Donor-derived endemic mycoses after solid organ transplantation: A review of reported cases

BACKGROUND

Donor-derived endemic mycoses are infrequently reported. We summarized the clinical characteristics and outcomes of these infections to provide guidance to transplant clinicians.

METHODS

Multiple databases were reviewed from inception through May 31, 2023 using endemic fungi as key words (e.g., Coccidioides, histoplasma, blastomyces, talaromyces, paracoccidioides). Only donor-derived infections (DDI) were included.

RESULTS

Twenty-four cases of DDI were identified from 18 published reports; these included 16 coccidioidomycosis, seven histoplasmosis, and one talaromycosis. No cases of blastomycosis and paracoccidiodomycosis were published. The majority were male (17/24,70.8%). Half of the cases were probable (12/24, 50%), seven were possible (29.2%), and only five were proven DDI (20.8%). Donor-derived coccidioidomycosis were observed in kidney (n = 11), lung (n = 6), liver (n = 3), heart (n = 2) and combined SOT recipients (1 KP, 1 KL) at a median time of .9 (range .2-35) months after transplantation. For histoplasmosis, the majority were kidney recipients (6 of 7 cases) at a median onset of 8 (range .4-48) months after transplantation. The single reported possible donor-derived talaromycosis occurred in a man whose organ donor had at-risk travel to Southeast Asia. Collectively, the majority of donors had high-risk exposure to Coccidioides (9/11) or Histoplasma sp. (6/6). Most donor-derived endemic mycoses were disseminated (18/24, 75%), and mortality was reported in almost half of recipients (11/24, 45.8%).

CONCLUSION

Donor-derived endemic mycoses are often disseminated and are associated with high mortality. A detailed evaluation of donors for the potential of an undiagnosed fungal infection prior to organ donation is essential to mitigate the risk of these devastating infections.

Coccidioides undetected in soils from agricultural land and uncorrelated with time or the greater soil fungal community on undeveloped land

Coccidioidomycosis is a typically respiratory fungal disease that, in the United States, occurs primarily in Arizona and California. In California, most coccidioidomycosis cases occur in the San Joaquin Valley, a primarily agricultural region where the disease poses a risk for outdoor workers. We collected 710 soil samples and 265 settled dust samples from nine sites in the San Joaquin Valley and examined how Coccidioides detection varied by month, site, and the presence and abundance of other fungal species. We detected Coccidioides in 89 of 238 (37.4%) rodent burrow soil samples at five undeveloped sites and were unable to detect Coccidioides in any of 472 surface and subsurface soil samples at four agricultural sites. In what is the largest sampling effort undertaken on agricultural land, our results provide no evidence that agricultural soils in the San Joaquin Valley harbor Coccidioides. We found no clear association between Coccidioides and the greater soil fungal community, but we identified 19 fungal indicator species that were significantly associated with Coccidioides detection in burrows. We also did not find a seasonal pattern in Coccidioides detection in the rodent burrow soils we sampled. These findings suggest both the presence of a spore bank and that coccidioidomycosis incidence may be more strongly associated with Coccidioides dispersal than Coccidioides growth. Finally, we were able to detect Coccidioides in only five of our 265 near-surface settled dust samples, one from agricultural land, where Coccidioides was undetected in soils, and four from undeveloped land, where Coccidioides was common in the rodent burrow soils we sampled. Our ability to detect Coccidioides in few settled dust samples indicates that improved methods are likely needed moving forward, though raises questions regarding aerial dispersal in Coccidioides, whose key transmission event likely occurs over short distances in rodent burrows from soil to naïve rodent lungs.

Coccidioidomycosis Seroincidence and Risk among Military Personnel, Naval Air Station Lemoore, San Joaquin Valley, California, USA1

We conducted a retrospective cohort study that tested 2,000 US military personnel for Coccidioides antibodies in a disease-endemic region. The overall incidence of seroconversion was 0.5 cases/100 person-years; 12.5% of persons who seroconverted had illnesses requiring medical care. No significant association was found between demographic characteristics and seroconversion or disease.

Coccidioidomycosis (Valley Fever) in Primary Care

Primary pulmonary coccidioidomycosis (valley fever) is caused by inhaling airborne spores of the fungus Coccidioides immitis or Coccidioides posadasii. Residing in or traveling to areas endemic for Coccidioides is required for the diagnosis; no person-to-person or zoonotic contagion occurs. The incidence of coccidioidomycosis is increasing in endemic areas, and it has been identified as the cause of as many as 17% to 29% of all cases of community-acquired pneumonia in some regions. Obtaining a travel history is recommended when evaluating patients with community-acquired pneumonia. Diagnosis usually relies on enzyme immunoassay with immunodiffusion confirmation, but these tests may not be positive for one to three weeks after disease onset. Antifungal agents are not recommended for treatment unless the patient is at risk of or shows signs of complicated or disseminated infection. When antifungals are used, fluconazole and itraconazole are most commonly recommended, except during pregnancy. Treatment may continue for as long as three to 12 months, although lifetime treatment is indicated for patients with coccidioidal meningitis. Monitoring of complement fixation titers and chest radiography is recommended until patients stabilize and symptoms resolve. In patients who are treated with antifungals, complement fixation titers should be followed for at least two years.

Occupational Coccidioidomycosis in a heavy equipment operator

This article describes a case of Coccidioidomycosis pneumonia in an individual who worked in the McKittrick Oil Field, Kern County, California, for 15 days during an approximate 1-month period in 2016. Coccidioidomycosis is caused by inhaling spores of Coccidioides immitis (C. immitis), a soil fungus endemic in regions of California, most notably the San Joaquin Valley. In California, Kern County has the highest incidence rate of Coccidioidomycosis, and the McKittrick Oil Field lies within the most highly endemic part of Kern County. The affected individual, who resided in a nonendemic state, traveled to Kern County to operate heavy equipment and also perform some laborer tasks. He experienced substantial exposure to soil dust without wearing adequate respiratory protection. Consideration of the relative amounts of soil dust exposure due to the individual's oil field work vs. ambient air permits a conclusion that his infection was work-related. In addition to respiratory protection, some measures needed to reduce soil dust exposure during construction work in areas endemic for C. immitis are discussed.

Risk Factors for Disseminated Coccidioidomycosis, United States

Of 150,000 new coccidioidomycosis infections that occur annually in the United States, ≈1% disseminate; one third of those cases are fatal. Immunocompromised hosts have higher rates of dissemination. We identified 8 patients with disseminated coccidioidomycosis who had defects in the interleukin-12/interferon-γ and STAT3 axes, indicating that these are critical host defense pathways.

A point-source outbreak of Coccidioidomycosis among a highway construction crew

Coccidioidomycosis is an infection caused by inhaling spores of the soil fungus Coccidioides immitis (hereafter termed Cocci). Cocci is endemic in certain areas of California. When soil containing the fungus is disturbed, as during earth-moving activities, respirable Cocci spores can become airborne and be inhaled by persons in the vicinity. This article describes a cluster of seven Cocciodioidomycosis cases among a highway construction crew that occurred in June/July 2008 in Kern County, CA, which is among the most highly endemic regions for Cocci in California. The exposures spanned no more than seven work days, and illness developed within two to three weeks of the exposures. Given the common source of exposure (soil dust generated at the work site) and the multiple cases occurring close in time, the cluster can also be termed a "point-source outbreak." The contractor was not informed of the infection risk and did not take adequate precautions against dust exposure. Appropriate engineering/administrative controls and respiratory protection are discussed.

A newly diagnosed Wegener's disease as the underlying cause for a disseminated coccidioidomycosis

In most cases coccidioidomycosis presents as a benign mildly severe respiratory disease with a benign course and spontaneous resolution. Rarely dissemination can lead to complications. We believe this is the first published case of a patient with a disseminated coccidioidomycosis, as shown on a urinary sample, in association with Wegener's disease. It was a challenge to diagnose and consecutively treat the patient as therapies seem to be conflictual. This case illustrates how migration, changing habits and attitudes, travelling, changing geo-ecological circumstances can lead to a change in medical environment. It is therefore essential that the microbiologist becomes a clinical microbiologist who communicates intensively with his fellow clinicians.

Pulmonary and extrapulmonary coccidioidomycosis, active component, U.S. Armed Forces, 1999-2011

Coccidioidomycosis is an infection caused by inhalation of Coccidioides species of fungi, which grow in the soil of the southwestern United States. Many thousands of military service members are assigned to, or perform training in, the endemic region. During the 13 years 1999 through 2011, 483 active component service members were diagnosed with coccidioidomycosis (rate: 2.69 cases per 100,000 person-years). Twelve percent of all diagnoses specified extrapulmonary infection, indicating dissemination to other organ systems (e.g., skin, skeleton, or central nervous system). Service members of Asian/Pacific Islander race had markedly higher incidence rates of coccidioidomycosis, particularly extrapulmonary disease, compared to members of other racial/ethnic groups. Crude incidence rates of coccidioidomycosis in service members older than 40 and males were higher than the rates of their respective counterparts. Preventive strategies to reduce exposure to this environmental pathogen are discussed.

Pulmonary coccidioidomycosis: import illness and the importance of travel history

A 35-year-old man presented at the outpatient department of pulmonary diseases with fever, rhinitis and coughing. He had recently been on holiday in California. Except for a body temperature of 39.7 degrees C there were no other abnormal findings at the physical examination. Chest X-ray showed a consolidation in the left upper lobe. Under antibiotic treatment his clinical condition deteriorated. Coccidioidomycosis was the suspected diagnosis and confirmed by the results of CT scanning and culture of bronchoalveolar lavage fluid. Treatment with itraconazole resulted in lasting improvement. The case stipulates the importance of travel history.

Coccidioidomycosis pneumonia in a nonendemic area associated with infliximab

Tumor necrosis factor (TNF) inhibitors, such as infliximab, are highly effective in the management of rheumatoid arthritis; however, these agents are associated with an increased risk of infectious complications. Individuals developing coccidiomycosis pneumonia frequently acquire this while residing in endemic regions. We present a patient with rheumatoid arthritis treated with infliximab who developed acute respiratory distress syndrome (ARDS) from coccidiomycosis pneumonia while residing in a non-endemic region near the Texas-Louisiana border and was successfully treated with antifungal therapy. The source for coccidiomycosis was suspected to be from inhalation of pulverized rock dust imported from Arizona. Patients treated with TNF inhibitors may acquire coccidiomycosis infection through fomite dust exposure.

The Prevention of Recrudescent Coccidioidomycosis After Solid Organ Transplantation

BACKGROUND

Coccidioidomycosis is an endemic fungal infection of the southwestern United States that causes considerable morbidity and mortality in transplant recipients, often as the result of reactivated infection.

METHODS

A retrospective review of the medical records of 47 patients with prior coccidioidomycosis who underwent solid organ transplantation (18 liver, 24 kidney, 3 pancreas, and 2 combined organ) at our tertiary care academic medical center.

RESULTS

Of 47 transplant recipients with a history of coccidioidomycosis, 44 had quiescent infection at transplantation. Of the three with active coccidioidomycosis at transplantation, two were taking azole prophylaxis and had no further coccidioidal infection after transplantation. One of the three had positive serologic findings identified only on the day of transplantation, and prophylaxis was initiated a few hours after surgery along with immunosuppression; nevertheless, the treatment course was complicated by disseminated coccidioidomycosis. Seven patients did not initiate or self-discontinued prophylaxis; one patient who discontinued prophylaxis experienced recurrent pulmonary infection.

CONCLUSIONS

For patients undergoing transplantation in an area endemic for coccidioidomycosis, we recommend routine evaluation for evidence of prior infection and initiation of azole prophylaxis. For our patients with quiescent infection, azoles suppressed any recrudescent coccidioidomycosis after transplantation. The selection of patients who would benefit from prophylaxis and the optimal dose and duration of such prophylaxis should be studied further.

Coccidioidomycosis in healthy persons evaluated for liver or kidney donation

Coccidioidomycosis is a fungal infection caused by Coccidioides species endemic to the southwestern United States, where it poses unique challenges for transplant recipients. Donor-derived coccidioidomycosis has been documented, but its risk of transmission is not known. We prospectively screened 568 healthy persons requesting evaluation for possible liver or kidney donation. Twelve (2.1%) of the 568 donor candidates were seropositive (11 initially and 1 with seroconversion and symptomatic illness within 1 week after negative screening). Three of these 12 patients proceeded to kidney donation, and a fourth patient proceeded to liver donation. None of the 4 transplant recipients received special coccidioidal prophylaxis, although all were administered fluconazole according to standard antifungal prophylaxis protocols. At follow-up (7-54 months), no coccidioidomycosis was identified in any recipient. The prevalence of coccidioidal antibodies was low among potential organ donor candidates, but the risk of donor-derived coccidioidomycosis remains unknown and further study is warranted.

Coccidioidomycosis in Patients Who Have Undergone Transplantation

In the early years of transplantation in Arizona, coccidioidomycosis occurred in 7% to 9% of recipients, with a mortality rate as high as 72% in some cases. In current transplant programs, however, evolution of immunosuppression and institution of targeted prophylaxis have resulted in coccidioidal infection rates ranging from 1% to 2%. The clinical characteristics of this infection among transplant recipients range from asymptomatic to fulminant and fatal. Dissemination is common, and mortality is high (28%). Because serologic response is often absent or slow, diagnosis can be challenging and often requires invasive diagnostic procedures. Pharmacologic treatment follows the guidelines of the Infectious Diseases Society of America, but control of infection may also dictate a decrease in immunosuppressant treatment. After infection is controlled, secondary azole prophylaxis is recommended to prevent relapse. Patients with a history of coccidioidomycosis may undergo successful transplantation when disease is inactive and azole prophylaxis is instituted. The incidence of donor-derived coccidioidomycosis is not known. The risk of coccidioidal infection among transplant recipients visiting in or relocating to an endemic area is low, and routine prophylaxis for this group is not recommended.

Fungal infections in solid organ transplantation

Fungal infections in solid organ transplant recipients continue to be a significant cause of morbidity and mortality. Candida spp. and Aspergillus spp. account for most invasive fungal infections. The incidence of fungal infection varies with type of solid organ transplant. Liver transplant recipients have highest reported incidence of candida infections while lung transplant recipients have highest rate of Aspergillus infections. Recent epidemiological studies suggest the emergence of resistant strains of candida as well as mycelial fungi other than Aspergillus in these patients. The current review incorporates the recent changes in the epidemiology of fungal infections in solid organ transplant recipients and highlights the newer data on the diagnosis, prophylaxis and treatment of fungal infections in these patients.

Coccidioidomycosis in Patients With Hematologic Malignancies

BACKGROUND

An endemic fungal infection of the desert southwestern United States, coccidioidomycosis is generally a self-limited illness in healthy persons. Immunosuppressed persons who contract coccidioidomycosis, however, are at increased risk for disseminated infection.

METHODS

We conducted a retrospective review of patients with coccidioidomycosis and hematologic malignancy or bone marrow disease.

RESULTS

Fifty-five patients were identified. The most common underlying malignancies were non-Hodgkin lymphoma and chronic lymphocytic leukemia. Extrathoracic (or disseminated) infection was observed in 12 patients (22%). Fifteen patients (27%) died with active coccidioidomycosis. Treatment of the hematologic disease with corticosteroids or antineoplastic chemotherapy increased the risk of death.

CONCLUSION

To date, this is the largest case series of patients with hematologic malignancy and coccidioidomycosis. In persons with hematologic malignancy, coccidioidomycosis can be a severe illness with a high risk for disseminated infection and death.

Coccidioidomycosis in liver transplant recipients relocating to an endemic area

Coccidioidomycosis is an endemic fungal infection of the desert southwestern United States. This infection occurs at a rate of 1% to 8% in solid organ transplant recipients residing in the endemic area, and it has a high rate of disseminated infection and mortality. The risk of infection among transplant recipients from nonendemic areas visiting or moving to an endemic region is not known. We reviewed the clinical course of 41 liver transplant recipients who originally resided in and underwent liver transplantation in an area of low coccidioidal endemicity and who later relocated their follow-up care to our program, which is located in an endemic area. No patients received antifungal prophylaxis to prevent primary coccidioidomycosis. Among 37 patients with at least 1 year of follow-up care, the incidence of new coccidioidal infection was 2.7%. Coccidioidomycosis was identified in one patient and was manifested by fatigue, anemia, and pulmonary nodules. This patient survived with oral antifungal therapy. Coccidioidomycosis was not a frequent event in liver transplant recipients from areas of low endemicity who relocated to our highly endemic area.

Mucosal and Systemic Fungal Infections in Patients with AIDS

In countries where highly active antiretroviral therapy (HAART) is widely available, a decrease in the incidence of fungal infections has been observed in the last 5 years compared with countries that cannot afford this treatment. Even refractory fungal infections may be controlled when HAART is given to patients, and end-stage AIDS infections, such as aspergillosis, are now only infrequently seen. In contrast, fungal infections in certain regions, such as penicilliosis in Southeast Asia or cryptococcosis in Sub-Saharan Africa, are a growing problem. Antifungal therapy for documented infections has not changed very much during recent years; however, new drugs such as caspofungin and voriconazole may be more effective in the treatment of opportunistic fungal infections, in particular, those involving resistant organisms. Secondary antifungal prophylaxis for many opportunistic pathogens can now be temporarily or even permanently discontinued in many HIV-positive patients who have a marked improvement in immune function parameters, such as CD4(+) cell counts, after initiation of HAART. The link between effective virustatic control of HIV infection and a decreasing incidence of fungal infections has been recognised; and so, despite the availability of very effective new antifungal drugs, the cornerstone of treatment and prevention of opportunistic fungal infections in patients with HIV infection is effective antiretroviral therapy including protease inhibitors.

Early results of targeted prophylaxis for coccidioidomycosis in patients undergoing orthotopic liver transplantation within an endemic area

Coccidioidomycosis (CM) is an endemic fungal infection of the desert southwestern United States. In immunocompromised hosts, such as transplant recipients, this infection is often a severe, disseminated disease with high mortality. A history of coccidioidal infection or positive serologic results increases the risk of CM after transplantation. At our institution, all liver transplant candidates with either positive history or serologic results for coccidioidal infection receive fluconazole in order to prevent recurrent infection after transplantation. Patients with neither a history of coccidioidal infection nor positive serologic results do not receive prophylaxis but are followed serologically every 3 months. From June 1999 to October 2001, 81 liver transplantations were performed at our institution in 76 patients with end-stage liver disease. Four of these 76 patients received prophylactic fluconazole in order to prevent CM. None of these 4 patients had reactivation of CM. A new coccidioidal infection developed after orthotopic liver transplantation in 1 of 72 patients (1.4%). Close surveillance and targeted prophylaxis are safe and effective alternatives to universal prophylaxis for CM in patients undergoing liver transplantation in an endemic area.

A risk analysis for airborne pathogens with low infectious doses: application to respirator selection against Coccidioides immitis spores

Probability models incorporating a deterministic versus stochastic infectious dose are described for estimating infection risk due to airborne pathogens that infect at low doses. Such pathogens can be occupational hazards or candidate agents for bioterrorism. Inputs include parameters for the infectious dose model, distribution parameters for ambient pathogen concentrations, the breathing rate, the duration of an exposure period, the anticipated number of exposure periods, and, if a respirator device is used, distribution parameters for respirator penetration values. Application of the models is illustrated with a hypothetical scenario involving exposure to Coccidioides immitis, a fungus present in soil in areas of the southwestern United States Inhaling C. immitis spores causes a respiratory tract infection and is a recognized occupational hazard in jobs involving soil dust exposure in endemic areas An uncertainty analysis is applied to risk estimation in the context of selecting respiratory protection with a desired degree of efficacy.

Disseminated coccidioidomycosis with intra- and paravertebral abscesses

We report a case of paravertebral and intravertebral abscesses caused by Coccidioides immitis in a Japanese man. The patient had lived in Arizona, United States, for 5 years, and suffered from overt disease after coming back to Japan. Culture of pus from the paravertebral abscess revealed Coccidioides immitis, and a diagnosis of disseminated coccidioidomycosis was made. Fluconazole (600 mg/day), taken orally, was started, and the abscesses surrounding the vertebral bodies disappeared after 2 years of treatment. The abscess in the vertebral bodies also responded to treatment, but a small lesion was still left in the 10th vertebral body after 2 years of treatment. Coccidioidomycosis is a fungal infection that is endemic in the southwestern United States and in Central and South America. Although coccidioidomycosis causes self-limiting flu-like illness or pneumonia, a small proportion of the infections progress to disseminated diseases. Because the incidence of coccidioidomycosis is increasing year by year, physicians not only in endemic but also in nonendemic areas have to consider coccidioidomycosis as one of the differential diagnoses when they examine patients from endemic areas.

Donor transfer of pulmonary coccidioidomycosis in lung transplantation

Transplant recipients living in endemic areas are at high risk of aerosol-transmitted fungal infections because of environmental exposure while on immunosuppressive drugs, as well as reactivation of latent infection from either the patient's or the donor's organs. The latter may account for early development of coccidioidomycosis after transplantation. We describe a case of pulmonary coccidioidomycosis in a lung transplant recipient who acquired the infection from the donor lung and presented with fulminant pneumonia in the immediate postoperative period.

Coccidioidomycosis complicating solid organ transplantation

Coccidioidomycosis is the most common endemic mycosis to cause disease in solid-organ transplant patients in North America. Underlying renal and liver disease, T-lymphocyte suppression from antirejection medication, and activation of immunomodulating viruses, such as cytomegalovirus, all increase the risk for coccidioidomycosis among these patients. About one half of all cases are the result of reactivation of previously acquired coccidioidal infection and occur during the first year after transplantation. Although disseminated infection is common, most cases manifest pulmonary symptoms. Culture of pulmonary secretions from bronchoscopy is frequently diagnostic. Serologic tests are particularly useful for identifying patients who are at high risk for reactivating coccidioidomycosis posttransplantation. Amphotericin B and azoles are the mainstay of therapy. Although there are no established approaches to preventing coccidioidomycosis among these patients, studies are underway examining the use of prophylactic azole antifungals with documented prior coccidioidal infection.

Primary pulmonary coccidioidomycosis

Coccidioidomycosis is an infection caused by the soil-inhabiting fungus Coccidioides immitis. The fungus is endemic in the desert Southwest, which is a major area for tourism and growth. Travel through this region results in many new coccidioidal pulmonary infections annually, including pneumonia, cavities, and nodules. Patients with coccidioidomycosis are therefore likely to present with pulmonary manifestations of infection when they return home to nonendemic parts of the country. This makes coccidioidomycosis a fungal infection of nationwide importance, and it is crucial that physicians everywhere have a heightened awareness of this disease to avert delays in diagnosis and treatment. This article describes primary pulmonary coccidioidomycosis and its complications for clinicians practicing both in endemic and nonendemic areas.

Coccidioidomycosis in non-endemic areas: a case series

Coccidioidomycosis is a systemic infection caused by the soil fungus Coccidioides immitis, which is endemic to the south-western United States. Manifestations range from flu-like illness to pneumonia and septic shock. Diagnosis may be delayed or missed in non-endemic areas because of the low index of suspicion. We describe a series of 23 patients with coccidioidomycosis at one institution in a non-endemic area. Diagnosis was often delayed. In two patients, the route of exposure could not be determined, but 20 patients had a history of residence or travel to endemic areas, and the remaining patient had an occupational history of exposure to fomites from an endemic region. Five patients were immunosuppressed. Most patients responded well to medical therapy, surgery, or both. Although coccidioidomycosis is rare in non-endemic areas, physicians must keep it in mind when evaluating patients who have traveled to endemic areas or who are immunosuppressed.

Centers for Disease Control and Prevention (CDC). Coccidioidomycosis in travelers returning from Mexico--Pennsylvania, 2000

Coccidioidomycosis (CM), a fungal disease caused by Coccidioides immitis, is endemic in the southwestern United States and parts of Central and South America. The disease is acquired by inhaling the arthroconidia of C. immitis present in the soil. Outbreaks of CM occur when susceptible persons are exposed to airborne arthroconidia from dust storms, natural disasters, and earth excavation (1,2). Persons who travel to areas where the disease is endemic may become infected and develop symptoms after returning home (3,4). This report describes an outbreak of CM among travelers returning to Pennsylvania from a trip to Mexico.

Hyphal forms in the central nervous system of patients with coccidioidomycosis

Coccidioides immitis is a dimorphic fungus that grows as a filamentous mold in soil and as a spherule at human body temperature. The hyphal or soil form is found rarely in human tissue. We report 5 cases of coccidioidomycosis in which hyphae were found in brain tissue or spinal fluid. The presence of central nervous system plastic devices appears to be associated with morphological reversion to the saprophytic form. This reversion has implications for diagnosis and therapy and may increase the risk of obstruction of the device(s).

Probable false positive coccidioidal serologic results in patients with cystic fibrosis

Coccidioidomycosis is an acquired fungal infection that afflicts primarily the respiratory tract. Cystic fibrosis patients who are being treated with glucocorticoids and immunosuppressed organ recipients may be at risk for infection with Coccidiodes immitis or reactivation of latent infection. The diagnosis is best made by demonstration of the organism in pathologic specimens or by culture. Serologic screening is another method that is reliable in most patients. We studied 98 patients who had serologic screening for Coccidiodes immitis performed as part of their evaluation for lung transplantation. This study revealed that approximately 15% of the cystic fibrosis patients screened had putative coccidioidal IgM, in the absence of an IgG response. None of the patients studied had a positive fungal culture for the organism. None of the non-cystic fibrosis patients screened had detectable coccidioidal IgG or IgM. We hypothesize that cystic fibrosis patients may have hyperimmune sera which interferes with serologic screening tests. We would recommend repeat serologic testing and attempts to identify the organism in tissue or by culture to confirm the diagnosis in these patients.

[Coccidioidomycosis: a new brazilian case]

A case of pulmonary coccidioidomycosis from the rural zone of Bertolinia, PI, is reported. The patient, a farm worker, attributed his illness to the dust inhaled while digging a water well during the dry season of the year, some weeks before the onset of the clinical manifestations. The main symptoms of the disease were severe chest pain and moderate fever. The diagnosis was made histopathologically: tissue phase fungal organisms--immature spherules and spherules with endospores--were observed in histological sections of a lung fragment obtained by open chest biopsy. This is the twelfth autochthonous case of coccidioidomycosis found so far in Brazil. All of them involved native inhabitants of the semi-arid part of Northeastern Brazil. The hot and dry environment of the region seems to favor the development of C. immitis in the soil. Humans and animals probably acquire the infection by digging the soil, when they become exposed to the conidium-bearing dust raised by this activity.

A model of coccidioidal meningoencephalitis and cerebrospinal vasculitis in the rabbit

Coccidiodal meningitis is a devastating complication of disseminated coccidioidomycosis. An animal model of this infection could enhance understanding of the pathogenesis of the disease and lead to improvements in therapy. A rabbit model of central nervous system infection simulating human disease was established using a blind cisternal tap technique to inoculate 4 x 10(3)-1 x 10(6) arthroconidia of Coccidioides immitis into the cisterna magna. Systemic, neurologic, and histopathologic findings of meningitis were observed in all rabbits, but an inoculum of 2 x 10(4) arthroconidia produced a chronic illness in which meningeal endarteritis obliterans was consistently observed. Serial sampling of cerebrospinal fluid demonstrated an inflammatory response. Growth of C. immitis was demonstrated by quantitative fungal culture from brains and proximal spinal cords.

Coccidioidomycosis in liver transplant patients

Eight (0.59%) of 1,347 patients who underwent liver transplantation at the UCLA Medical Center (Los Angeles) developed coccidioidomycosis. Whereas only one case occurred during the first 8 years and 10 months of the UCLA Liver Transplant Program (February 1984 to December 1992), seven cases occurred within the following 23-month period (December 1992 to November 1994). The median time of onset for infection after transplantation was 8 weeks (range, 4-312 weeks). Clinical presentations of patients with coccidioidomycosis included pneumonia (six cases), pneumonia with meningitis (one case), hepatitis (one case), and monoarticular arthritis (one case). Despite therapy with amphotericin B alone (six cases) or amphotericin B plus fluconazole (two cases), infection was fatal in four of eight cases. As of this writing, the four surviving patients are receiving chronic maintenance therapy with either fluconazole (three patients) or itraconazole (one patient). These experiences show that coccidioidomycosis can be a serious and frequently fatal infection after liver transplantation and that the incidence of this disease appears to be increasing.

Cutaneous manifestations of systemic mycoses

Systemic fungal diseases are primary pulmonary diseases caused by the dimorphic fungal pathogens, Blastomyces dermatitides, Coccidioides immitis. Histoplasma capsulatum, or Paracoccidioides brasiliensis. Infection occurs after inhalation of the infectious form of the fungus and may be acute, self-limited, or subclinical. Primary cutaneous infection occurs only after traumatic implantation of the fungus and is unusual. Erythema nodosum or erythema multiforme may accompany the acute form of the disease. Other cutaneous manifestations represent disseminated disease and, as such, require systemic antifungal therapy. Because cutaneous lesions have occurred coincidentally with other cutaneous pathologies, emphasis should be placed on a complete clinical history, physical examination, and diagnosis by histopathology and culture.

Coccidioidomycosis among visitors to a Coccidioides immitis-endemic area: an outbreak in a military reserve unit

An outbreak of coccidioidomycosis occurred in a US Marine reserve unit based in Tennessee after a 3-week training exercise in California that involved substantial exposure to soil and dust. Interviews and serologic testing were done on three occasions (6, 11, and 15 weeks) after the men returned from California, and spherulin skin tests were done at 6 months. Of 27 men, 8 (30%) had evidence of recent coccidioidal infection. Of these, 7 (88%) had an illness consistent with coccidioidomycosis that, despite medical evaluation, was diagnosed incorrectly in 5 men (71%). Diagnosis of coccidioidal pneumonia outside an area in which Coccidioides immitis is endemic is unlikely unless the health care provider is aware that the patient traveled recently. Detection of coccidioidomycosis could be facilitated if organizations that regularly send people to C. immitis-endemic regions were to inform these persons about the risks of infection.

Persistent coccidioidal seropositivity without clinical evidence of active coccidioidomycosis in patients infected with human immunodeficiency virus

We retrospectively identified 13 patients infected with human immunodeficiency virus (HIV) who had persistently positive coccidioidal serological tests without evidence of active coccidioidomycosis--to our knowledge, a heretofore undescribed phenomenon. The median duration of follow-up was 19 months. Five patients developed active coccidioidomycosis during this follow-up period; the median interval from the initial positive serological test to the development of active disease was 23 months. There were no significant differences between patients who developed active coccidioidomycosis and those who did not with regard to CD4 lymphocyte count or previous antifungal therapy. Moreover, when all 13 patients were compared with 21 patients who had HIV infection and active coccidioidomycosis, no differences were found with regard to age, race, risk factor for HIV infection, or initial CD4 lymphocyte count. In summary, persistently positive coccidioidal serological tests in HIV-infected patients appear to represent true coccidioidal infection and are associated with a significant risk of the development of active coccidioidomycosis.