1
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Sivasubramanian G, Kadakia S, Kim JM, Pervaiz S, Yan Y, Libke R. Challenges in the Long-term Management of Patients With Coccidioidal Meningitis: A Retrospective Analysis of Treatment and Outcomes. Open Forum Infect Dis 2023; 10:ofad243. [PMID: 37333722 PMCID: PMC10270562 DOI: 10.1093/ofid/ofad243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 04/27/2023] [Indexed: 06/20/2023] Open
Abstract
Background Coccidioidal meningitis (CM) is the most severe form of disseminated coccidioidomycosis. Despite years of clinical experience, it remains a difficult condition to treat, often requiring surgical procedures, such as placement of a ventriculoperitoneal shunt, in addition to lifelong antifungal therapy. Methods We performed a retrospective analysis of patients with CM seen in a large referral center in Central Valley, California, from 2010 to 2020. Data pertinent to CM were collected and analyzed. Results Among 133 patients with CM identified in the 10-year period, nonadherence to antifungal therapy was noted in 43% of patients. Of the 80 patients who underwent ventriculoperitoneal shunt placement for management of intracranial pressure, shunt failure requiring revision surgery occurred in 42 (52.5%). Rehospitalizations due to CM-related reasons occurred in 78 of 133 patients (59%). Twenty-three percent of patients (n = 29) died due to complications from CM, on an average 22 months after the diagnosis of CM. Encephalopathy at presentation was associated with a significantly higher risk of death. Conclusions Patients with CM in central California are predominantly rural agricultural workers with elevated levels of poverty and low health literacy and many barriers to care, leading to high rates of medication nonadherence and loss to follow-up outpatient care. Management challenges are frequent, such as failure of antifungal therapy, high rates of rehospitalization, and the need for repeated shunt revision surgeries. In addition to the development of curative new antifungal agents, understanding the barriers to patient adherence to care and antifungal therapy and identifying means to overcome such barriers are of paramount importance.
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Affiliation(s)
- Geetha Sivasubramanian
- Correspondence: Geetha Sivasubramanian, MD, FIDSA, Division of Infectious Diseases, Department of Internal Medicine, University of California, San Francisco at Fresno, 155 N Fresno St, Suite 307, Fresno, CA 93701 (); Robert Libke, MD, Division of Infectious Diseases, Department of Internal Medicine, University of California, San Francisco at Fresno, 155 N Fresno St, Suite 307, Fresno, CA 93701 ()
| | - Saurin Kadakia
- Department of Internal Medicine, University of California, San Francisco, Fresno, California, USA
| | - Jani M Kim
- Division of Infectious Disease, University of California, San Francisco, Fresno, California, USA
| | - Sarah Pervaiz
- Division of Infectious Disease, University of California, San Francisco, Fresno, California, USA
| | - Yueqi Yan
- HSRI Biostatistics and Data Support Core, University of California, Merced, California, USA
| | - Robert Libke
- Correspondence: Geetha Sivasubramanian, MD, FIDSA, Division of Infectious Diseases, Department of Internal Medicine, University of California, San Francisco at Fresno, 155 N Fresno St, Suite 307, Fresno, CA 93701 (); Robert Libke, MD, Division of Infectious Diseases, Department of Internal Medicine, University of California, San Francisco at Fresno, 155 N Fresno St, Suite 307, Fresno, CA 93701 ()
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2
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McHardy IH, Barker B, Thompson GR. Review of Clinical and Laboratory Diagnostics for Coccidioidomycosis. J Clin Microbiol 2023; 61:e0158122. [PMID: 36883820 PMCID: PMC10204634 DOI: 10.1128/jcm.01581-22] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
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.
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Affiliation(s)
- Ian H. McHardy
- Scripps Medical Laboratory, Scripps Health, San Diego, California, USA
- University of California, Davis Center for Valley Fever, Sacramento, California, USA
| | - Bridget Barker
- Department of Biological Sciences, Northern Arizona University, Flagstaff, Arizona, USA
| | - George R. Thompson
- Department of Internal Medicine, Division of Infectious Diseases, University of California, Davis Medical Center, Sacramento, California, USA
- University of California, Davis Center for Valley Fever, Sacramento, California, USA
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3
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Galgiani JN, Hsu AP, Powell DA, Vyas JM, Holland SM. Genetic and Other Determinants for the Severity of Coccidioidomycosis: A Clinician's Perspective. J Fungi (Basel) 2023; 9:jof9050554. [PMID: 37233265 DOI: 10.3390/jof9050554] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/30/2023] [Accepted: 05/06/2023] [Indexed: 05/27/2023] Open
Abstract
The endemic fungal infection, coccidioidomycosis, occurs after inhalation of one or very few Coccidioides spp. spores. Infections produce diverse clinical manifestations, ranging from insignificant to extremely destructive, even fatal. Approaches to understanding this range of consequences have traditionally categorized patients into a small number of groups (asymptomatic, uncomplicated self-limited, fibro-cavitary, and extra-thoracic disseminated) and then looked for immunologic differences among them. Recently, variants within genes of innate pathways have been found to account, in part, for infections that result in disseminated disease. This discovery raises the very attractive theory that, in patients without severe immunosuppression, much of the disease spectrum can be accounted for by various combinations of such deleterious variants in innate pathways. In this review, we summarize what is known about genetic determinants that are responsible for the severity of coccidioidal infections and how complex innate genetic differences among different people might account for the spectrum of disease observed clinically.
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Affiliation(s)
- John N Galgiani
- Valley Fever Center for Excellence, College of Medicine-Tucson, University of Arizona, Tucson, AZ 85721, USA
- Department of Medicine, College of Medicine-Tucson, University of Arizona, Tucson, AZ 85721, USA
- Department of Immunobiology, College of Medicine-Tucson, University of Arizona, Tucson, AZ 85721, USA
- BIO5 Institute, University of Arizona, Tucson, AZ 85721, USA
| | - Amy P Hsu
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD 20892, USA
| | - Daniel A Powell
- Valley Fever Center for Excellence, College of Medicine-Tucson, University of Arizona, Tucson, AZ 85721, USA
- BIO5 Institute, University of Arizona, Tucson, AZ 85721, USA
| | - Jatin M Vyas
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
| | - Steven M Holland
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD 20892, USA
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4
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Gupta S, Ampel NM, Klanderman M, Grill MF, Blair JE. Fluconazole Failure in the Treatment of Coccidioidal Meningitis. J Fungi (Basel) 2022; 8:1157. [PMID: 36354924 PMCID: PMC9697806 DOI: 10.3390/jof8111157] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 10/27/2022] [Accepted: 10/29/2022] [Indexed: 09/02/2023] Open
Abstract
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.
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Affiliation(s)
- Simran Gupta
- Department of Internal Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Neil M. Ampel
- Division of Infectious Diseases, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Molly Klanderman
- Department of Quantitative Health Sciences, Phoenix, AZ 85054, USA
| | - Marie F. Grill
- Department of Neurology, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Janis E. Blair
- Division of Infectious Diseases, Mayo Clinic, Phoenix, AZ 85054, USA
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5
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Thompson GR, Ampel NM, Blair JE, Donovan F, Fierer J, Galgiani JN, Heidari A, Johnson R, Shatsky SA, Uchiyama CM, Stevens DA. Controversies in the Management of Central Nervous System Coccidioidomycosis. Clin Infect Dis 2022; 75:555-559. [PMID: 35717645 DOI: 10.1093/cid/ciac478] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Indexed: 11/12/2022] Open
Abstract
Central nervous system infection with Coccidioides spp is fatal if untreated, and complications occur even when therapy is directed by experienced clinicians. We convened a panel of clinicians experienced in the management of coccidioidal meningitis to summarize current controversies and provide consensus for the management of this difficult infection.
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Affiliation(s)
- George R Thompson
- Department of Internal Medicine, Division of Infectious Diseases and the Department of Medical Microbiology and Immunology, University of California-Davis Medical Center; Sacramento, CA USA.,University of California - Davis Center for Valley Fever, Sacramento, CA USA
| | - Neil M Ampel
- Division of Infectious Diseases, Mayo Clinic in Arizona, Phoenix, AZ, USA.,University of Arizona College of Medicine, Tucson, AZ, USA
| | - Janis E Blair
- Division of Infectious Diseases, Mayo Clinic in Arizona, Phoenix, AZ, USA
| | - Fariba Donovan
- University of Arizona College of Medicine, Tucson, AZ, USA.,Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, AZ, USA
| | - Joshua Fierer
- Division of Infectious Disease, Department of Medicine, University of California San Diego School of Medicine, La Jolla, CA, USA.,Infectious Diseases Section, VA Healthcare San Diego, San Diego, CA, USA
| | - John N Galgiani
- University of Arizona College of Medicine, Tucson, AZ, USA.,Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, AZ, USA
| | - Arash Heidari
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Kern Medical, Bakersfield, CA, USA.,Valley Fever Institute, Kern Medical Center, Bakersfield, CA, USA
| | - Royce Johnson
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Kern Medical, Bakersfield, CA, USA.,Valley Fever Institute, Kern Medical Center, Bakersfield, CA, USA
| | | | - Christopher M Uchiyama
- Department of Neurosurgery, Scripps Clinic and Scripps Green Hospital, La Jolla, CA, USA
| | - David A Stevens
- California Institute for Medical Research, San Jose, CA, USA.,Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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6
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Thompson GR, Boulware DR, Bahr NC, Clancy CJ, Harrison TS, Kauffman CA, Le T, Miceli MH, Mylonakis E, Nguyen MH, Ostrosky-Zeichner L, Patterson TF, Perfect JR, Spec A, Kontoyiannis DP, Pappas PG. Noninvasive Testing and Surrogate Markers in Invasive Fungal Diseases. Open Forum Infect Dis 2022; 9:ofac112. [PMID: 35611348 PMCID: PMC9124589 DOI: 10.1093/ofid/ofac112] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 03/02/2022] [Indexed: 02/04/2023] Open
Abstract
Invasive fungal infections continue to increase as at-risk populations expand. The high associated morbidity and mortality with fungal diseases mandate the continued investigation of novel antifungal agents and diagnostic strategies that include surrogate biomarkers. Biologic markers of disease are useful prognostic indicators during clinical care, and their use in place of traditional survival end points may allow for more rapid conduct of clinical trials requiring fewer participants, decreased trial expense, and limited need for long-term follow-up. A number of fungal biomarkers have been developed and extensively evaluated in prospective clinical trials and small series. We examine the evidence for these surrogate biomarkers in this review and provide recommendations for clinicians and regulatory authorities.
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Affiliation(s)
- George R Thompson
- Division of Infectious Diseases, Department of Internal Medicine, University of California-Davis Medical Center, Sacramento California, USA
- Department of Medical Microbiology and Immunology, University of California-Davis, Davis, California, USA
| | - David R Boulware
- Division of Infectious Diseases, Department of Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, Kansas, USA
| | - Cornelius J Clancy
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Thomas S Harrison
- Centre for Global Health, Institute of Infection and Immunity, St George’s University of London, London, United Kingdom
- Clinical Academic Group in Infection, St George’s Hospital NHS Trust, London, United Kingdom
- MRC Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Carol A Kauffman
- VA Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan, USA
| | - Thuy Le
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, North Carolina, USA
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Eleftherios Mylonakis
- Division of Infectious Diseases, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - M Hong Nguyen
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Thomas F Patterson
- Division of Infectious Diseases, Department of Medicine, The University of Texas Health Science Center, San Antonio, Texas, USA
| | - John R Perfect
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, North Carolina, USA
- Division of Infectious Diseases, Department of Molecular Genetics and Microbiology, Duke University, Durham, North Carolina, USA
| | - Andrej Spec
- Division of Infectious Diseases, Department of Medicine, Washington University in St. Louis, School of Medicine, St. Louis, Missouri, USA
| | - Dimitrios P Kontoyiannis
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Peter G Pappas
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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7
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Pulmonary Coccidioidomycosis: A Case Report and Literature Review. Medicina (B Aires) 2022; 58:medicina58050655. [PMID: 35630071 PMCID: PMC9143117 DOI: 10.3390/medicina58050655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 04/28/2022] [Accepted: 05/10/2022] [Indexed: 12/03/2022] Open
Abstract
Coccidioidomycosis is an infectious disease caused by Coccidioides immitis or C. posadasii fungus. Humans usually get infected by inhaling spores risen from the soil. Although in 60 percent of cases symptoms are absent, remaining patients can develop various manifestations of the disease, from flu-like symptoms to severe dissemination or meningitis. In endemic regions (California, Arizona, Mexico, Central, and South America), pulmonary coccidioidomycosis causes 25% of community-acquired cases of pneumonia. We present the first registered case of pulmonary coccidioidomycosis in Lithuania. Clinical presentation, pathogenesis, treatment options, and diagnostic alternatives are discussed.
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8
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Butkiewicz CD, Alcott CJ, Renschler J, Wheat LJ, Shubitz LF. The utility of Coccidioides antigen and antibody detection in cerebrospinal fluid in the diagnosis of canine central nervous system coccidioidomycosis. Am J Vet Res 2022; 83:59-63. [PMID: 34773701 DOI: 10.2460/ajvr.21.08.0121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the utility of enzyme immunoassays (EIAs) for the detection of Coccidioides antigen and antibody in CSF in the diagnosis of CNS coccidioidomycosis in dogs. ANIMALS 51 dogs evaluated for CNS disease in a single specialty center in Tucson in 2016. PROCEDURES Excess CSF after routine analysis was banked after collection from dogs presented to the neurology service. Samples were tested by EIA for presence of Coccidioides antigen and antibody. Clinical data were collected from medical records retrospectively. RESULTS 22 dogs were diagnosed with CNS coccidioidomycosis (CCM) or another neurologic disease (non-CCM). These groups of dogs overlapped in the presenting complaints, MRI results, and routine CSF analysis results. Four dogs, all with CCM, had positive antigen EIA results. With clinical diagnosis used as the reference standard, CSF antigen testing had low sensitivity (20%) but high specificity (100%) for diagnosis of CCM. Ten dogs with CCM and 4 dogs with other diagnoses had antibody detected in CSF by EIA. Sensitivity of CSF antibody testing was 46%, specificity was 86%, and positive and negative predictive values for the study population were 71% and 68%, respectively. Clinical Relevance Diagnosis of CNS coccidioidomycosis in dogs in an endemic region was hampered by overlap of clinical signs with other neurologic disorders and the low sensitivity of confirmatory diagnostics. The evaluated Coccidioides-specific EIAs performed on CSF can aid in the diagnosis. A prospective study is warranted to corroborate and refine these preliminary findings.
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Affiliation(s)
| | | | | | | | - Lisa F Shubitz
- The Valley Fever Center for Excellence, University of Arizona, Tucson, AZ
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9
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Abstract
Coccidioidomycosis, caused by the dimorphic pathogenic fungi Coccidioides immitis and Coccidioides posadassi, is endemic to the southwestern United states and Central and South America. The incidence of coccidioidomycosis continues to increase. Coccidioidomycosis is typically a self-limiting influenza-like respiratory illness; however, it can lead to disseminated disease outside of the lungs. Not all nondisseminated cases require therapy, but antifungal therapy is typically beneficial requiring treatment ranging from months to lifelong. Clinical factors related to treatment decisions include severity of symptoms, radiography, coccidioidomycosis serologic results, and concurrent medical problems including immunosuppression. This review summarizes the epidemiology, clinical manifestations, and treatment options.
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Affiliation(s)
- Derek J Bays
- Department of Internal Medicine, Division of Infectious Diseases, University of California Davis Medical Center, 4150 V Street, PSSB, Suite G500, Sacramento, CA 95817, USA
| | - George R Thompson
- Department of Internal Medicine, Division of Infectious Diseases, University of California Davis Medical Center, 4150 V Street, PSSB, Suite G500, Sacramento, CA 95817, USA; Department of Medical Microbiology and Immunology, University of California, Davis, Davis, CA, USA.
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10
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De la Cerda-Vargas MF, Sandoval-Bonilla BA, McCarty JM, De León FCP, Candelas-Rangel JA, Rodríguez-Rodríguez JD, Navarro-Domínguez P, Muñoz-Hernández MA, Meza-Mata E, Fernández-González EM, Sámano-Aviña MG. Hydrocephalus in Mexican children with Coccidioidal Meningitis: Clinical, serological, and neuroimaging findings. Surg Neurol Int 2021; 12:119. [PMID: 33880224 PMCID: PMC8053472 DOI: 10.25259/sni_895_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 02/08/2021] [Indexed: 01/03/2023] Open
Abstract
Background Coccidioidal meningitis (CM) is a fungal infectious disease that rarely affects children. Even in endemic areas, coccidiomycosis rarely affects the pediatric population. However, 40% of affected children develop hydrocephalus. Here, we describe the clinical, serological, and neuroimaging findings in a series of Mexican children admitted to our neurosurgical service with hydrocephalus and subsequently diagnosed with CM. Methods We report a prospective series of pediatric patients with hydrocephalus secondary to CM in an endemic area at the north of Mexico. Our report includes children with CM who were hospitalized from 2015 to 2019 in a regional hospital in Torreón, Coahuila. Clinical evolution was monitored for 1 year after hospital discharge. Results Our series include five children with CM (2-17-years-old, three female), who were hospitalized for hydrocephalus and developed intracranial hypertension. The most frequent neuroimaging findings were leptomeningeal enhancement (5/5) and basal arachnoiditis (4/5), followed by asymmetric hydrocephalus (3/5), abnormalities in fourth ventricle morphology (3/5), and cerebral vasculitis (2/5). CM was diagnosed by positive serology or pathology studies. All children were initially managed with fluconazole and a shunt was placed for management of hydrocephalus. Four patients recovered without permanent neurological deficits and one subject developed persistent vegetative state. One year after hospital discharge, none of the subjects died. Conclusion This series contributes to the limited number of pediatric CM cases reported in the literature, and describes neuroimaging findings in the pediatric population. The cases here presented show that the identification of Coccidioides as causal agent in pediatric meningitis is crucial for targeted treatment and can affect dramatically neurological prognosis. Furthermore, our report stresses that even in endemic areas pediatric coccidiomycosis represents a diagnostic challenge, which is further exacerbated by the limited availability of resources in these regions. Therefore, a positive immunoglobulin G by enzyme immunoassay is enough for diagnosis of CM in endemic areas without access to CF.
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Affiliation(s)
- María F De la Cerda-Vargas
- Department of Neurosurgery, Hospital de Especialidades N° 71, Instituto Mexicano del Seguro Social, Torreón Coahuila
| | - B A Sandoval-Bonilla
- Department of Neurosurgery, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, México City, México
| | - James M McCarty
- Department of Pediatrics, School of Medicine, Stanford University, Stanford, California, United States
| | | | - José A Candelas-Rangel
- Department of Neurosurgery, Hospital de Especialidades N° 71, Instituto Mexicano del Seguro Social, Torreón Coahuila
| | - Jorge D Rodríguez-Rodríguez
- Department of Neurosurgery, Hospital de Especialidades N° 71, Instituto Mexicano del Seguro Social, Torreón Coahuila
| | - Pedro Navarro-Domínguez
- Department of Neurosurgery, Hospital de Especialidades N° 71, Instituto Mexicano del Seguro Social, Torreón Coahuila
| | - Melisa A Muñoz-Hernández
- Department of Health Education and Research, Hospital de Especialidades N° 71, Instituto Mexicano del Seguro Social, Torreón Coahuila
| | - Elizabeth Meza-Mata
- Department of Anatomycal Pathology, Hospital de Especialidades N° 71, Instituto Mexicano del Seguro Social, Torreón Coahuila
| | - Elena M Fernández-González
- Department of Health Education, Hospital de Especialidades N° 71, Instituto Mexicano del Seguro Social, Torreón Coahuila
| | - Mariana G Sámano-Aviña
- Department of Pediatric Infectious Disease, Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, México City, Mexico
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11
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Jackson NR, Blair JE, Ampel NM. Central Nervous System Infections Due to Coccidioidomycosis. J Fungi (Basel) 2019; 5:jof5030054. [PMID: 31261704 PMCID: PMC6787616 DOI: 10.3390/jof5030054] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 06/20/2019] [Accepted: 06/26/2019] [Indexed: 12/11/2022] Open
Abstract
Coccidioidomycosis is a common infection in the western and southwestern United States as well as parts of Mexico and Central and South America and is due to the soil-dwelling fungi Coccidioides. Central nervous system (CNS) infection is an uncommon manifestation that is nearly always fatal if untreated. The presentation is subtle, commonly with headache and decreased mentation. The diagnosis should be considered in patients with these symptoms in association with a positive serum coccidioidal antibody test. The diagnosis can only be established by analysis of cerebrospinal fluid (CSF), which typically demonstrates a lymphocytic pleocytosis, hypoglycorrhachia, elevated protein, and positive CSF coccidioidal antibody. Cultures are infrequently positive but a proprietary coccidioidal antigen test has reasonable sensitivity. Current therapy usually begins with fluconazole at 800 mg daily but other triazole antifungals also have efficacy and are often used if fluconazole fails. Triazole therapy should be lifelong. Intrathecal amphotericin B, the original treatment, is now reserved for those in whom triazoles have failed. There are several distinct complications of CNS coccidioidal infection, the most common of which is hydrocephalus. This is nearly always communicating and requires mechanical shunting in addition to antifungal therapy. Other complications include cerebral vasculitis, brain abscess, and arachnoiditis. Management of these is difficult and not well established.
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Affiliation(s)
- Niki R Jackson
- Division of Infectious Diseases, Mayo Clinic in Arizona, Phoenix, AZ 85054, USA
| | - Janis E Blair
- Division of Infectious Diseases, Mayo Clinic in Arizona, Phoenix, AZ 85054, USA
| | - Neil M Ampel
- Division of Infectious Diseases, Mayo Clinic in Arizona, Phoenix, AZ 85054, USA.
- University of Arizona College of Medicine, Tucson, AZ 85724, USA.
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12
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Isavuconazole in the Treatment of Coccidioidal Meningitis. Antimicrob Agents Chemother 2019; 63:AAC.02232-18. [PMID: 30559134 DOI: 10.1128/aac.02232-18] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 12/10/2018] [Indexed: 12/17/2022] Open
Abstract
Patients with coccidioidal meningitis require lifelong antifungal therapy. Cumulative toxicity and lack of antifungal efficacy require salvage therapy in the treatment of some patients. In a retrospective review of nine patients with coccidioidal meningitis treated with isavuconazole, successful therapy was seen in three patients and stable disease was confirmed in six patients. Isavuconazole may be a useful addition to the therapeutic choices currently available for coccidioidal meningitis.
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13
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D'Assumpcao C, Heidari A, Johnson RH. Patient With a 42-Year History of Coccidioidal Meningitis. J Investig Med High Impact Case Rep 2018; 6:2324709618820047. [PMID: 30622991 PMCID: PMC6302271 DOI: 10.1177/2324709618820047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 11/13/2018] [Indexed: 11/28/2022] Open
Abstract
This is a case of a 56-year-old man diagnosed with coccidioidal meningitis 42 years ago at the age of 14. He was treated with intrathecal amphotericin B deoxycholate by cisternal puncture for 15 years before switching to fluconazole once it became available in 1991. Over 42 years of treatment, he developed hearing loss due to auditory nerve neurotoxicity, hydrocephalus requiring ventriculoperitoneal shunting with associated malfunctions, lumbar arachnoiditis, and hypokalemic paralysis. Regular cerebrospinal fluid studies to this day do not show disease clearance. Many of the lessons from his clinical history are enshrined in the current iteration of the Infectious Diseases Society of America Coccidioidomycosis Treatment Guidelines. To our knowledge, he is the longest surviving coccidioidal meningitis patient.
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Affiliation(s)
- Carlos D'Assumpcao
- Kern Medical-UCLA, Bakersfield, CA, USA.,Ross University, Miramar, FL, USA
| | - Arash Heidari
- Kern Medical-UCLA, Bakersfield, CA, USA.,Valley Fever Institute, Bakersfield, CA, USA
| | - Royce H Johnson
- Kern Medical-UCLA, Bakersfield, CA, USA.,Valley Fever Institute, Bakersfield, CA, USA
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Vaysman T, Villaflores S, Estrella C, Radhakrishna S, Liu A. Myelitis due to Coccidioidomycosis in an Immunocompetent Patient. Case Rep Infect Dis 2018; 2018:2176269. [PMID: 29808132 PMCID: PMC5902110 DOI: 10.1155/2018/2176269] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 02/02/2018] [Accepted: 02/25/2018] [Indexed: 01/07/2023] Open
Abstract
Myelitis of the spinal cord is an uncommon presentation of disseminated coccidioidomycosis. Most infected patients present subclinically, but patients, especially those who are immunocompromised, may progress to disseminated disease. We present a 50-year-old immunocompetent patient with no significant past medical history exhibiting symptoms of altered mental status, dizziness, headache, nausea, and quadriplegia. Upon investigation with lumbar puncture, cerebrospinal fluid (CSF) culture, and coccidioidal antibody studies, the patient was found to have acute coccidioidomycosis. Magnetic resonance imaging (MRI) of the brain demonstrated meningeal enhancements suggestive of meningitis, and further MRI study of the cervical spine revealed myelitis. Treatment with IV fluconazole for 2 weeks and IV voriconazole therapy over 3 weeks yielded limited improvement. The presentation of myelitis due to coccidioidomycosis infection is very rare and has infrequently reported in the literature. Awareness of this potentially fatal complication in immunocompetent patients can aid in faster recognition and treatment.
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Affiliation(s)
- Tetyana Vaysman
- Department of Neurology and Infectious Disease, California Hospital Medical Center, Los Angeles, CA, USA
| | - Sean Villaflores
- Department of Neurology and Infectious Disease, California Hospital Medical Center, Los Angeles, CA, USA
| | - Carlyn Estrella
- Department of Neurology and Infectious Disease, California Hospital Medical Center, Los Angeles, CA, USA
| | - Suman Radhakrishna
- Department of Neurology and Infectious Disease, California Hospital Medical Center, Los Angeles, CA, USA
| | - Antonio Liu
- Department of Neurology and Infectious Disease, California Hospital Medical Center, Los Angeles, CA, USA
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15
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Johnson R, Ho J, Fowler P, Heidari A. Coccidioidal Meningitis: A Review on Diagnosis, Treatment, and Management of Complications. Curr Neurol Neurosci Rep 2018. [DOI: 10.1007/s11910-018-0824-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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16
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Stewart ER, Eldridge ML, McHardy I, Cohen SH, Thompson GR. Liposomal Amphotericin B as Monotherapy in Relapsed Coccidioidal Meningitis. Mycopathologia 2018; 183:619-622. [PMID: 29340909 DOI: 10.1007/s11046-017-0240-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 12/18/2017] [Indexed: 02/01/2023]
Abstract
Coccidioidal meningitis remains a difficult clinical problem, and despite life-long therapy with triazole antifungals, relapses of disease and medication intolerance occur necessitating salvage treatment. We report two patients with recurrent coccidioidal meningitis who improved following a 2-week course of liposomal amphotericin B monotherapy and discuss potential advantages of this treatment option.
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Affiliation(s)
- Ethan R Stewart
- Department of Internal Medicine, Division of Infectious Diseases, University of California Davis Medical Center, 4150 V Street, Suite G500, Sacramento, CA, 95817, USA
| | - Matthew L Eldridge
- Department of Internal Medicine, Division of Infectious Diseases, University of California Davis Medical Center, 4150 V Street, Suite G500, Sacramento, CA, 95817, USA
| | - Ian McHardy
- Department of Medical Microbiology and Immunology, Department of Medicine, Division of Infectious Diseases, University of California - Davis, One Shields Ave, Tupper Hall, Rm 3138, Davis, CA, 95616, USA
| | - Stuart H Cohen
- Department of Internal Medicine, Division of Infectious Diseases, University of California Davis Medical Center, 4150 V Street, Suite G500, Sacramento, CA, 95817, USA
| | - George R Thompson
- Department of Internal Medicine, Division of Infectious Diseases, University of California Davis Medical Center, 4150 V Street, Suite G500, Sacramento, CA, 95817, USA. .,Department of Medical Microbiology and Immunology, Department of Medicine, Division of Infectious Diseases, University of California - Davis, One Shields Ave, Tupper Hall, Rm 3138, Davis, CA, 95616, USA.
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Tager D, Hatch A, Segar J, Roller B, Al Mohajer M, Zangeneh TT. Coccidioidal meningitis complicated by central nervous system vasculitis in a patient with leukemia. Med Mycol Case Rep 2017; 16:8-11. [PMID: 28386527 PMCID: PMC5374848 DOI: 10.1016/j.mmcr.2017.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 03/22/2017] [Indexed: 11/17/2022] Open
Abstract
Central Nervous System (CNS) vasculitis is the most common life-threatening complication of coccidioidal meningitis. It is manifested by cerebral ischemia, hemorrhage, and infarction. We report a case of CNS vasculitis in a patient receiving chemotherapy and review of the literature on coccidioidal meningitis. The patient was treated with combination antifungal therapy and a short course of high dose corticosteroids with a modest improvement in her neurological examination after initiation of steroids.
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Affiliation(s)
- Dany Tager
- University of Arizona, College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724, USA
| | - Anne Hatch
- Department of Neurology, Banner University Medical Center, University of Arizona, 1501 N Campbell Ave, Tucson, AZ 85724, USA
| | - Jennifer Segar
- Department of Medicine, Banner University Medical Center, University of Arizona, 1501 N Campbell Ave, Tucson, AZ 85724, USA
| | - Brentin Roller
- Division of Infectious Diseases, Department of Medicine, Banner University Medical Center, University of Arizona, 1501 N Campbell Ave, Tucson, AZ 85724, USA
| | - Mayar Al Mohajer
- Division of Infectious Diseases, Department of Medicine, Banner University Medical Center, University of Arizona, 1501 N Campbell Ave, Tucson, AZ 85724, USA
| | - Tirdad T. Zangeneh
- Division of Infectious Diseases, Department of Medicine, Banner University Medical Center, University of Arizona, 1501 N Campbell Ave, Tucson, AZ 85724, USA
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Ho J, Fowler P, Heidari A, Johnson RH. Intrathecal Amphotericin B: A 60-Year Experience in Treating Coccidioidal Meningitis. Clin Infect Dis 2017; 64:519-524. [PMID: 27927853 DOI: 10.1093/cid/ciw794] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 11/22/2016] [Indexed: 12/14/2022] Open
Abstract
Coccidioidal meningitis (CM) is a devastating complication of coccidioidomycosis. Since the late 1950s, intrathecal (IT) amphotericin B deoxycholate (AmBd) has been successfully used to treat and often cure this disease, reducing mortality rates from 100% to approximately 30%. The introduction of azoles further revolutionized the treatment of coccidioidal infections. However, IT AmBd remains the only known curative option in the management of CM. While the use of IT AmBd is well described in many articles, few discuss the actual methods behind preparation, titration, and dosing strategies utilized. The practitioners at Kern Medical (Bakersfield, California) have >60 years of experience in the utilization of IT AmBd and the treatment of CM. This article describes the practice experience in the treatment of CM, preparation of IT AmBd, and the different dosing strategies used in regard to route of administration (ie, cisternal, lumbar, ventricular).
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Affiliation(s)
- Jackie Ho
- Department of Pharmacy, Kern Medical, Bakersfield, California, USA
| | - Pete Fowler
- Department of Pharmacy, Kern Medical, Bakersfield, California, USA
| | - Arash Heidari
- Department of Medicine, Kern Medical, Bakersfield, California, USA.,David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Royce H Johnson
- Department of Medicine, Kern Medical, Bakersfield, California, USA.,David Geffen School of Medicine, University of California, Los Angeles, California, USA
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21
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Galgiani JN, Ampel NM, Blair JE, Catanzaro A, Geertsma F, Hoover SE, Johnson RH, Kusne S, Lisse J, MacDonald JD, Meyerson SL, Raksin PB, Siever J, Stevens DA, Sunenshine R, Theodore N. 2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Treatment of Coccidioidomycosis. Clin Infect Dis 2016; 63:e112-46. [PMID: 27470238 DOI: 10.1093/cid/ciw360] [Citation(s) in RCA: 317] [Impact Index Per Article: 39.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 05/26/2016] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
| | - Neil M Ampel
- Division of Infectious Diseases, University of Arizona, Tucson
| | - Janis E Blair
- Division of Infectious Diseases, Mayo Clinic, Scottsdale, Arizona
| | - Antonino Catanzaro
- Division of Pulmonary and Critical Care, University of California, San Diego
| | - Francesca Geertsma
- Department of Pediatrics, Infectious Diseases, Stanford University School of Medicine, California
| | | | - Royce H Johnson
- David Geffen School of Medicine at UCLA, Department of Medicine, Kern Medical Center, Bakersfield, California
| | - Shimon Kusne
- Division of Infectious Diseases, Mayo Clinic, Scottsdale, Arizona
| | - Jeffrey Lisse
- Department of Rheumatology, University of Arizona, Tucson
| | - Joel D MacDonald
- Department of Neurosurgery School of Medicine, University of Utah, Salt Lake City
| | - Shari L Meyerson
- Division of Thoracic Surgery, Northwestern University, Feinberg School of Medicine
| | - Patricia B Raksin
- Division of Neurosurgery, John H. Stroger Jr Hospital of Cook County, Chicago, Illinois
| | | | - David A Stevens
- Division of Infectious Diseases, Stanford University School of Medicine, California
| | - Rebecca Sunenshine
- Career Epidemiology Field Officer Program, Division of State and Local Readiness, Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention Maricopa County Department of Public Health
| | - Nicholas Theodore
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
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22
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Garoon RB, Foroozan R, Vaphiades MS. Don't drink in the valley. Surv Ophthalmol 2016; 62:383-386. [PMID: 27102841 DOI: 10.1016/j.survophthal.2016.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 04/11/2016] [Indexed: 10/21/2022]
Abstract
A 39-year-old man presented with chronic headaches and intermittent blurred vision with previous neuroimaging and blood work that was reportedly normal. He had papilledema and further questioning elicited a history of extensive alcohol use, unexplained weight loss, and night sweats. Magnetic resonance imaging of the brain demonstrated communicating hydrocephalus and leptomeningeal enhancement. The patient underwent ventriculoperitoneal shunt placement and leptomeningeal biopsy, which was initially unrevealing. Cerebrospinal fluid eventually yielded positive titers for coccidioides, a diagnosis that was confirmed by biopsy culture results.
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Affiliation(s)
| | - Rod Foroozan
- Baylor College of Medicine, Houston, Texas, USA.
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Abstract
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.
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Affiliation(s)
- Neil M Ampel
- College of Medicine, University of Arizona, Tucson, AZ, USA
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Bamberger DM, Pepito BS, Proia LA, Ostrosky-Zeichner L, Ashraf M, Marty F, Scully E, Wheat LJ. Cerebrospinal fluidCoccidioidesantigen testing in the diagnosis and management of central nervous system coccidioidomycosis. Mycoses 2015; 58:598-602. [DOI: 10.1111/myc.12366] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 07/15/2015] [Accepted: 07/16/2015] [Indexed: 11/29/2022]
Affiliation(s)
| | | | | | | | | | - Francisco Marty
- Brigham and Women's Hospital/Harvard Medical School; Boston MA USA
| | - Eileen Scully
- Brigham and Women's Hospital/Harvard Medical School; Boston MA USA
| | - L. Joseph Wheat
- MiraVista Diagnostics and MiraVista Technologies; Indianapolis IN USA
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Abstract
For over the last three decades, extensive testing of antifungal compounds in clinical trials has been essential to the development of treatment guidelines for the most common invasive fungal infections, including cryptococcosis, candidiasis, aspergillosis, and the endemic fungi. These guidelines have greatly helped guide clinicians in the management of these complicated diseases. The data on which most of these guidelines are based are among the most widely recognized and cited clinical trials comparing antimicrobial agents. Unfortunately, there are many unanswered questions with respect to the diagnosis and treatment of these emerging disorders. Regarding treatment, there is a need for more clinically effective and less toxic agents. The current armamentarium of antifungal agents represents important progress over gold standard agents such as amphotericin B, but there is much progress to be made. With respect to diagnostics, mycology has generally lagged behind other disciplines in microbiology, as there are very few rapid, sensitive, specific, and point-of-care diagnostics. The ability to implement therapies for at-risk patients based on positive early diagnostic signals would greatly enhance the ability to intervene with appropriate antifungal therapy in a more targeted and specific manner. This article will review some of the major advances, as well as significant challenges that remain in the management of invasive mycoses.
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Affiliation(s)
- Peter G Pappas
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama 35294-0006
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27
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Micosis sistémicas en pacientes con virus de la inmunodeficiencia humana/sida. ACTAS DERMO-SIFILIOGRAFICAS 2014; 105:5-17. [DOI: 10.1016/j.ad.2012.06.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 05/08/2012] [Accepted: 06/24/2012] [Indexed: 11/19/2022] Open
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Rodríguez-Cerdeira C, Arenas R, Moreno-Coutiño G, Vásquez E, Fernández R, Chang P. Systemic Fungal Infections in Patients with human inmunodeficiency virus. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.adengl.2012.06.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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29
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Levy ER, McCarty JM, Shane AL, Weintrub PS. Treatment of Pediatric Refractory Coccidioidomycosis With Combination Voriconazole and Caspofungin: A Retrospective Case Series. Clin Infect Dis 2013; 56:1573-8. [DOI: 10.1093/cid/cit113] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Vertebral coccidioidomycosis: presentation and multidisciplinary management. Am J Med 2012; 125:304-14. [PMID: 22340929 DOI: 10.1016/j.amjmed.2011.10.018] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Revised: 09/05/2011] [Accepted: 10/14/2011] [Indexed: 11/22/2022]
Abstract
BACKGROUND Vertebral involvement is a severe complication of infection caused by Coccidioides species. METHODS We conducted a retrospective review of patients diagnosed with vertebral coccidioidomycosis at an academic medical center between 1996 and 2009. RESULTS We identified 39 cases of vertebral coccidioidomycosis. Thirty-four patients (79%) were male, and 23 patients (61%) were black. Black patients were overrepresented in comparison with all other patients by a 50-fold odds ratio (95% confidence interval, 26-95). Only 8 patients (20%) were immunocompromised, including 7 who had received systemic steroids. The number of infected vertebrae ranged from 1 to 24; 8 patients (21%) had epidural involvement. All patients received a triazole as part of medical therapy, and 20 patients also received amphotericin B, typically early in the course. Twenty-six patients (67%) required surgery, 18 of whom also required hardware placement. The most common indication for surgery was pain, but 7 patients had neurologic compromise. No patients developed recurrent or refractory infection at the site of surgical debridement, but 6 patients experienced disease relapse after stopping antifungal therapy. CONCLUSION Vertebral infection caused by Coccidioides species requires a multispecialty approach that always includes medical therapy and frequently requires surgical intervention for debridement or stabilization. A favorable outcome can usually be achieved, but discontinuation of medical therapy is associated with a high risk of relapse, which can occur years later.
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Bercovitch RS, Catanzaro A, Schwartz BS, Pappagianis D, Watts DH, Ampel NM. Coccidioidomycosis during pregnancy: a review and recommendations for management. Clin Infect Dis 2012; 53:363-8. [PMID: 21810749 DOI: 10.1093/cid/cir410] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Pregnancy is an established risk factor for the development of severe and disseminated coccidioidomycosis, particularly when infection is acquired during the later stages of gestation. Although recent studies suggest that the incidence of symptomatic coccidioidomycosis during pregnancy is decreasing and that outcome has improved, management is complicated by the observations that azole antifungal agents can be teratogenic when given to some women, particularly at high doses, early in pregnancy. This article summarizes the data on these issues and offers guidance on the management of coccidioidomycosis during pregnancy.
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Schein R, Homans J, Larsen RA, Neely M. Posaconazole for Chronic Refractory Coccidioidal Meningitis. Clin Infect Dis 2011; 53:1252-4. [DOI: 10.1093/cid/cir734] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Hector RF, Rutherford GW, Tsang CA, Erhart LM, McCotter O, Anderson SM, Komatsu K, Tabnak F, Vugia DJ, Yang Y, Galgiani JN. The public health impact of coccidioidomycosis in Arizona and California. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2011; 8:1150-73. [PMID: 21695034 PMCID: PMC3118883 DOI: 10.3390/ijerph8041150] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Revised: 04/12/2011] [Accepted: 04/13/2011] [Indexed: 01/01/2023]
Abstract
The numbers of reported cases of coccidioidomycosis in Arizona and California have risen dramatically over the past decade, with a 97.8% and 91.1% increase in incidence rates from 2001 to 2006 in the two states, respectively. Of those cases with reported race/ethnicity information, Black/African Americans in Arizona and Hispanics and African/Americans in California experienced a disproportionately higher frequency of disease compared to other racial/ethnic groups. Lack of early diagnosis continues to be a problem, particularly in suspect community-acquired pneumonia, underscoring the need for more rapid and sensitive tests. Similarly, the inability of currently available therapeutics to reduce the duration and morbidity of this disease underscores the need for improved therapeutics and a preventive vaccine.
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Affiliation(s)
- Richard F Hector
- Global Health Sciences, University of California, San Francisco,1200 Beale St, #1200, San Francisco, CA 94105, USA.
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Mathisen G, Shelub A, Truong J, Wigen C. Coccidioidal meningitis: clinical presentation and management in the fluconazole era. Medicine (Baltimore) 2010; 89:251-284. [PMID: 20827104 DOI: 10.1097/md.0b013e3181f378a8] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Despite the advent of new antifungal agents, coccidioidal meningitis (CM) remains a difficult-to-treat condition with significant morbidity and mortality. In this study we directly compare the clinical presentation and management of patients with Coccidioides immitis meningitis in the azole era (after 1980) to that of a cohort of patients from the pre-azole era. We reviewed 30 CM cases seen at 3 Los Angeles hospitals between the years 1993 to 2008 ("2008 cohort") and compared them to 31 patients ("1980 cohort") described by Bouza et al in a previous study. The demographics and clinical presentation of patients in the 2008 cohort were similar to those of the 1980 cohort except for a higher incidence of Hispanic patients (2008: 53% vs. 1980: 6%) and a greater percentage of patients with underlying, predisposing clinical conditions (2008: 66% vs. 1980: 32%). Ten patients in the 2008 cohort had human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), a condition not reported in the earlier study. Laboratory findings were similar between the 2 groups except for a lower incidence of peripheral leukocytosis and eosinophilia in the 2008 group.There were marked differences in drug treatment between the 2 eras. In the 2008 cohort, 29 patients received fluconazole therapy: 13 were treated with fluconazole monotherapy, and 16 received a combination of fluconazole and intravenous amphotericin B. Although almost all patients (29/31) in the 1980 cohort received intrathecal amphotericin B, only 3 patients in the 2008 study received amphotericin B via this route. With respect to complications of CM, a similar percentage of patients in each cohort developed complications such as stroke and hydrocephalus. The 2008 cohort (40%) had similar mortality compared to patients in the 1980 study (39%); survivors in both groups experienced significant impairment of activities of daily living. Although recommended as first-line therapy for CM, azole-based therapies are not curative and do not necessarily prevent complications associated with the disease.CM remains a serious illness with a high rate of morbidity and mortality. Immunocompromised individuals, especially those with HIV/AIDS, are at special risk for CM and represent a greater share of the overall population with this condition. Despite the clear advantages of azole treatment in CM, new therapeutic approaches are needed to provide definitive cure and to reduce the need for long-term suppressive therapy.
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Affiliation(s)
- Glenn Mathisen
- From Cedars Sinai-UCLA Affilialted Multicampus Infectious Disease Program (GM, AS, JT, CW), Los Angeles; Cedars Sinai Medical Center, Los Angeles; Olive View-UCLA Medical Center (GM, JT, CW), Sylmar; VA West Los Angeles Medical Center, Los Angeles; Los Angeles County Department of Public Health (CW), Los Angeles; and Southern California Kaiser Permanente Medical Group (JT), Los Angeles, California
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Magrath GN, Pulido JS, Montero J, Mason C, Wilson J. Cystoid macular edema secondary to fluconazole toxicity. Ocul Immunol Inflamm 2010; 18:472-4. [PMID: 20735297 DOI: 10.3109/09273948.2010.507320] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Fluconazole is an antifungal commonly used to treat Coccidioides immitis, but this medication has a number of side effects including fatigue, rash, headache, dizziness, nausea, vomiting, diarrhea, and elevated liver enzymes. We are unaware of any cases of retinal toxicity related to fluconazole. In this case we present a 76 year old woman with longstanding Coccidioides treated with high dose fluconazole. She becomes symptomatic with fluconazole toxicity and subsequently develops bilateral cystoid macular edema. As her dose of fluconazole is decreased and she is transitioned to voriconazole the edema resolves and her visual acuity improves. This patient's clinical course illustrates retinal toxicity may present with high and prolonged doses of fluconazole.
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Affiliation(s)
- George N Magrath
- Storm Eye Institute, Department of Ophthalmology, Medical University of South Carolina, Charleston, South Carolina, USA
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37
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Segal BH, Herbrecht R, Stevens DA, Ostrosky-Zeichner L, Sobel J, Viscoli C, Walsh TJ, Maertens J, Patterson TF, Perfect JR, Dupont B, Wingard JR, Calandra T, Kauffman CA, Graybill JR, Baden LR, Pappas PG, Bennett JE, Kontoyiannis DP, Cordonnier C, Viviani MA, Bille J, Almyroudis NG, Wheat LJ, Graninger W, Bow EJ, Holland SM, Kullberg BJ, Dismukes WE, De Pauw BE. Defining responses to therapy and study outcomes in clinical trials of invasive fungal diseases: Mycoses Study Group and European Organization for Research and Treatment of Cancer consensus criteria. Clin Infect Dis 2009; 47:674-83. [PMID: 18637757 DOI: 10.1086/590566] [Citation(s) in RCA: 330] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Invasive fungal diseases (IFDs) have become major causes of morbidity and mortality among highly immunocompromised patients. Authoritative consensus criteria to diagnose IFD have been useful in establishing eligibility criteria for antifungal trials. There is an important need for generation of consensus definitions of outcomes of IFD that will form a standard for evaluating treatment success and failure in clinical trials. Therefore, an expert international panel consisting of the Mycoses Study Group and the European Organization for Research and Treatment of Cancer was convened to propose guidelines for assessing treatment responses in clinical trials of IFDs and for defining study outcomes. Major fungal diseases that are discussed include invasive disease due to Candida species, Aspergillus species and other molds, Cryptococcus neoformans, Histoplasma capsulatum, and Coccidioides immitis. We also discuss potential pitfalls in assessing outcome, such as conflicting clinical, radiological, and/or mycological data and gaps in knowledge.
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Affiliation(s)
- Brahm H Segal
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York 14263, USA.
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Blair JE. Coccidioidal meningitis: Update on epidemiology, clinical features, diagnosis, and management. Curr Infect Dis Rep 2009; 11:289-95. [DOI: 10.1007/s11908-009-0043-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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39
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Chiou CC, Walsh TJ, Groll AH. Clinical pharmacology of antifungal agents in pediatric patients. Expert Opin Pharmacother 2007; 8:2465-89. [DOI: 10.1517/14656566.8.15.2465] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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40
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Nolt JD, Geertsma FR. Deep solitary brain mass in a four-month-old male with disseminated coccidioidomycosis: case report. Ann N Y Acad Sci 2007; 1111:385-94. [PMID: 17344521 DOI: 10.1196/annals.1406.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Parenchymal brain involvement from disseminated coccidioidomycosis occurs rarely and there are few documented pediatric cases. We report a four-month-old male infant with a cerebellar lesion seen in the brain on computed tomography (CT). Coccidioides immitis (C. immitis) grew on bronchoscopic fluid samples and serum titers to C. immitis were 1:1024. Antifungal treatment was initiated and after 3 months, CT scans demonstrated brain mass resolution and serum titers were decreased.
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Affiliation(s)
- Jennifer D Nolt
- Children's Hospital Central California, Madera, California, USA.
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41
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Galgiani JN. Coccidioidomycosis: changing perceptions and creating opportunities for its control. Ann N Y Acad Sci 2007; 1111:1-18. [PMID: 17344530 DOI: 10.1196/annals.1406.041] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The perceptions of coccidioidomycosis as a medical problem has undergone sequential and dramatic metamorphoses since its first description more than a century ago. First thought to be rare and lethal, coccidioidomycosis was subsequently found to be common and often mild. During World War II, its overall impact upon large populations came sharply into focus and the consequences for public health became clearer. Early treatments had significant limitations and toxicities, and therefore treatment of coccidioidomycosis was reserved for only the sickest patients. Since then, safer oral therapies have become commonplace. Despite their availability, there has been no investigation of their use in the less severe and much more common early infections. Even newer drugs such as nikkomycin Z, which might actually cure infections, until very recently have had trouble finding a sponsor to move it through clinical trials. Perceptions once formed by the understanding of coccidioidomycosis as a medical problem now appear to hinder the future study of newer therapeutic opportunities. It is suggested in this review that it is time to revisit and possibly change these perceptions if we are to improve our care of patients.
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Affiliation(s)
- John N Galgiani
- Medical Service (1-111INF), Southern Arizona VA Health Care System, 3601 South Sixth Avenue, Tucson, AZ 85723, USA.
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42
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Abstract
Coccidioidal meningitis affects between 200 to 300 persons annually within the endemic area of the United States, with much larger numbers expected in epidemic years. Because this represents a chronic disease for survivors, several thousand patients may be under treatment at any given time. Epidemiology, background, and diagnosis are reviewed. Azole therapy has replaced intrathecal amphotericin B for induction and maintenance therapy for this disease, given its ease of administration and equivalent efficacy in controlling infection even at the cost of losing the opportunity for cure. Both itraconazole and fluconazole have demonstrated efficacy, but have not been compared in randomized human studies. One of the uses of intrathecal amphotericin B is as "add on" therapy in failing azole regimens without evidence of antagonism. Details of therapeutic approach are reviewed. Approach to diagnosis and management of the two principal potentially life threatening complications, hydrocephalus and vasculitis, is also discussed.
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Affiliation(s)
- Paul L Williams
- The Permanente Medical Group, 2651 Highland Avenue, Selma, CA 93662, USA.
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43
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Abstract
PURPOSE OF REVIEW To describe and bring together recent development in the diagnosis and treatment of both community-acquired and opportunistic fungal infections in the intensive care unit. RECENT FINDINGS The past few years have brought major advances to both the diagnosis and treatment of fungal infections. The development of newer therapeutic modalities to supplement existing treatment options includes a new class of antifungal agents, the echinocandins. Newer and improved agents of the azole class have arrived as well as better delineation for the role of liposomal amphotericins. Newer, nonculture-based diagnostic tests have allowed earlier, more timely diagnosis of opportunistic fungal infections, allowing more rapid initiation of therapy. SUMMARY Improved diagnostic tests and newer antifungal agents have been introduced, leading to earlier diagnosis and treatment.
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Affiliation(s)
- George A Sarosi
- Indiana University School of Medicine, Indianapolis, Indiana 46202, USA.
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44
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Baumann RJ, Espinosa PS. Neuroepidemiology of HIV/AIDS. HANDBOOK OF CLINICAL NEUROLOGY 2007; 85:3-31. [PMID: 18808973 DOI: 10.1016/s0072-9752(07)85002-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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45
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Kamberi P, Sobel RA, Clemons KV, Waldvogel A, Striebel JM, Williams PL, Stevens DA. Comparison of itraconazole and fluconazole treatments in a murine model of coccidioidal meningitis. Antimicrob Agents Chemother 2006; 51:998-1003. [PMID: 17178793 PMCID: PMC1803148 DOI: 10.1128/aac.00332-06] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Coccidioidal meningitis (CM) is a devastating disease that requires long-term therapy and for which there is little hope of a cure. A model was used to compare the efficacies of itraconazole and fluconazole. CD-1 mice were infected intrathecally with 30 to 36 viable arthroconidia of Coccidioides. Oral therapy with cyclodextrin (control) or itraconazole or fluconazole at 10, 25, or 50 mg/kg of body weight twice daily (BID) was given for 12 days, from day 3 of infection. Treatment with both antifungals at all doses prolonged survival compared with that of the control treatment (P < 0.01 to 0.0001). At 50 mg/kg, itraconazole and fluconazole were equivalent, whereas itraconazole at 10 or 25 mg/kg prolonged survival compared to that achieved with fluconazole at these dosages (P < 0.05 and 0.01, respectively). Early histologic analysis (10 days of treatment) with 50 mg/kg BID itraconazole or fluconazole showed suppression of CM in all five animals per group; in quantitative cultures, three of three animals from each group had no detectable infection in the brain, spinal cord, or a site of secondary infection, the lungs. In contrast, four of seven controls showed mild to severe meningitis, with arteritis detected in three animals. In a short-term organ clearance study, 5 days of treatment with 10 or 50 mg/kg BID itraconazole or fluconazole reduced the tissue burdens in the brain and spinal cord compared to the tissue burdens in the controls (P < 0.02 to 0.0003). Fluconazole at 10 mg/kg did not reduce the fungal burden in secondary sites, the lungs and kidneys, whereas this itraconazole dose was more effective in clearing the fungi from both organs (P < 0.05 and P < 0.001, respectively). At 50 mg/kg, itraconazole and fluconazole were equivalent in clearing the fungi from the brain and kidney, but itraconazole was superior to fluconazole in clearing the fungi from the spinal cord and lungs (P < 0.05). Thus, both itraconazole and fluconazole were effective at controlling CM, but neither eliminated Coccidioides from tissues. Overall, itraconazole was more efficacious on an mg/kg basis; at high doses they were similarly effective.
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Affiliation(s)
- Perparim Kamberi
- Division of Infectious Diseases, Department of Medicine, Santa Clara Valley Medical Center, 751 S. Bascom Ave., San Jose, CA 95128-2699, USA
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Abstract
The difficulties in managing this potentially horrific disease, with its myriad manifestations, are immense, because host factors dramatically impact outcome. Coccidioidomycosis should warrant great respect among clinicians, because, even with dramatic improvements in therapies, outcomes remain poor. Although there have been outstanding successes with these new therapies, tragic losses after years of immense patient suffering still occur. Coccidioidomycosis is a geographically restricted fungus but is one that inflicts tremendous suffering on affected patients. In addition, because of travel and the influx of susceptible hosts, dramatic increases in patients at risk for infection are seen throughout the southwest United States. The extended-spectrum azoles, such as posaconazole and voriconazole, may prove to be more efficacious in the treatment of coccidioidomycosis than prior agents, including amphotericin B, fluconazole, and itraconazole. Additional resources are needed to conduct randomised, controlled clinical trials for the treatment of this disease.
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Affiliation(s)
- Gregory M Anstead
- Department of Medicine, Division of Infectious Diseases, University of Texas Health Science Center at San Antonio, TX 78229, USA.
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Johnson R, Einstein H. Reply to Stevens. Clin Infect Dis 2006. [DOI: 10.1086/505604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Dismukes WE. Antifungal therapy: lessons learned over the past 27 years. Clin Infect Dis 2006; 42:1289-96. [PMID: 16586389 DOI: 10.1086/503043] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2006] [Accepted: 01/30/2006] [Indexed: 11/04/2022] Open
Abstract
As principal investigator of the National Institute of Allergy and Infectious Diseases-sponsored Mycoses Study Group for the past 27 years, I have been fortunate to play a role in the many advances in the field of clinical mycology and antifungal therapy. For the Finland lecture, I will briefly discuss the development of the Mycoses Study Group, provide an overview of the currently available antifungal agents, and describe advances and lessons related to the treatment and management of cryptococcal meningitis (the most common form of fungal meningitis), 3 important endemic mycoses (namely, blastomycosis, histoplasmosis, and coccidioidomycosis), candidemia and invasive candidiasis (the most common forms of nosocomial fungal disease), and invasive aspergillosis (the most common form of invasive mould disease). My concluding remarks will address the increasing hurdles and challenges, as well as the rewards, facing investigators who focus on clinical trials.
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Affiliation(s)
- William E Dismukes
- Division of Infectious Diseases, Department of Medicine, University of Alabama, Birmingham, AL 35294-0006, USA.
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50
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Kotton CN, Marconi VC, Fishman JA, Chung RT, Elias N, Hertl M. Coccidioidal Meningitis after Liver Transplantation in a Nonendemic Region: A Case Report. Transplantation 2006; 81:132-4. [PMID: 16421490 DOI: 10.1097/01.tp.0000184755.03306.14] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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