Characteristics of patients with mild to moderate primary pulmonary coccidioidomycosis

In Arizona, USA, primary pulmonary coccidioidomycosis accounts for 15%-29% of community-acquired pneumonia. To determine the evolution of symptoms and changes in laboratory values for patients with mild to moderate coccidioidomycosis during 2010-2012, we conducted a prospective 24-week study of patients with primary pulmonary coccidioidomycosis. Of the 36 patients, 16 (44%) were men and 33 (92%) were White. Median age was 53 years, and 20 (56%) had received antifungal treatment at baseline. Symptom scores were higher for patients who received treatment than for those who did not. Median times from symptom onset to 50% reduction and to complete resolution for patients in treatment and nontreatment groups were 9.9 and 9.1 weeks, and 18.7 and 17.8 weeks, respectively. Median times to full return to work were 8.4 and 5.7 weeks, respectively. One patient who received treatment experienced disseminated infection. For otherwise healthy adults with acute coccidioidomycosis, convalescence was prolonged, regardless of whether they received antifungal treatment.

Routine CSF analysis in coccidioidomycosis is not required

Although routinely done, there has been no evaluation of the utility of performing routine cerebrospinal fluid (CSF) examination in patients with active coccidioidomycosis and high complement fixation (IgG) antibody titers or other risk factors for disseminated infection. In our review 100% of patients diagnosed with coccidioidal meningitis had at least one sign or symptom consistent with infection of the central nervous system, headache was present in 100% of those with meningitis, while no patients without signs/symptoms of CNS infection were found to have coccidioidal meningitis, irrespective of antibody titers or other risk factors. Thus routine lumbar puncture may be unnecessary for patients with coccidioidomycosis who lack suggestive clinical symptoms.

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.

Experimental animal models of coccidioidomycosis

Experimental models of coccidioidomycosis performed using various laboratory animals have been, and remain, a critical component of elucidation and understanding of the pathogenesis and host resistance to infection with Coccidioides spp., as well as to development of more efficacious antifungal therapies. The general availability of genetically defined strains, immunological reagents, ease of handling, and costs all contribute to the use of mice as the primary laboratory animal species for models of this disease. Five types of murine models are studied and include primary pulmonary disease, intraperitoneal with dissemination, intravenous infection emulating systemic disease, and intracranial or intrathecal infection emulating meningeal disease. Each of these models has been used to examine various aspects of host resistance, pathogenesis, or antifungal therapy. Other rodent species, such as rat, have been used much less frequently. A rabbit model of meningeal disease, established by intracisternal infection, has proven to model human meningitis well. This model is useful in studies of host response, as well as in therapy studies. A variety of other animal species including dogs, primates, and guinea pigs have been used to study host response and vaccine efficacy. However, cost and increased needs of animal care and husbandry are limitations that influence the use of the larger animal species.

Fatigue in coccidioidomycosis. Quantification and correlation with clinical, immunological, and nutritional factors

While described in the past, the frequency and degree of fatigue associated with symptomatic coccidioidomycosis has never been quantified. Using the Fatigue Severity Scale (FSS), severe fatigue (FSS score = 41) was found in 65% of cases of active coccidioidomycosis compared to 42% in cohort of control subjects with chronic medical diseases (P=0.024). Fatigue in patients with symptomatic coccidioidomycosis declined significantly over four months (P=0.023). Severe fatigue in patients with symptomatic coccidioidomycosis was significantly associated with low body mass index (BMI; P=0.024) but was not significantly associated with either serum leptin (r2=0.078, P=0.261) or serum TNF-alpha (r2=0.028, P=0.504) concentrations. Severe fatigue is a common condition among patients with active coccidioidomycosis and is associated with a declining BMI.

Innate immunity to the pathogenic fungus Coccidioides posadasii is dependent on Toll-like receptor 2 and Dectin-1

Coccidioides posadasii is a pathogenic fungus that causes endemic and epidemic coccidioidomycosis in the deserts of North, Central, and South America. How the innate immune system responds to the organism is not well understood. Here we show that elicited mouse peritoneal macrophages respond to spherules (the tissue form of the fungus) by producing proinflammatory cytokines as measured by quantitative PCR of cellular transcripts and by enzyme-linked immunosorbent assay (ELISA) assays for secreted protein. We examined the contribution of Toll-like receptors (TLR) and MyD88 in macrophage responses to formalin-killed spherules (FKS) by comparing cytokine responses of elicited macrophages from different knockout mice. FKS were added to elicited mouse peritoneal macrophages from wild-type, TLR2-/-, and MyD88-/- cells, and wild-type cells made more tumor necrosis factor alpha, MIP-2, and interleukin 6 than did the mutant macrophages. In contrast, the C3H/HeJ mice, which have a point mutation in TLR4, and TLR4-/- B6 mice exhibited no defect in cytokine production compared to the control mice. We also investigated the role of the macrophage beta-glucan receptor, Dectin-1. RAW 264.7 macrophages overexpressing Dectin-1 produced more cytokines in respond to FKS, live spherules, and purified beta-glucan than did control RAW cells. Blockage of Dectin-1 with antibodies inhibited cytokine production in elicited mouse peritoneal macrophages. Taken together, these results show that cytokine responses in mouse peritoneal macrophages to C. posadasii spherules are dependent on TLR2, MyD88, and Dectin-1.

Parasitic mycelial forms of coccidioides species in Mexican patients

Of 26 cases of coccidioidomycosis reported here, 15 showed hyphae, atypical parasitic structures of Coccidioides spp. in fresh cytologic and/or histologic specimen preparations. The finding of this morphology could have implications which should be considered, especially when the disease affects areas of nonendemicity.

Coccidioidomycosis outbreak among United States Navy SEALs training in a Coccidioides immitis-endemic area--Coalinga, California

An outbreak of coccidioidomycosis among 22 Navy SEALs occurred during training exercises in Coalinga, California. Ten (45%) of the 22 men had serologic evidence of acute coccidioidomycosis, the highest attack rate ever reported for a military unit. All case patients were symptomatic, and 50% had abnormal chest radiographs. There were no cases of dissemination and no deaths to date. Coccidioidomycosis continues to be a threat to military members and civilians who reside or train in areas where Coccidioides immitis, the causative agent, is endemic.

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.

Coccidioidomycosis in solid organ transplantation

Coccidioidomycosis is an endemic fungal infection of the southwestern United States. Normally a self-limited infection in healthy hosts, coccidioidomycosis can become a serious complication in patients who have had solid organ transplantation. Among patients whose solid organ transplantation was complicated by coccidioidomycosis, the infection has a variety of clinical presentations. Disseminated disease is common and has substantial morbidity. Patients at risk for coccidioidal infection should be identified so that antifungal prophylactic therapy can be initiated. Treatment options include amphotericin B or azoles. Secondary prophylaxis is recommended because relapse is frequent.

Risk factors for severe pulmonary and disseminated coccidioidomycosis: Kern County, California, 1995-1996

Surveillance for coccidioidomycosis (CM) and a case-control study for risk factors among adults were conducted in Kern County, California. From January 1995 through December 1996, 905 cases of CM were identified, for an annual incidence of 86 cases per 100,000 population. A total of 380 adults were enrolled in the case-control study: 77 had severe pulmonary disease, 33 had disseminated disease, and 270 control patients had mild disease. Independent risk factors for severe pulmonary disease included diabetes, recent history of cigarette smoking, income of < $15,000 per year, and older age. Oral antifungal therapy before hospitalization was associated with a reduced risk of CM pneumonia. Risk factors for disseminated disease were black race, income of < $15,000 per year, and pregnancy. Early treatment of CM with oral antifungal agents may prevent severe pulmonary disease in groups considered to be at high risk, such as elderly individuals, persons with diabetes, and smokers. Persons at risk for severe CM may benefit from vaccination once an effective CM vaccine is available.

Risk factors for severe pulmonary and disseminated coccidioidomycosis: Kern County, California, 1995-1996

Surveillance for coccidioidomycosis (CM) and a case-control study for risk factors among adults were conducted in Kern County, California. From January 1995 through December 1996, 905 cases of CM were identified, for an annual incidence of 86 cases per 100,000 population. A total of 380 adults were enrolled in the case-control study: 77 had severe pulmonary disease, 33 had disseminated disease, and 270 control patients had mild disease. Independent risk factors for severe pulmonary disease included diabetes, recent history of cigarette smoking, income of < $15,000 per year, and older age. Oral antifungal therapy before hospitalization was associated with a reduced risk of CM pneumonia. Risk factors for disseminated disease were black race, income of < $15,000 per year, and pregnancy. Early treatment of CM with oral antifungal agents may prevent severe pulmonary disease in groups considered to be at high risk, such as elderly individuals, persons with diabetes, and smokers. Persons at risk for severe CM may benefit from vaccination once an effective CM vaccine is available.

Prediction of relapse after treatment of coccidioidomycosis

Relapse after apparently successful treatment of coccidioidomycosis has been a problem with both amphotericin B and the azoles. We conducted a retrospective cohort study of 34 patients who required therapy for coccidioidomycosis between 1973 and 1993; 10 relapsed and 25 (one patient received two courses of therapy) did not relapse during follow-up. The mean time to relapse after completion of therapy was 7.3 months (range, 1-21 months). All 34 patients responded clinically to therapy. A fourfold or greater decrease in titers of antibody, as determined by complement fixation (CF), during therapy was seen in seven (78%) of nine patients who relapsed and 17 (85%) of 20 patients who did not relapse (P = .956). There was no significant difference between relapsers and nonrelapsers in terms of the lowest CF titer during therapy, the CF titer at the end of therapy, or the peak CF titer. The risk of relapse was increased among those with a peak CF titer of > or = 1:256 (relative risk [RR] = 4.7; 95% confidence interval [CI] = 1.4-16.1), as compared with patients who did not mount such a high antibody response. Similarly, the risk of relapse was higher among those with serially negative coccidioidin skin tests (CSTs) than those with serially positive CSTs (RR = 4.8; 95% CI = 1.2-19.5). We conclude that clinical response, lowest CF titer, end-of-therapy CF titer, and decrease in the CF titer of at least fourfold are not predictive of relapse in patients with coccidioidomycosis. Negative serial coccidioidin skin tests and a peak CF antibody titer of > or = 1:256 are independently associated with increased risk of relapse.

Coccidioidomycosis in Tulare County, California, 1991: reemergence of an endemic disease

In 1991, 1208 cases of coccidioidomycosis were reported to the California Department of Health Services, compared with an annual average of 450 during 1986-90. We conducted a study in Tulare County to define the epidemiology of the disease and identify risk factors for severe disease, focusing on the epidemic period September 1991-December 1991. To identify cases, we used data from the Coccidioidomycosis Serology Laboratory at the University of California, Davis, other laboratories, and the Tulare County Health Department's coccidioidomycosis reporting system. We compared patients who were hospitalized with those who were not to determine risk factors for severe disease. We identified 128 cases of acute coccidioidomycosis diagnosed between 1 September and 31 December 1991 (attack rate 41/100,000); south central Tulare County had the highest attack rate. Thirty-five (27%) case-patients were hospitalized. Male sex (relative risk (RR) 2.5, 95% confidence interval (CI) 1.2-5.0), black people and Asian races (RR 4.8, 95% CI 2.4-9.6), and age > or = 20 years (RR 8.3, 95% CI 1.2-57.4) were univariately significant and remained independently associated with hospitalization in multivariate analysis. The 1991 Tulare County outbreak of coccidioidomycosis was part of a much larger outbreak that began in California during 1991 and continued through 1993. The outbreak was preceded by an unusually rainy spring. Although dust reduction measures during times of increased coccidioidomycosis incidence can help reduce exposure, definitive control awaits the development of a safe, effective vaccine.

Atypical coccidioidomycosis in an AIDS patient successfully treated with fluconazole

Cervical lymphadenopathy due to Coccidioides immitis occurred as the sole opportunistic infection in a Spanish patient with the acquired immunodeficiency syndrome. Twelve years earlier the patient had lived in the desert regions of the southwestern USA. After an initial course of high doses of fluconazole, the patient recovered without any sequelae. This is the first case of coccidioidomycosis in Spain.

Coccidioidomycosis in patients infected with human immunodeficiency virus: review of 91 cases at a single institution

We retrospectively evaluated the clinical manifestations, diagnosis, treatment, and outcome of coccidioidomycosis in 91 patients infected with human immunodeficiency virus (HIV) at a single institution. Coccidioidomycosis was the AIDS-defining illness in 37 patients. Fever and chills, weight loss, and night sweats were the most frequent symptoms. The lung was the most frequently involved organ (80%), followed by the meninges (15%). A diffuse reticulonodular infiltrate was seen in 59 patients (65%), and 13 (14%) had focal pulmonary disease; for 15 patients (16%), the chest radiograph was normal. Coccidioidal serologies were positive for 60 patients (68%), while for 23% with proven coccidioidomycosis such tests were negative Most patients were treated with systemic amphotericin B and then an oral azole. The mortality for the whole group was 60%. Patients with diffuse pulmonary disease had the highest mortality (68%), with a median duration of survival of 54 days (P < .05; 95% confidence interval, 147-175 days). The presence of diffuse pulmonary disease and a CD4 lymphocyte count of < 50/microL were independent predictors of death. In our experience, coccidioidomycosis is an important opportunistic infection that causes substantial morbidity and mortality among HIV-infected patients living in an area of endemicity.

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.

Clinical manifestations of pulmonary fungal infections

Coccidioidomycosis, histoplasmosis, cryptococcosis, and blastomycosis are the most common deep pulmonary fungal infections encountered by the clinician. Each has a particular environmental habitat. As world travel increases, exposure to these infections becomes increasingly more common. The article reviews the microbiology, natural history, and clinical and laboratory findings of these diseases. Treatment options for these infections also are discussed.

Coccidioidomycosis at a university health service

At a single university health service within an endemic area, 172 cases of coccidioidomycosis were retrospectively identified by fungal cultures, serologic studies, or intercurrent skin test conversions. The average annual incidence of symptomatic infection was 0.43% for susceptible students. Peak case rates occurred in November and June (11 cases/10,000 clinic visits) and were 1.5 to 6 times greater than in other months. Although mononucleosis was diagnosed approximately twice as frequently as coccidioidomycosis, coccidioidal infections required 74% more visits per patient and over 3 times longer clinical supervision than did mononucleosis. Although only 2 patients disseminated, diagnosis and management of patients with coccidioidomycosis constituted more than 2% of our clinic's visits, for an estimated annual cost of more than $34,000. Because our patient population is young and otherwise healthy, our estimates of the impact of primary coccidioidal infection may underestimate that on civilian public health as a whole.

Fungal infections in the immunocompromised host

Invasive fungal infections cause significant morbidity and mortality in patients with impaired immune defences. Defects in neutrophil function and neutropenia predispose to disseminated Candida, Aspergillus and Mucoraceae infections while altered T-lymphocyte mononuclear phagocyte function predisposes to infection with C. neoformans, Histoplasma and Coccidioides. Fungal infections in the immunocompromised host are difficult to diagnose and difficult to treat successfully. The diagnosis is often missed or delayed because of the non-specific clinical features, the failure to isolate or difficulty in interpreting the presence of the fungus from routine microbiological cultures, and the limited usefulness of available serological tests. The assay for cryptococcal antigen is the only currently available reliable serological test used to diagnose an invasive fungal infection. Definitive diagnosis is made by histopathological demonstration of the fungus in tissue or a positive culture from a sterile body site. Invasive procedures are often necessary to obtain adequate tissue for histology and culture. The treatment of invasive fungal infection in the immunocompromised host is amphotericin B with or without 5FC. The usual recommended dose is 1.5 to 3 g total amphotericin B over 6 to 12 weeks. The optimal dose and duration of therapy for each infection is not known. Treatment failures and relapses are common in patients who do not achieve remission of their underlying disease. Ketoconazole, a new broad-spectrum oral antifungal medication, does not appear to be effective therapy for invasive fungal infection in the immunocompromised patient based on results of small clinical trials. New diagnostic methods and therapeutic approaches are necessary to improve the outcome of these infections. Areas of current research include serological assays for fungal antigens and metabolites which may allow earlier diagnosis, treatment with combinations of antifungal agents, and the development of new antifungal agents.

Central nervous system coccidioidomycosis: a clinicopathologic study of treatment with and without amphotericin B

The clinical and pathologic findings in 32 patients with central nervous system (CNS) coccidioidomycosis were studied. Seventeen patients had received more than 1.5 g of amphotericin B (AMB), chiefly intravenously, during treatment periods of up to eight years. Eight patients had received 246 mg to 1.3 g of AMB, and three patients had received only brief treatment (one to three days; total dose, no more than 100 mg). Fifteen patients had not received AMB. Significant clinical differences between the patients treated with and without AMB were longer survival time following diagnosis of illness (P less than 0.05) and more frequent cranial nerve signs in the treated patients (P = 0.089). The wide spectrum of macroscopic and microscopic lesions in the CNS included meningitis, ventriculitis, hydrocephalus, and cerebritis. Long-standing infections were associated with disseminated discrete foci of gliosis and infarcts in the brain, particularly in the basal ganglia and deep white matter, related to endarteritis obliterans in basilar meninges. In contrast to patients with CNS and systemic mycoses treated with amphotericin B methyl ester (J Infect Dis 146:125, 1982), no diffuse lesions of white matter were found in patients treated with or without AMB. Histopathologic patterns observed in this study included leptomeningitis alone, leptomeningitis with cerebritis, leptomeningitis with cerebritis and infarcts, and the unusual pattern of disseminated miliary granulomas. The frequency and extent of CNS lesions in the groups treated with and without AMB were not significantly different. It is concluded that AMB therapy, while prolonging survival, does not alter the spectrum of pathologic findings in CNS coccidioidomycosis infection.

Relationship of progesterone- and estradiol-binding proteins in Coccidioides immitis to coccidioidal dissemination in pregnancy

Pregnancy is a major risk factor for coccidioidal dissemination. Because rates of Coccidioides immitis growth and endospore release are stimulated in vitro by levels of unbound progesterone and 17 beta-estradiol that are achievable, in vivo, in the sera of pregnant women (i.e., 10(-9) to 10(-8) M), a specific-hormone-binding system in C. immitis was sought. Fungal cytosols were incubated with tritiated steroids plus or minus radioinert steroids to identify specific binding systems. All five strains of C. immitis tested exhibited specific saturable binding for progestin, estrogen, androgen, and (to a lesser extent) corticosterone and glucocorticoid hormone classes. Only low or inconsistent estrogen or androgen binding was found in Blastomyces dermatitidis and Torulopsis glabrata. Cryptococcus neoformans, Paracoccidioides brasiliensis, and non-albicans Candida species showed no binding. Scatchard analysis of progestin and estrogen binding in C. immitis revealed a high-capacity, low-affinity binding system that was unaffected by RNase and DNase, but 40 to 60% degraded by trypsin or heating. Ammonium sulfate precipitation resolved a high-affinity, low-capacity binding system (Kd = 1.24 X 10(-9) to 3.60 X 10(-8) M; number of binding sites = 0.014 to 0.20 pmol/mg of protein). The Kd of this system is sufficient to compete for unbound hormone in the sera of pregnant women. The high-capacity, low-affinity system may serve as a repository for hormone before its attachment to the specific binder. These studies suggest that the effects of nanomolar concentrations of sex hormones on C. immitis may be mediated by a specific cytosol protein-binding system and that stimulatory events observed in vitro may have relevance for the mechanism of coccidioidal dissemination in pregnancy.