both cohorts, 70.9% (444/626) and 71.6% (1140/1592) of patients initiated first-line antifungal treatment, most with fluconazole (881/1140, 77.3% to 372/444, 83.8%), followed by an azole + lipid amphotericin B (21/444, 4.7% to 81/1140, 7.1%). Azole monotherapy was used often over subsequent lines of antifungal treatment in both cohorts (1049/1140, 92.0% to 122/129, 94.6%). Polyenes peaked in the latter lines of therapy (24/182, 13.2% to 79/408, 19.4%), mostly administered with azoles. Median baseline costs in the CNS and non-CNS cohorts were substantial ($9122 and $8242, respectively). After diagnosis, 29.7% (186/626) of patients in the CNS cohort experienced a subsequent hospitalization and all-cause cost of $28 664 per person per year. The non-CNS patients experienced a similar proportion of patients requiring hospitalization (469/1592, 29.5%) and all-cause costs of $21 240 per person per year. Between 5.4% (34/626) and 6.7% (106/1592) of patients died during follow-up, with death more likely in those with concomitant pulmonary coccidioidomycosis, sepsis, certain immunosuppressive diseases, and prior azole use.

DISCUSSION

Most patients with either CNS or non-CNS disseminated coccidioidomycosis received an azole first line and demonstrated azole-cycling over subsequent lines. Polyenes were used in the latter lines. Patients utilized substantial healthcare resources and accrued appreciable costs, both before and after diagnosis.

Discovery of novel antifungal drugs via screening repurposing libraries against Coccidioides posadasii spherule initials

Coccidioidomycosis or valley fever is a treatment-limited fungal infection endemic to the alkaline deserts of North and South America for which two classes of antifungals are typically used: the polyenes and the triazoles. In light of the limited usefulness of the echinocandins and a growing trend of azole resistance, it is essential that we identify novel antifungals. In this study, we have developed and optimized a screening methodology for identifying potential antifungals effective against Coccidioides spherule initials using a metabolic assay, used it to screen four diverse drug libraries with limited drug overlap, and established safety and efficacy data for a majority of the compounds, including the Broad Repurposing Hub, Prestwick Chemicals 1520, Selleck L8200 Anti-parasitic, and MedChemExpress CNS Penetrants libraries. Hits were defined as compounds with strong metabolic inhibition (≥70%), which were significantly different compared to the median plate readout (B-scores ≤ -3). We identified 30 promising hits and found 12 compounds exhibiting half-maximal inhibitory concentrations below 6 µM. Among these, oxethazaine, niclosamide ethanolamine, 10058-F4, niclosamide (NIC), and pentamidine isethionate showed synergy with amphotericin B, suggesting their potential use in combination therapy. Further assessment of lead compounds' effects on spherules was conducted by image flow cytometry. Additionally, we explored the potential to use an attenuated, Biosafety Level 2 containment mutant, C. posadasii ∆cts2/∆ard1/∆cts3 (∆T), as a surrogate model for drug screening. Overall, our findings provide a foundation for future research focused on screening and developing novel coccidioidomycosis treatments.IMPORTANCEThe antifungal treatment arsenal is especially limited against Coccidioides. Due to toxicity concerns, amphotericin B is generally reserved for triazole-recalcitrant infections. Recent laboratory susceptibility tests show an increase in fluconazole resistance, highlighting a need for new treatments. We have developed a large-scale metabolic screening assay under Biosafety Level 3 containment to identify existing drugs with novel activity against Coccidioides spherules. This drug-repurposing approach represents a convenient and cost-effective strategy to increase the available antifungals effective against these infections.

The Burden of Hospital Illness Associated with Disseminated Versus Isolated Pulmonary Coccidioidomycosis in the United States

There are scarce data comparing inpatient mortality, length of stay (LOS) and all-cause hospital costs in disseminated coccidioidomycosis (DCM) vs. isolated pulmonary coccidioidomycosis (IPCM). We assessed the burden of hospital illness associated with DCM versus IPCM. This study was performed using National Inpatient Sample data from 2019 to 2021. DCM was defined as having a primary International Classification of Diseases-Tenth Revision (ICD-10) code for coccidioidal meningitis, a non-primary code for coccidioidal meningitis in the presence of a primary code for a meningitis complication or a procedure code depicting the need for a meningitis-related procedure, or a primary code for DCM without a code for unspecified disease. IPCM was defined as a primary code for pulmonary coccidioidomycosis without codes for DCM or unspecified disease. Multivariable regression was used to compare the odds of in-hospital mortality, LOS and all-cause hospital costs (2023 US$) for DCM versus IPCM, after covariate adjustment. A total of 6195 hospitalizations were identified, 2305 for DCM and 3890 for IPCM. Patients experiencing a DCM hospitalization had a 19.7% incidence of concomitant pulmonary coccidioidomycosis. Coccidioidal meningitis constituted 81.3% of all DCM hospitalizations, of which 78.1% received a meningitis-related procedure or were admitted for a meningitis complication. DCM was associated with an increased odds of death (odds ratio = 2.76, 95% confidence interval [CI] = 1.26-6.04) versus IPCM. DCM was associated with a longer mean hospital LOS (4.51 days, 95%CI = 3.39-5.63) and higher mean all-cause costs ($20,008, 95%CI = $15,313-$24,704) versus IPCM. DCM hospitalizations were associated with higher odds of inpatient mortality, longer LOS, and higher costs versus IPCM.

Valley-Forecast: Forecasting Coccidioidomycosis incidence via enhanced LSTM models trained on comprehensive meteorological data

Coccidioidomycosis (cocci), or more commonly known as Valley Fever, is a fungal infection caused by Coccidioides species that poses a significant public health challenge, particularly in the semi-arid regions of the Americas, with notable prevalence in California and Arizona. Previous epidemiological studies have established a correlation between cocci incidence and regional weather patterns, indicating that climatic factors influence the fungus's life cycle and subsequent disease transmission. This study hypothesizes that Long Short-Term Memory (LSTM) and extended Long Short-Term Memory (xLSTM) models, known for their ability to capture long-term dependencies in time-series data, can outperform traditional statistical methods in predicting cocci outbreak cases. Our research analyzed daily meteorological features from 2001 to 2022 across 48 counties in California, covering diverse microclimates and cocci incidence. The study evaluated 846 LSTM models and 176 xLSTM models with various fine-tuning metrics. To ensure the reliability of our results, these advanced neural network architectures are cross analyzed with Baseline Regression and Multi-Layer Perceptron (MLP) models, providing a comprehensive comparative framework. We found that LSTM-type architectures outperform traditional methods, with xLSTM achieving the lowest test RMSE of 282.98 (95% CI: 259.2-306.8) compared to the baseline's 468.51 (95% CI: 458.2-478.8), demonstrating a reduction of 39.60% in prediction error. While both LSTM (283.50, 95% CI: 259.7-307.3) and MLP (293.14, 95% CI: 268.3-318.0) also showed substantial improvements over the baseline, the overlapping confidence intervals suggest similar predictive capabilities among the advanced models. This improvement in predictive capability suggests a strong correlation between temporal microclimatic variations and regional cocci incidences. The increased predictive power of these models has significant public health implications, potentially informing strategies for cocci outbreak prevention and control. Moreover, this study represents the first application of the novel xLSTM architecture in epidemiological research and pioneers the evaluation of modern machine learning methods' accuracy in predicting cocci outbreaks. These findings contribute to the ongoing efforts to address cocci, offering a new approach to understanding and potentially mitigating the impact of the disease in affected regions.

Estimating the Exposure-Response Relationship between Fine Mineral Dust Concentration and Coccidioidomycosis Incidence Using Speciated Particulate Matter Data: A Longitudinal Surveillance Study

BACKGROUND

Coccidioidomycosis, caused by inhalation of Coccidioides spp. spores, is an emerging infectious disease that is increasing in incidence throughout the southwestern US. The pathogen is soil-dwelling, and spore dispersal and human exposure are thought to co-occur with airborne mineral dust exposures, yet fundamental exposure-response relationships have not been conclusively estimated.

OBJECTIVES

We estimated associations between fine mineral dust concentration and coccidioidomycosis incidence in California from 2000 to 2017 at the census tract level, spatiotemporal heterogeneity in exposure-response, and effect modification by antecedent climate conditions.

METHODS

We acquired monthly census tract-level coccidioidomycosis incidence data and modeled fine mineral dust concentrations from 2000 to 2017. We fitted zero-inflated distributed-lag nonlinear models to estimate overall exposure-lag-response relationships and identified factors contributing to heterogeneity in exposure-responses. Using a random-effects meta-analysis approach, we estimated county-specific and pooled exposure-responses for cumulative exposures.

RESULTS

We found a positive exposure-response relationship between cumulative fine mineral dust exposure in the 1-3 months before estimated disease onset and coccidioidomycosis incidence across the study region [incidence rate ratio (IRR) for an increase from 0.1 to 1.1   μ g / m 3 = 1.60 ; 95% CI: 1.46, 1.74]. Positive, supralinear associations were observed between incidence and modeled fine mineral dust exposures 1 [IRR = 1.13 (95% CI: 1.10, 1.17)], 2 [IRR = 1.15 (95% CI: 1.09, 1.20)] and 3 [IRR = 1.08 (95% CI: 1.04, 1.12)] months before estimated disease onset, with the highest exposures being particularly associated. The cumulative exposure-response relationship varied significantly by county [lowest IRR, western Tulare: 1.05 (95% CI: 0.54, 2.07); highest IRR, San Luis Obispo: 3.01 (95% CI: 2.05, 4.42)]. Season of exposure and prior wet winter were modest effect modifiers.

DISCUSSION

Lagged exposures to fine mineral dust were strongly associated with coccidioidomycosis incidence in the endemic regions of California from 2000 to 2017. https://doi.org/10.1289/EHP13875.

Valley fever under a changing climate in the United States

This review summarizes studies on the relationships between climate change and Valley Fever (VF), also termed Coccidioidomycosis, a potentially fatal upper-respiratory fungal infection caused by the pathogenic fungi, C. immitis or C. posadasii. The intensified onset of climate change has caused frequencies and possibly intensities of natural hazard events like dust storms and drought to increase, which has been correlated with greater prevalence of VF. These events, followed by changes in patterns of precipitation, not only pick up dust and spread it throughout the air, but also boost the growth and spread of Coccidioides. In California alone, cases of VF have increased fivefold from 2001 to 2021, and are expected to continue to increase. From 1999 to 2019, there was an average of 200 deaths per year caused by VF in the United States. The number of deaths caused by VF fluctuates year to year, but because more infections are predicted to occur due to a changing climate, deaths are expected to rise; thus, the rising prevalence of the disease is becoming a larger focus of the scientific community and poses an increased threat to public health. By reviewing recent and past studies on Coccidioidomycosis and its relationships with climate factors, we categorize future impacts of this disease on the United States, and highlight areas that need more study. Factors affecting the incidence of VF, such as modes of dispersal and the optimum environment for Coccidioides growth, that could potentially increase its prevalence as weather patterns change are discussed and how the endemic regions could be affected are assessed. In general, regions of the United States, including California and Arizona, where VF is endemic, are expanding and incidences of VF are increasing in those areas. The surrounding southern states, including Nevada, New Mexico, Utah, and Texas, are experiencing similar changes. In addition, the entire endemic region of the United States is predicted to spread northward as drought is prolonged and temperatures steadily increase. The findings from the keyword search from eight databases indicate that more studies on VF and its relation to dust and climate are needed especially for endemic states like Nevada that are currently not adequately studied. Overall, results of this survey summarize mechanisms and climate factors that might drive spread of VF and describes trends of incidence of VF in endemic states and predicted likely trends that might occur under a changing climate. Through reviewing recent and past studies of Coccidioidomycosis and its relationships with climate factors, future impacts of this disease have been categorized and speculated on effects it might have on the United States. Better understanding of how climate factors affect VF as well as identifying regions that require more research could inform both environmental managers and medical professionals with the resources needed to make more accurate predictions, design better mitigation strategies, send timely warnings, and protect public health. Shortened version This review explores how climate change affects Valley Fever (VF), a dangerous fungal infection caused by C. immitis or C. posadasii. Climate change has increased natural hazard events such as dust storms and droughts, which have caused the spread of VF. Cases of the disease have increased fivefold between 2001 and 2021 in California alone, and it poses an increasing threat to public health. The review summarizes mechanisms that drive the spread of VF and highlights trends in endemic states under a changing climate. It recommends more studies on VF and its relation to dust and climate, especially for states like Nevada. Identifying regions that require more research can help make more accurate predictions, design better mitigation strategies, send timely warnings, and protect public health.

The Known and Unknown "Knowns" of Human Susceptibility to Coccidioidomycosis

Coccidioidomycosis occurs after inhalation of airborne spores of the endemic, dimorphic fungus, Coccidioides. While the majority of individuals resolve the infection without coming to medical attention, the fungus is a major cause of community-acquired pneumonia in the endemic region, and chronic pulmonary and extrapulmonary disease poses significant personal and economic burdens. This review explores the literature surrounding human susceptibility to coccidioidomycosis, including chronic pulmonary and extrapulmonary dissemination. Over the past century of study, themes have emerged surrounding factors impacting human susceptibility to severe disease or dissemination, including immune suppression, genetic susceptibility, sex, pregnancy, and genetic ancestry. Early studies were observational, frequently with small numbers of cases; several of these early studies are highly cited in review papers, becoming part of the coccidioidomycosis "canon". Specific genetic variants, sex, and immune suppression by TNF inhibitors have been validated in later cohort studies, confirming the original hypotheses. By contrast, some risk factors, such as ABO blood group, Filipino ancestry, or lack of erythema nodosum among black individuals, are repeated in the literature despite the lack of supporting studies or biologic plausibility. Using examination of historical reports coupled with recent cohort and epidemiology studies, evidence for commonly reported risk factors is discussed.

Orbital Osteomyelitis and Periorbital Abscess Due to Coccidioidomycosis Following Trauma

Ocular involvement due to Coccidioides sp.is extremely rare, and most patients with disseminated coccidioidomycosis present as extrapulmonary or disseminated disease that involves the skin, bone joints, and central nervous system. Here, we describe a 13-year-old previously healthy Black male residing in an area endemic for coccidioidomycosis. The child presented to our hospital with left eye pain, diplopia, and proptosis two weeks after being struck on the left side of the face with a basketball. He was initially presumed to have bacterial orbital cellulitis and was started on empiric antibiotics. Due to severe disease, he underwent surgical drainage and debridement. Fungal stain from the intraoperative specimen showed spherules with endosporulation, and fungal culture revealed Coccidioides immitis. Based on this, the child was diagnosed with orbital osteomyelitis and periorbital abscess due to coccidioidomycosis. He was started on intravenous liposomal amphotericin B and fluconazole. Antibiotics were discontinued. He underwent additional investigations to assess for sites of dissemination. His nuclear medicine bone scintigraphy and cerebrospinal fluid studies were negative. A computed tomography (CT) scan of the chest demonstrated multiple small pulmonary nodules. His Coccidioides complement fixation(CF) titer was 1:32. The patient completed one month of treatment with liposomal amphotericin B and fluconazole. Our case highlights the need for healthcare professionals to consider coccidioidomycosis when evaluating patients with orbital disease as delays in the diagnosis may result in visual loss and central nervous system involvement. Prompt diagnosis, evaluation, and treatment are crucial to reduce long-term morbidity and mortality.

Differentiating Lung Nodules Due to Coccidioides from Those Due to Lung Cancer Based on Radiographic Appearance

BACKGROUND

Coccidioidomycosis (cocci) is an endemic fungal disease that can cause asymptomatic or post-symptomatic lung nodules which are visible on chest CT scanning. Lung nodules are common and can represent early lung cancer. Differentiating lung nodules due to cocci from those due to lung cancer can be difficult and lead to invasive and expensive evaluations.

MATERIALS AND METHODS

We identified 302 patients with biopsy-proven cocci or bronchogenic carcinoma seen in our multidisciplinary nodule clinic. Two experienced radiologists who were blinded to the diagnosis read the chest CT scans and identified radiographic characteristics to determine their utility in differentiating lung cancer nodules from those due to cocci.

RESULTS

Using univariate analysis, we identified several radiographic findings that differed between lung cancer and cocci infection. We then entered these variables along with age and gender into a multivariate model and found that age, nodule diameter, nodule cavitation, presence of satellite nodules and radiographic presence of chronic lung disease differed significantly between the two diagnoses. Three findings, cavitary nodules, satellite nodules and chronic lung disease, have sufficient discrimination to potentially be useful in clinical decision-making.

CONCLUSIONS

Careful evaluation of the three obtained radiographic findings can significantly improve our ability to differentiate benign coccidioidomycosis infection from lung cancer in an endemic region for the fungal disease. Using these data may significantly reduce the cost and risk associated with distinguishing the cause of lung nodules in these patients by preventing unnecessary invasive studies.

Microbiology and Climate Change: a Transdisciplinary Imperative

Climate change is a complex problem involving nonlinearities and feedback that operate across scales. No single discipline or way of thinking can effectively address the climate crisis. Teams of natural scientists, social scientists, engineers, economists, and policymakers must work together to understand, predict, and mitigate the rapidly accelerating impacts of climate change. Transdisciplinary approaches are urgently needed to address the role that microorganisms play in climate change. Here, we demonstrate with case studies how diverse teams and perspectives provide climate-change insight related to the range expansion of emerging fungal pathogens, technological solutions for harmful cyanobacterial blooms, and the prediction of disease-causing microorganisms and their vector populations using massive networks of monitoring stations. To serve as valuable members of a transdisciplinary climate research team, microbiologists must reach beyond the boundaries of their immediate areas of scientific expertise and engage in efforts to build open-minded teams aimed at scalable technologies and adoptable policies.

Risk of Exposure to Coccidioides spp. in the Temblor Special Recreation Management Area (SRMA), Kern County, CA

The Temblor Mountain Special Recreation Area (SRMA) on the western flank of the San Joaquin Valley, CA, is located in the endemic area of Coccidioides, a fungal pathogen responsible for the increasing incidence of coccidioidomycosis (Valley fever). Recreationists in the SRMA, such as off-highway vehicle (OHV) drivers and mountain bikers who disturb the soils, are at risk of being exposed to airborne arthroconidia (asexual spores) of the pathogen. To reduce the risk of pathogen exposure for visitors, the Bureau of Land Management (BLM) plans to limit recreational activities to areas with a reduced pathogen presence. They envision an official OHV park in the future, by also restricting access to areas with ongoing restoration efforts and by limiting soil erosion in sensitive areas. To investigate which soils in the Temblor SRMA are most likely to support the growth of Coccidioides spp., soil samples were collected over a 3-year period from dominant soil types in a northern and a southern sampling area and analyzed for the pathogen using a culture-independent PCR-based method. In addition, soil pH and electrical conductivity were determined. The results of this study revealed slight genetic variance in the Coccidioides sequences obtained from the soils of the Temblor SRMA. An analysis of variance (ANOVA) could not confirm differences in soil pH and electrical conductivity (EC) between the different soil types investigated and between sites where the pathogen was detected compared to sites where it could not be found. However, the year of sampling appeared to have an influence on observed soil pH and EC, and the presence of the pathogen. Of all dominant soil types investigated, those belonging to the Littlesignal-Cochora association were the least likely to contain the pathogen, whereas soils of the Beam-Panoza-Hillbrick association appeared more supportive. In addition to pointing out OHV areas with lower pathogen exposure risk in the Temblor SRMA, recommendations were made to educate visitors and BLM workers about the risk of contracting Valley fever.

Improving Early Recognition of Coccidioidomycosis in Urgent Care Clinics: Analysis of an Implemented Education Program

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.

Surgical Resection to Treat a Japanese Patient with Pulmonary Coccidioidomycosis

Coccidioidomycosis is an endemic disease that is particularly prevalent in the United States. However, its geographic distribution is becoming widespread. Here, we present a Japanese male who resided in the United States for 1 year, where he was diagnosed with pulmonary coccidioidomycosis that was accompanied by cavity formation. He did not tolerate antifungal therapy and consequently underwent partial resection of the upper lobe of his left lung upon his return to Japan. The patient's symptoms improved after surgery. The trend toward global networking and logistics means that a diagnosis of coccidioidomycosis should be considered in routine practice in nonendemic areas. Due to the rarity of surgical treatment for this disease, prolonged follow-up is necessary. During the last follow-up, the patient was symptom-free.

Immunogenetics associated with severe coccidioidomycosis

Disseminated coccidioidomycosis (DCM) is caused by Coccidioides, pathogenic fungi endemic to the southwestern United States and Mexico. Illness occurs in approximately 30% of those infected, less than 1% of whom develop disseminated disease. To address why some individuals allow dissemination, we enrolled patients with DCM and performed whole-exome sequencing. In an exploratory set of 67 patients with DCM, 2 had haploinsufficient STAT3 mutations, and defects in β-glucan sensing and response were seen in 34 of 67 cases. Damaging CLEC7A and PLCG2 variants were associated with impaired production of β-glucan-stimulated TNF-α from PBMCs compared with healthy controls. Using ancestry-matched controls, damaging CLEC7A and PLCG2 variants were overrepresented in DCM, including CLEC7A Y238* and PLCG2 R268W. A validation cohort of 111 patients with DCM confirmed the PLCG2 R268W, CLEC7A I223S, and CLEC7A Y238* variants. Stimulation with a DECTIN-1 agonist induced DUOX1/DUOXA1-derived hydrogen peroxide [H2O2] in transfected cells. Heterozygous DUOX1 or DUOXA1 variants that impaired H2O2 production were overrepresented in discovery and validation cohorts. Patients with DCM have impaired β-glucan sensing or response affecting TNF-α and H2O2 production. Impaired Coccidioides recognition and decreased cellular response are associated with disseminated coccidioidomycosis.

Fluconazole Failure in the Treatment of Coccidioidal Meningitis

INTRODUCTION

Coccidioidal meningitis (CM) is the most lethal form of disseminated coccidioidomycosis. Current guidelines recommend fluconazole as initial therapy but there has been a paucity of data regarding failure of fluconazole and optimal fluconazole dosage in the treatment of CM. We conducted this study to understand risk factors for fluconazole failure.

METHODS

We conducted a single-center retrospective chart review of patients diagnosed with coccidioidal meningitis between 1 January 1988 and 15 May 2021. Relevant demographic and clinical variables were collected, along with outcomes including treatment failure and death at any point. Univariate tests were conducted using the chi-squared goodness of fit test and analysis of variance.

RESULTS

Among 71 patients who began treatment for CM with fluconazole, 22 (31%) developed worsening meningitis at a median time of 206 days. Longer time from symptom onset to diagnosis of CM was a risk factor for fluconazole failure. Although the absolute failure rate of fluconazole starting dose of 400 mg daily was higher than that of 800 mg daily, the differences did not achieve statistical significance (p = 0.39).

CONCLUSION

Fluconazole failure is not uncommon in the treatment of CM. A dose of 800 mg daily was not superior to a dose of 400 mg daily. All patients on fluconazole for CM require close monitoring.

Natural history of pulmonary coccidioidomycosis: Further examination of the VA-Armed Forces Database

There are still many limitations related to the understanding of the natural history of differing forms of coccidioidomycosis (CM), including characterizing the spectrum of pulmonary disease. The historical Veterans Administration-Armed Forces database, recorded primarily before the advent of antifungal therapy, presents an opportunity to characterize the natural history of pulmonary CM. We performed a retrospective cohort study of 342 armed forces service members who were diagnosed with pulmonary CM at VA facilities between 1955 to 1958, followed through 1966, who did not receive antifungal therapy. Patients were grouped by predominant pulmonary finding on chest radiographs. The all-cause mortality was low for all patients (4.6%). Cavities had a median size of 3-3.9 cm (IQR: 2-2.9-4-4.9 cm), with heterogeneous wall thickness and no fluid level, while nodules had a median size of 1-1.19 cm (Interquartile range [IQR] 1-1.9-2-2.9 cm) and sharp borders. The majority of cavities were chronic (85.6%), and just under half were found incidentally. Median complement fixation titers in both the nodular and cavitary groups were negative, with higher titers in the cavitary group overall. This retrospective cohort study of non-disseminated coccidioidomycosis, the largest to date, sheds light on the natural history, serologic markers, and radiologic characteristics of this understudied disease. These findings have implications for the evaluation and management of CM.

Vaccines to Prevent Coccidioidomycosis: A Gene-Deletion Mutant of Coccidioides Posadasii as a Viable Candidate for Human Trials

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.

Update on the Epidemiology, Diagnosis, and Treatment of Coccidioidomycosis

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.

Current Landscape of Coccidioidomycosis

Coccidioidomycosis, also known as Valley fever, is an endemic fungal infection commonly found in the southwestern parts of the United States. However, the disease has seen an increase in both in its area of residency and its prevalence. This review compiles some of the latest information on the epidemiology, current and in-development pharmaceutical approaches to treat the disease, trends and projections, diagnostic concerns, and the overlapping dynamics of coccidioidomycosis and COVID-19, including in special populations. This review provides an overview of the current diagnostic and therapeutic strategies and identifies areas of future development.

Economic Burden of Fungal Diseases in the United States

We conservatively estimated the US economic burden of fungal diseases as $11.5 billion in 2019: direct medical costs ($7.5 billion), productivity loss due to absenteeism ($870 million), and premature deaths ($3.2 billion). An alternative "value of statistical life" approach yielded >$48 billion. These are likely underestimates given underdiagnosis and underreporting.

Δcps1 vaccine protects dogs against experimentally induced coccidioidomycosis

Coccidioidomycosis is a significant health problem of dogs and humans in endemic regions, especially California and Arizona in the U.S. Both species would greatly benefit from a vaccine to prevent this disease. A live avirulent vaccine candidate, Δcps1, was tested for tolerability and efficacy to prevent pulmonary coccidioidomycosis in a canine challenge model. Vaccine injection-site reactions were transient and there were no systemic effects observed. Six of seven vaccine sites tested and all draining lymph nodes were sterile post-vaccination. Following infection with Coccidioides posadasii, strain Silveira, arthroconidia into the lungs, dogs given primary and booster vaccinations had significantly reduced lung fungal burdens (P = 0.0003) and composite disease scores (P = 0.0002) compared to unvaccinated dogs. Dogs vaccinated once had fungal burdens intermediate between those given two doses or none, but disease scores were not significantly different from unvaccinated (P = 0.675). Δcps1 was well-tolerated in the dogs and it afforded a high level of protection when given as prime and boost. These results drive the Δcps1 vaccine toward a licensed veterinary vaccine and support continued development of this vaccine to prevent coccidioidomycosis in humans.

Disseminated Coccidioidomycosis in an Adolescent With Crohn's Disease

Coccidioidomycosis is a systemic mycosis caused by Coccidioides immitis/posadasii. This dimorphic fungus is endemic to the Southwestern United States, particularly in California and Arizona. Most infections are asymptomatic or mild, but around 5% of patients develop complicated pulmonary infection, and approximately 1% may progress to disseminated disease. We present the case of an adolescent male with Crohn's disease who received the integrin inhibitor, vedolizumab, and developed disseminated coccidioidomycosis. This case underscores the importance of considering severe and/or disseminated coccidioidomycosis in immunosuppressed children. In our case, clinical suspicion and bronchoscopy helped confirm the diagnosis and facilitate appropriate evaluation and treatment.

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.

Point Process Models for the Spread of Coccidioidomycosis in California

Coccidioidomycosis is an infectious disease of humans and other mammals that has seen a recent increase in occurrence in the southwestern United States, particularly in California. A rise in cases and risk to public health can serve as the impetus to apply newly developed methods that can quickly and accurately predict future caseloads. The recursive and Hawkes point process models with various triggering functions were fit to the data and their goodness of fit evaluated and compared. Although the point process models were largely similar in their fit to the data, the recursive point process model offered a slightly superior fit. We explored forecasting the spread of coccidioidomycosis in California from December 2002 to December 2017 using this recursive model, and we separated the training and testing portions of the data and achieved a root mean squared error of just 3.62 cases/week.

The Consequences of Our Changing Environment on Life Threatening and Debilitating Fungal Diseases in Humans

Human activities have significantly impacted the environment and are changing our climate in ways that will have major consequences for ourselves, and endanger animal, plant and microbial life on Earth. Rising global temperatures and pollution have been highlighted as potential drivers for increases in infectious diseases. Although infrequently highlighted, fungi are amongst the leading causes of infectious disease mortality, resulting in more than 1.5 million deaths every year. In this review we evaluate the evidence linking anthropomorphic impacts with changing epidemiology of fungal disease. We highlight how the geographic footprint of endemic mycosis has expanded, how populations susceptible to fungal infection and fungal allergy may increase and how climate change may select for pathogenic traits and indirectly contribute to the emergence of drug resistance.

Life Cycle Dominates the Volatilome Character of Dimorphic Fungus Coccidioides spp

Valley fever (coccidioidomycosis) is an endemic fungal pneumonia of the North and South American deserts. The causative agents of Valley fever are the dimorphic fungi Coccidioides immitis and C. posadasii, which grow as mycelia in the environment and as spherules within the lungs of vulnerable hosts. Current diagnostics for Valley fever are severely lacking due to poor sensitivity and invasiveness, contributing to a 23-day median time to diagnosis, and therefore, new diagnostic tools are needed. We are working toward the development of a breath-based diagnostic for coccidioidomycosis, and in this initial study, we characterized the volatile metabolomes (or volatilomes) of in vitro cultures of Coccidioides. Using solid-phase microextraction (SPME) and comprehensive two-dimensional gas chromatography coupled to time of flight mass spectrometry (GC×GC-TOFMS), we characterized the volatile organic compounds (VOCs) produced by six strains of each species during mycelial or spherule growth. We detected a total of 353 VOCs that were at least 2-fold more abundant in a Coccidioides culture than in medium controls and found that the volatile metabolome of Coccidioides is more dependent on the growth phase (spherules versus mycelia) than on the species. The volatile profiles of C. immitis and C. posadasii have strong similarities, indicating that a single suite of Valley fever breath biomarkers can be developed to detect both species.

IMPORTANCE Coccidioidomycosis, or Valley fever, causes up to 30% of community-acquired pneumonias in highly populated areas of the U.S. desert southwest where the disease is endemic. The infection is difficult to diagnose by standard serological and histopathological methods, which delays appropriate treatment. Therefore, we are working toward the development of breath-based diagnostics for Valley fever. In this study, we characterized the volatile metabolomes (or volatilomes) of six strains each of Coccidioides immitis and C. posadasii, the dimorphic fungal species that cause Valley fever. By analyzing the volatilomes during the two modes of growth of the fungus—mycelia and spherules—we observed that the life cycle plays a significant role in the volatiles produced by Coccidioides. In contrast, we observed no significant differences in the C. immitis versus C. posadasii volatilomes. These data suggest that life cycle, rather than species, should guide the selection of putative biomarkers for a Valley fever breath test.

Advances in Diagnosis of Progressive Pulmonary and Disseminated Coccidioidomycosis

BACKGROUND

Antibody detection is the main method for diagnosis of coccidioidomycosis, but it has limitations. The Coccidioides antigen enzyme immunoassay is recommended for testing cerebrospinal fluid in suspected meningitis. Reports on urine and serum antigen detection evaluated small numbers of patients who were mostly immunocompromised. The purpose of this study was to assess the accuracy of combined antibody and antigen detection for diagnosis.

METHODS

A retrospective study, including all patients in whom Coccidioides antigen detection in serum was performed between January 2013 and May 2017, was conducted at Valleywise Health Medical Center (formerly Maricopa Integrated Health System). Sensitivity and specificity of antigen and antibody were evaluated in 158 cases and 487 controls.

RESULTS

The sensitivity of antibody detection by immunodiffusion (ID) was 84.2%. The sensitivity of antigen detection was 57.0% if both urine and serum were tested and 36.7% if urine alone was tested. The sensitivity of combining antigen and ID antibody detection was 93.0%. The sensitivity of urine and serum antigen detection was 55.4% in proven and 58.7% in probable cases, 79.1% in disseminated and 41.6% in pulmonary cases, and 74.7% in immunocompromised and 40.0% in immunocompetent patients. Specificity was 99.4% for antigen detection and 96.5% for ID antibody detection. Diagnostic accuracy was 95.4% for ID antibody and antigen detection, 93.6% for ID antibody alone, and 89.1% for pathology or culture.

CONCLUSIONS

These findings support combined antibody and antigen detection for diagnosis of progressive coccidioidomycosis. The diagnosis may have been missed if antigen detection was not performed.

Clinical and Economic Burden of Valley Fever in Arizona: An Incidence-Based Cost-of-Illness Analysis

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.

Coccidioidomycosis in Brazil: Historical Challenges of a Neglected Disease

Coccidioidomycosis is a deep-seated fungal infection that occurs exclusively in semiarid areas in the Americas. In Brazil, coccidioidomycosis occurs exclusively in rural areas in the northeast region and affects counties that are hit by recurrent droughts, poverty and economic stagnation. Since 1978, approximately 136 cases of the disease have been reported in Brazil, according to scientific publications. However, a lack of governmental epidemiological data as well as a similarity to tuberculosis have led scientists and experts to assume that a greater number of cases occur in the country, which are not diagnosed and/or reported. In this review, general characteristics of coccidioidomycosis are presented, followed by a description of the main clinical and epidemiological data of cases in Brazil. The purpose of this article is to discuss the inclusion of coccidioidomycosis in the list of neglected tropical diseases. We believe that the adoption of coccidioidomycosis as a neglected tropical disease will enable the creation of an effective epidemiological surveillance system and the development of feasible public health solutions for its control in vulnerable populations.

Economic Valuation of Coccidioidomycosis (Valley Fever) Projections in the United States in Response to Climate Change

Coccidioidomycosis, or valley fever, is an infectious fungal disease currently endemic to the southwestern United States. Symptoms of valley fever range in severity from flu-like illness to severe morbidity and mortality. Warming temperatures and changes in precipitation patterns may cause the area of endemicity to expand northward throughout the western United States, putting more people at risk for contracting valley fever. This may increase the health and economic burdens from this disease. We developed an approach to describe the relationship between climate conditions and valley fever incidence using historical data and generated projections of future incidence in response to both climate change and population trends using the Climate Change Impacts and Risk Analysis (CIRA) framework developed by the U.S. Environmental Protection Agency. We also developed a method to estimate economic impacts of valley fever that is based on case counts. For our 2000-15 baseline time period, we estimated annual medical costs, lost income, and economic welfare losses for valley fever in the United States were $400,000 per case, and the annual average total cost was $3.9 billion per year. For a high greenhouse gas emission scenario and accounting for population growth, we found that total annual costs for valley fever may increase up to 164% by year 2050 and up to 380% by 2090. By the end of the twenty-first century, valley fever may cost $620,000 per case and the annual average total cost may reach $18.5 billion per year. This work contributes to the broader effort to monetize climate change-attributable damages in the United States.

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.

Nikkomycin Z-Ready to Meet the Promise?

Nikkomycin Z (NikZ) has fungicidal activity against some fungal species which currently requires patients to endure chronic therapy, sometimes for years. This review highlights reports of NikZ activity against fungal species for which current therapeutics are still inadequate, as a potential roadmap for continuing investigation. The possibility of faster and more complete clinical resolution by using NikZ has attracted scientific attention for decades. NikZ inhibits chitin structure formation, which is important for fungi, but not found in mammals. NikZ raised no safety concerns in a human Phase 1 trial or in extensive toxicology studies. NikZ showed strong clinical benefit in dogs with natural Coccidioides infection. NikZ has protected animals against fatal infections of Candida albicans. NikZ provides high protection in synergistic combination with several agent classes against Candida and Aspergillus species.

A quantitative enzyme-linked immunoassay (ELISA) to approximate complement-fixing antibody titers in serum from patients with coccidioidomycosis

Coccidioidomycosis is most frequently diagnosed serologically, and the quantitative test for complement-fixing antibodies is considered prognostically useful. Because complement-fixing antibody testing is complex, labor-intensive, and poorly standardized, an enzyme-linked immunoassay (ELISA) alternative would be attractive. In this report, we restrict the complement-fixing, antibody-binding domain to a 200-amino-acid recombinant peptide of the known antigen. Over-lapping truncations of this peptide do not bind complement-fixing antibodies, suggesting that the responsible epitope(s) are conformational. Further, anchoring the antigenic peptide to the ELISA plate by means of a C-terminal biotin-mimic peptide tag instead of allowing the peptide to randomly adhere to the plastic plate improves sensitivity of antibody detection by 1-2 logs in different sera. The newly developed ELISA shows a significant quantitative correlation with complement-fixing antibody titers. This ELISA shows potential as the basis for a new quantitative assay for coccidioidal antibodies.

Valley Fever: Environmental Risk Factors and Exposure Pathways Deduced from Field Measurements in California

Coccidioidomycosis, also known as Valley fever, has been reported among military personnel in Coccidioides-endemic areas of the southwestern United States since World War II. In this study, the prevalence of Coccidioides was confirmed in different soil and dust samples collected near three military bases in California using DNA extraction and Polymerase Chain Reaction (PCR) methods. Analyses of physical and chemical parameters revealed no significant differences between Coccidioides-positive and -negative sites. Soil samples collected in the Mojave Desert (near Twentynine Palms MCAGCC) showed the highest percentage of Coccidioides-positive soil and dust samples. Samples from the San Joaquin Valley (near NAS Lemoore) showed the lowest percentage of positive samples and were restricted to remnants of semi-natural areas between agricultural fields. Our results suggest that soil disturbance around all three military bases investigated poses a potential Coccidioides exposure risk for military personnel and the public. We conclude that once lands have been severely disturbed from their original state, they become less suitable for Coccidioides growth. We propose a conceptual framework for understanding exposure where disturbance of soils that exhibit natural or remnants of native vegetation (Creosote and Salt Bush) generate a high risk of exposure to the pathogen, likely during dry periods. In contrast, Coccidioides-positive sites, when undisturbed, will not pose a high risk of exposure.

Endemic mycoses: epidemiology and diagnostic strategies

INTRODUCTION

The global frequency of endemic mycoses has considerably increased, mainly due to environmental changes, population growth in endemic areas, and the increase in HIV-related immunosuppressed status. Among the most frequent endemic mycoses are coccidioidomycosis in semi-desert climates, and paracoccidioidomycosis, and histoplasmosis in tropical climates. The inoculum can enter the host through the airway or directly through the skin. Lymphatic and hematogenous spread may involve the skin.

AREAS COVERED

In this article, we provide up-to-date epidemiological and diagnostic data on major (histoplasmosis, paracoccidioidomycosis, coccidioidomycosis, blastomycosis) and minor (talaromycosis, adiaspiromycosis, emergomycosis) endemic mycoses.

EXPERT OPINION

Endemic mycoses include diseases with a localized endemic area, and a few of them converge. These mycoses all have in common the airway involvement and can cause pulmonary symptoms following initial asymptomatic infection. Among the risk groups to acquire these mycoses are travelers from endemic areas, archeologists, speleologists, and immigrants. Promising and useful diagnostic tools have been developed in endemic mycoses; however, most of them are not standardized or available in low-income countries.

Clinician Practice Patterns That Result in the Diagnosis of Coccidioidomycosis Before or During Hospitalization

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.

Earthquake-Ridden Area in USA Contains Coccidioides, the Valley Fever Pathogen

Early July 2019, two major earthquakes occurred in the Mojave Desert of California near the city of Ridgecrest and the community of Trona and generated a large dust plume that lingered for days. The earthquakes hit an area endemic for Coccidioides, a soil-borne fungal pathogen that can become airborne when soil is disturbed and typically manifests as a pulmonary disease when inhaled. This study is the first to confirm the presence of Coccidioides in soils near Trona using a nested polymerase chain reaction (PCR) approach. First responders to earthquake events, the public, and physicians in the San Joaquin Valley and the Mojave Desert should be informed about the risk of pathogen exposure during and after the time of an earthquake, since there are many fault lines in addition to the large San Andreas Fault and future earthquakes in this region are expected to occur.

Coccidioidomycosis in solid organ transplant recipients

PURPOSE OF REVIEW

The purpose of the review is an update of diagnosis and treatment of coccidioidomycosis infection in solid organ transplant (SOT) patients. Endemic fungal infections continue to be a cause of serious morbidity and mortality in transplant recipients.

RECENT FINDINGS

In transplant patients there are recommendations regarding screening in areas that are endemic for coccidioidomycosis. This screening involves serologic testing and chest imaging. In endemic areas pretransplant seropositivity varies from 1.4 to 5.6%. In immunocompromised patients with elevated complement fixation titers, evaluation of cerebrospinal fluid is recommended even in the absence of symptoms. Although coccidioidomycosis can be a self-limited disease in immunocompotent patients, all SOT patients should be treated regardless of severity. This may include intravenous amphotericin B in severe cases and fluconazole therapy in milder episodes. In those SOT recipients with evidence of prior coccidioidomycosis, lifelong secondary prophylaxis with fluconazole given risk of recurrent disease.

SUMMARY

Coccidioidomycosis continues to be a cause of serious morbidity and mortality in transplant recipients but with proper screening and treatment can be successfully managed.

Shunt Treatment for Coccidioidomycosis-Related Hydrocephalus: A Single-Center Series

OBJECTIVE

Coccidioidomycosis is a fungal infection endemic to the southwestern United States. Hydrocephalus can develop after intracranial dissemination, and management of this disease entity is difficult. We present our institutional experience with shunting coccidioidomycosis-related hydrocephalus.

METHODS

A cohort of patients with coccidioidomycosis-related hydrocephalus undergoing an intracranial shunt placement were retrospectively identified over a 24-year period. Demographics and treatment characteristics were obtained from the electronic medical record.

RESULTS

Thirty patients undergoing 83 procedures were identified, with a median follow-up of 19.4 months. The average age of the cohort was 43 years at the time of initial shunt placement. Most patients (66.7%) had ≥1 shunt failure, and the average number of revisions required was 2.6 for patients who had shunt failure. The average shunt valve pressure threshold required was 5.5 cm H₂O, and patients who harbored the disease for a longer period (>7 months) had a lower pressure setting for initial shunt valves. Shunts without an antisiphon component were more likely to be failure free on multivariate analysis (odds ratio, 9.2; 95% confidence interval, 2.4-35.7). Death was associated with a longer diagnosis-to-shunt time interval, and patients having been diagnosed with intracranial disease for more than 10 months before shunt placement had significantly higher rates of death on follow-up.

CONCLUSIONS

Patients with coccidioidomycosis-related hydrocephalus typically have normal to low pressure setting requirements, high shunt failure rates, prolonged hospitalizations, and mortality. In this disease context, shunt valves without an antisiphon component are associated with lower shunt failure rates.

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.

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.