Coccidioidomycosis Infection Research Articles

A rare case of peritoneal coccidioidomycosis.

Coccidioidomycosis, also known as valley fever, is a fungal infection that can develop after inhalation of arthroconidia from soil. Coccidioidomycosis infections are most common in the southwestern United States and typically involve the lungs. Risk factors for extrapulmonary spread, which can be life-threatening, include older age, diabetes, HIV and AIDS, late-term pregnancy, immunosuppressant drug use and African or Filipino ancestry. This article describes incidental identification of coccidioidomycosis of the peritoneum, an extremely rare site for dissemination, during bariatric surgery in a patient without known risk factors.

Risk of Coccidioidomycosis Infection Among Individuals Using Biologic Response Modifiers, Corticosteroids, and Oral Small Molecules.

The study objective was to examine associations between the use of biologic response modifiers (BRMs), corticosteroids, and oral small molecules (OSMs) and subsequent coccidioidomycosis infection risk among US Medicare beneficiaries with rheumatic or autoimmune diseases. This retrospective cohort study used US 2011 to 2016 Medicare claims data. We identified geographic areas with endemic coccidioidomycosis (≥25 cases per 10,000 beneficiaries). Among beneficiaries having any rheumatic/autoimmune diseases, we identified those initiating BRMs, corticosteroids, and OSMs. Based on refill days supplied, we created time-varying exposure variables for BRMs, corticosteroids, and OSMs with a 90-day lag period after drug cessation. We examined BRMs, corticosteroids, and OSMs and subsequent coccidioidomycosis infection risk using multivariable Cox proportional hazard regression. Among 135,237 beneficiaries (mean age: 67.8 years; White race: 83.1%; Black race: 3.6%), 5,065 had rheumatic or autoimmune diseases, of which 107 individuals were diagnosed with coccidioidomycosis during the study period (6.1 per 1,000 person-years). Increased risk of coccidioidomycosis was observed among beneficiaries prescribed any BRMs (17.7 per 1,000 person-years; adjusted hazard ratio [aHR] 3.94; 95% confidence interval [CI] 1.18-13.16), followed by individuals treated with only corticosteroids (12.2 per 1,000 person-years; aHR 2.29; 95% CI 1.05-5.03) compared to those treated with only OSMs (4.2 per 1,000 person-years). The rate of those treated with only OSMs was the same as that of beneficiaries without these medications. Incidence of coccidioidomycosis was low among 2011 to 2016 Medicare beneficiaries with rheumatic or autoimmune diseases. BRM and corticosteroid users may have higher risks of coccidioidomycosis compared to nonusers, warranting consideration of screening for patients on BRMs and corticosteroids in coccidioidomycosis endemic areas.

Diagnostic Delays in Cutaneous Coccidioidomycosis: a Report from Central California.

Cutaneous Coccidioidomycosis (CC) infection can present with a wide variety of clinical presentations and is well known as a 'great imitator'. We performed a retrospective analysis of patients with CC in a large referral center in Central Valley, California, from 2010 to 2022 using the ICD9 and ICD10 codes for coccidioidomycosis and CC. We identified forty patients with CC during the study period. The mean age of the study population was 43 years (with standard deviation of 14.08). Among these, 60% were men and 40% women. The appearance of the lesions varied from ulcers, plaques, nodules, blisters, cellulitis, and abscesses. The most common site of CC lesions was in the lower extremities (42.5%), followed by upper extremities (30%), chest and abdomen, head and neck (25% each). Only 22.5% of the 40 cases were diagnosed as CC and 15% were diagnosed as erythema nodosum. Rest were diagnosed initially as bacterial cellulitis in 37.5%, tinea in 7.5% and others in 12.5%. There was resolution of the cutaneous lesions in all patients with antifungal treatment. The mean time of diagnosis from onset of symptoms on an average was 12 weeks (8-16weeks) in our study with 75% cases initially misdiagnosed. Comprehensive knowledge about the manifestations and evaluation of CC among primary care providers and emergency room physicians is essential to prevent delays in diagnosis and treatment.

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

Background: Coccidioidomycosis (cocci) is an endemic fungal disease that can cause asymptomatic or post-symptomatic lung nodules which are visible on chest CT scanning. Lung nodules are common and can represent early lung cancer. Differentiating lung nodules due to cocci from those due to lung cancer can be difficult and lead to invasive and expensive evaluations. Materials and Methods: We identified 302 patients with biopsy-proven cocci or bronchogenic carcinoma seen in our multidisciplinary nodule clinic. Two experienced radiologists who were blinded to the diagnosis read the chest CT scans and identified radiographic characteristics to determine their utility in differentiating lung cancer nodules from those due to cocci. Results: Using univariate analysis, we identified several radiographic findings that differed between lung cancer and cocci infection. We then entered these variables along with age and gender into a multivariate model and found that age, nodule diameter, nodule cavitation, presence of satellite nodules and radiographic presence of chronic lung disease differed significantly between the two diagnoses. Three findings, cavitary nodules, satellite nodules and chronic lung disease, have sufficient discrimination to potentially be useful in clinical decision-making. Conclusions: Careful evaluation of the three obtained radiographic findings can significantly improve our ability to differentiate benign coccidioidomycosis infection from lung cancer in an endemic region for the fungal disease. Using these data may significantly reduce the cost and risk associated with distinguishing the cause of lung nodules in these patients by preventing unnecessary invasive studies.

Risk of systemic fungal infections after exposure to wildfires: a population-based, retrospective study in California

Large-scale wildfires in California, USA, are increasing in both size and frequency, with substantial health consequences. The capacity for wildfire smoke to displace microbes and cause clinically significant fungal infections is poorly understood. We aimed to determine whether exposure to wildfire smoke was associated with an increased risk of hospital admissions for systemic fungal infections.In this population-based, retrospective study, we used hospital administrative data from 22 hospitals in California, USA, to analyse the association between wildfire smoke exposure and monthly hospital admissions for aspergillosis and coccidioidomycosis. We included hospitals that were members of the Vizient Clinical Data Base or Resource Manager during the study and excluded those that did not have complete reporting into Vizient during the study period. Smoke exposure was estimated using satellite-imaged smoke plumes in the hospital county. Incident rate ratios were calculated for all infection types 1 month and 3 months after smoke exposure.Between Oct 1, 2014, and May 31, 2018, there were a median of 1638 annual admissions per hospital in the study sample. Individual patient demographics were not collected. We did not observe an association between smoke exposure and rate of hospital admission for aspergillosis. However, hospital admission for coccidioidomycosis increased by 20% (95% CI 5-38) in the month following any smoke exposure. Hospital admission increased by 2% (0-4) for every day that there had been smoke exposure in the previous month, after adjustment for temperature and temporal trend. Similar results were obtained with smoke exposure data from the 3 months before admission.In the months following wildfire smoke exposure, California hospitals saw increased coccidioidomycosis infections. Given the projected increase in California wildfires and their expansion in endemic territories of soil-dwelling fungi, the ability for wildfire smoke to carry microbes and cause human disease warrants further research.None.

Duration of neurological deficit and outcomes in the surgical treatment of spinal coccidioidomycosis.

Vertebral osteomyelitis is a rare complication of coccidioidomycosis infection. Surgical intervention is indicated when there is failure of medical management or presence of neurological deficit, epidural abscess, or spinal instability. The relationship between timing of surgical intervention and recovery of neurological function has not been previously described. The purpose of this study was to investigate if the duration of neurological deficits at presentation affects neurological recovery after surgical intervention. This was a retrospective study of all patients diagnosed with coccidioidomycosis involving the spine at a single tertiary care center between 2012 and 2021. Data collected included patient demographics, clinical presentation, radiographic information, and surgical intervention. The primary outcome was change in neurological examination after surgical intervention, quantified according to the American Spinal Injury Association Impairment Scale. The secondary outcome was the complication rate. Logistic regression was used to test if the duration of neurological deficits was associated with improvement in the neurological examination after surgery. Twenty-seven patients presented with spinal coccidioidomycosis between 2012 and 2021; 20 of these patients had vertebral involvement on spinal imaging with a median follow-up of 8.7 months (IQR 1.7-71.2 months). Of the 20 patients with vertebral involvement, 12 (60.0%) presented with a neurological deficit with a median duration of 20 days (range 1-61 days). Most patients presenting with neurological deficit (11/12, 91.7%) underwent surgical intervention. Nine (81.2%) of these 11 patients had an improved neurological examination after surgery and the other 2 had stable deficits. Seven patients had improved recovery sufficient to improve by 1 grade according to the AIS. The duration of neurological deficits on presentation was not significantly associated with neurological improvement after surgery (p = 0.49, Fisher's exact test). The duration of neurological deficits on presentation should not deter surgeons from operative intervention in cases of spinal coccidioidomycosis.

Fatal Disseminated Coccidioidomycosis in Cirrhosis: A Case Series

PurposeCoccidioidomycosis is endemic to the Southwest United States and Mexico. In this case series we describe 3 cases, occurring in the Southwest United States, of patients with disseminated coccidioidomycosis infection in cirrhosis, all with a miliary pattern present on chest imaging. MethodsThis case series was performed conducting a review of patients’ electronic health records and thorough review of the literature for coccidioidomycosis infection in patients with liver disease. ResultsThree patients with different etiology of liver disease with Model for End-stage Liver Disease – Sodium (MELD-Na) scores >20 had chest imaging findings indicative of a miliary pattern on presentation. Each patient subsequently had extensive infectious disease workup that showed evidence of disseminated coccidioidomycosis. All 3 patients clinically worsened and eventually died. ConclusionsThis case series highlights the severity of disseminated coccidioidomycosis in patients with cirrhosis in an endemic area, as well as potential early clues such as miliary patterns on chest imaging. A review of the literature found a significant connection among potential mechanisms describing why patients with cirrhosis have such adverse outcomes in the setting of disseminated coccidioidomycosis, including cirrhosis-associated immune dysfunction and genetic defects in immune functioning.

Reactivation of Coccidioidomycosis in a Mouse Model of Asymptomatic Controlled Disease.

The majority of human coccidioidomycosis infections are asymptomatic or self-limited but may have sequestered spherules in highly structured granulomas. Under immunosuppression, reactivation of fungal growth can result in severe disease. B6D2F1 mice asymptomatically infected with C. posadasii strain 1038 were immunosuppressed with dexamethasone (DXM) in drinking water. Treated mice died 16–25 days later, while untreated mice survived (p < 0.001). Flow cytometry of lung granulomas on days 5, 10, 15, and 20 of DXM treatment showed immune cell populations decreased 0.5–1 log compared with untreated mice though neutrophils and CD19+IgD−IgM− cells rebounded by day 20. Histopathology demonstrated loss of granuloma structure by day 5 and increasing spherules through day 20. On day 20, T-cells were nearly absent and disorganized pyogranulomatous lesions included sheets of plasma cells and innumerable spherules. Mice given DXM for 14 days then stopped (DXM stop) survived 6 weeks (9/10). Lung fungal burdens were significantly lower (p = 0.0447) than mice that continued treatment (DXM cont) but higher than untreated mice. Histopathologically, DXM stop mice did not redevelop controlled granulomas by sacrifice, though T-cells were densely scattered throughout the lesions. This demonstrates a mouse model suitable for further study to understand the immunologic components responsible for maintenance control of coccidioidomycosis.

The Utility of (1→3)-β-D-Glucan Testing in the Diagnosis of Coccidioidomycosis in Hospitalized Immunocompromised Patients.

Coccidioidomycosis is a fungal infection endemic to the Southwestern United States which is associated with high morbidity and mortality in immunocompromised hosts. Serology is the main diagnostic tool, although less sensitive among immunocompromised hosts. (1→3)-β-D-glucan (BDG) is a non-specific fungal diagnostic test that may identify suspected coccidioidomycosis and other invasive fungal infections. We retrospectively investigated the utility of BDG between 2017 and 2021 in immunocompromised hosts with positive Coccidioides spp. cultures at our institutions. During the study period, there were 368 patients with positive cultures for Coccidioides spp.; among those, 28 patients were immunocompromised hosts, had both Coccidioides serology and BDG results available, and met other inclusion and exclusion criteria. Half of the patients had positive Coccidioides serology, and 57% had a positive BDG ≥ 80 pg/mL. Twenty-three (82%) had at least one positive test during their hospitalization. Among immunocompromised hosts with suspicion for coccidioidomycosis, the combination of Coccidioides serology and BDG can be useful in the initial work up and the timely administration of appropriate antifungal therapy. However, both tests failed to diagnose many cases, underscoring the need for better diagnostic techniques for identifying coccidioidomycosis in this population.

115. The Utility of (1→3)-β-D-glucan Assay in the Diagnosis of Severe Coccidioidomycosis Infections among Immunocompromised Hosts

BackgroundCoccidioidomycosis is associated with increased morbidity and mortality in immunocompromised (IC) patients. The diagnosis of invasive fungal infections can be challenging in IC hosts. Culture results may take time to identify Coccidioides species, and serologic based tests are less sensitive in IC patients. (1-3)-β-d-glucan (BDG) has been reported to be detected in patients with coccidioidomycosis. We hypothesized that BDG in combination with serology may assist in the early detection of coccidioidomycosis in IC patients.MethodsAfter the institutional review board approved the study, we conducted a retrospective chart review from 10/1/2017 through 09/15/2020, including ≥18 years old IC patients with a confirmed diagnosis of coccidioidomycosis by culture. Information regarding demographics, comorbidities, immunosuppression, medications, BDG, serology, and clinical presentation was collected. Patients with infusions that can result in possible false-positive BDG were excluded. Patients with other fungal infections were also excluded. Chi-square test was used to compare categorical variables, Wilcoxon rank-sum and Kruskal-Wallis tests were used to compare non-parametric variables, accordingly.ResultsOver the study period, 269 encounters with positive Coccidioides spp. cultures were identified, 78/269 of patients were IC patients, 55/78 were excluded, and 23 cases were included in the final analysis. Among the 23 IC patients, the median age was 64, 43% were female, 74% were White. There were 8 post solid organ transplantation, 7 with a hematological malignancy, and 8 with other types of IC conditions. 19/23 had a pulmonary infection. 4/23 patients died within one month of their encounter. There was no statistical significance difference between positive BDG and serology tests, with 12/23 had positive BDG, and another 12/23 had positive serology. Combined serology and BDG detected 18/23 of the Coccidioidomycosis cases. 17% of the cohort died within the one-month follow-up.ConclusionThe combined use of BDG assay and Coccidioides serology increases the sensitivity of coccidioidomycosis diagnosis to 78% in IC patients. Future prospective studies are needed to further evaluate the utility of serum BDG in diagnosing coccidioidomycosis in IC patients.Disclosures Mohanad Al Obaidi, MD, Shionogi Inc. (Advisor or Review Panel member)

980. Universal Lifelong Fungal Prophylaxis and Risk of Coccidioidomycosis in Lung Transplant Recipients Living in an Endemic Area

Abstract Background Previous studies suggested that 6-12 months of universal or targeted azole prophylaxis is effective in preventing coccidioidomycosis for various organ transplant recipients. However, limited reports have described outcomes with longer prophylactic durations or using mold-active azoles in lung transplant recipients. Therefore, the purpose of this study was to investigate the incidence of coccidioidomycosis and tolerability of universal lifelong azole therapy in this high-risk patient population. Methods This study was an IRB-approved, retrospective cohort study of lung transplant recipients transplanted from January 2013 through December 2018. Adult recipients who were initiated on azole antifungal prophylaxis were eligible for inclusion. Recipients who died or received pre-emptive or definitive treatment for coccidioidomycosis during the transplant admission, or who received a previous transplant were excluded from the study. Outcomes were assessed through December 2019 or until the time of coccidioidomycosis diagnosis, death, second transplant, or date lost to follow-up. Results Of 544 lung transplants completed between 2013-2018, 493 patients were included with a mean age at transplant of 62 ± 11; 57.3% were male, 88.6% were white, and 77.1% developed post-transplant diabetes. The majority of patients ( &amp;gt; 70%) lived in Arizona or California pre-transplant and at 1-year post-transplant, and most patients had primary transplant indication of COPD and/or pulmonary fibrosis (~75%). One proven coccidioidomycosis infection and one new asymptomatic seropositivity for Coccidioides (incidence 0.2% each) occurred during the study period with median follow-up duration of 31 months. Azole therapy changes were common but permanent discontinuation was rare (1.4%) with reasons for azole switch varying among the different agents as summarized in Table 1. Table 1. Comparison of azole antifungal exposures and reasons for discontinuation Conclusion Lifelong azole antifungal prophylaxis was well-tolerated and effectively protected lung transplant recipients at an Arizona transplant center against coccidioidomycosis. Thus, in the absence of documented intolerance or contraindication, universal lifelong azole antifungal prophylaxis should be considered for all lung transplant recipients residing in a coccidioidomycosis-endemic area. Disclosures Michael D. Nailor, PharmD, BCPS (AQ-ID), AbbVie (Consultant)Merck (Consultant)Shionogi (Consultant) Rajat Walia, MD, Astellas (Consultant, Speaker)

27924 Screening for coccidioidomycosis prior to immunosuppressive therapy in dermatology patients

Introduction: Coccidioidomycosis infection is caused by the inhalation of Coccidioides fungal spores residing in soil in the southwestern US and parts of Mexico and South America. Although most coccidioidomycosis infections are subclinical, patients with impaired cellular immunity are at risk of developing severe pulmonary complications and disseminated disease. Many dermatologic conditions are treated with systemic immunosuppressive agents, which provides relevance in evaluating these patients for underlying coccidioidomycosis infection prior to treatment.

1180. Seroincidence and Risk of Coccidioidomycosis Infection Among Active Duty Personnel Stationed at Naval Air Station Lemoore in the San Joaquin Valley of California

BackgroundCoccidioidomycosis ranges clinically from a self-limited respiratory illness to multi-organ dissemination. Based largely on skin testing from the 1940s, 60% of infections are thought to be asymptomatic. Limited Coccidioides seroincidence data support our understanding of the epidemiology and pathogenicity of this disease.MethodsThis retrospective cohort study tested 2000 U.S. military personnel for Coccidioides exposure after transfer to an endemic region of California between 2011 and 2017. The presence of IgG and IgM anti-Coccidioides antibodies were tested on pre- and post-transfer serum samples from the DoD Serum Repository to establish rates of seroconversion. Medical histories and participant demographics including race/ethnicity and military occupational specialty codes were collected from the electronic medical record and participants were stratified by a history of Coccidioides-specific or general respiratory illness based on ICD9/ICD10 coding.ResultsThirty of 2000 participants tested newly positive for anti-Coccidioides antibodies after 12 months on station. Seroconversion incidence varied from 0.0-1.32 annually and overall 0.5 per 100 person years. Seroconverters were more frequently diagnosed with coccidioidomycosis or pneumonia than non-converters (p=0.027). No statistically significant association between demographic characteristics and seroconversion or disease was observed. Clinical disease was detected in only three seroconverters (10%).Incidence Rate of Coccidioidomycosis Infection among Active Duty Stationed at NAS Lemoore, 2011-2017 Seroconversion Status by Cocci/Pneumonia Diagnosis Status ConclusionIn this study Coccidioides seroincidence was similar to that observed by others, adding longitudinal evidence to epidemiologic assumptions about coccidioidomycosis. A trend toward increasing incidence over the course of the study is consistent with the classification of coccidioidomycosis as an emerging infectious disease. While transmission is typically related to exposure, we did not detect a difference based on military occupational specialty codes. Overall, rates of diagnosed disease in our cohort were lower than the historically-assumed 40% symptomatic rate, although this conclusion is limited by the retrospective nature of the study. Further clinical and epidemiologic coccidioidomycosis research, particularly in broader endemic regions, is warranted.Disclosures All Authors: No reported disclosures

Primary Analysis of Zuma-5: A Phase 2 Study of Axicabtagene Ciloleucel (Axi-Cel) in Patients with Relapsed/Refractory (R/R) Indolent Non-Hodgkin Lymphoma (iNHL)

Primary Analysis of Zuma-5: A Phase 2 Study of Axicabtagene Ciloleucel (Axi-Cel) in Patients with Relapsed/Refractory (R/R) Indolent Non-Hodgkin Lymphoma (iNHL)

Transcend CLL 004: Phase 1 Cohort of Lisocabtagene Maraleucel (liso-cel) in Combination with Ibrutinib for Patients with Relapsed/Refractory (R/R) Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL)

Transcend CLL 004: Phase 1 Cohort of Lisocabtagene Maraleucel (liso-cel) in Combination with Ibrutinib for Patients with Relapsed/Refractory (R/R) Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL)

Cocci Are in the Air

The San Joaquin Valley in Central California is a semiarid region that is known to be highly endemic for coccidioidomycosis infections in high-risk groups. Coccidioidomycosis, also known as valley fever, is caused by the fungal spore Coccidioides, which can be found in the soil in arid and semiarid regions in the Southwest United States and parts of Central and South America. When soil is disturbed through excavation, agricultural activities, or with any other soil movement, these activities can release the fungal spores into air; people who are in close proximity can potentially inhale them. The purpose of this clinical case study is to address the need for coccidioidomycosis infection awareness and educate primary care providers to determine the diagnostic reasoning and process. A simple algorithm and template will aid them to accurately diagnose and treat patients with valley fever earlier in the disease process.

COCCIDIOIDES KILLS: A CASE REPORT

SESSION TITLE: Fellows Lung Pathology Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Coccidioidomycosis immitis is a dimorphic fungus that infects the host via inhalation of spores found in the soil of endemic areas such as the southwestern United States. In immunocompetent patients it usually presents as a flu like illness. In patients that are immunocompromised it can lead to disseminated disease affecting numerous organs. CASE PRESENTATION: A 32-year-old male with a history of asthma presented to the ED with fevers, back pain, shaking chills, shortness of breath, and a nonproductive cough for two weeks. A CT chest was performed that revealed diffuse bilateral ground glass opacities (Figure 1). His respiratory status worsened despite treatment for pneumonia and he was subsequently intubated. MRI of the thoracic spine was performed given his back pain, which showed T8-T12 paravertebral abscess (Figure 2). It was also noted while gathering history that he played football in Arizona and lived in that area for some time. Aspiration of the paraspinal abscess was performed. Patient was placed on empiric amphotericin B as he developed worsening acute respiratory distress syndrome (ARDS). Despite being on lung protective strategies, he was difficult to oxygenate and placed on ECMO. Infectious workup for other organisms was also performed including bacterial and viral co-infection in the blood, cerebrospinal fluid (CSF), and bronchial fluids. His spinal cultures and CSF grew Coccidioides immitis along with spherules noted in his bronchial washings. He was also found to have cutaneous disseminated lesions on his upper extremity (Figure 3). Despite best efforts, patient continued to decompensate. Palliative care was consulted and withdrawal of support was performed after patient was noted to have multiple cardiac arrests. DISCUSSION: Symptomatic patients with coccidioidomycosis typically present with community acquired pneumonia. Uncommonly, in about 1% of infections, hematogenous, extra pulmonary dissemination can occur to the spine, meninges, joints, and skin. Coccidioidomycosis is commonly diagnosed in disease-endemic areas but frequently overlooked in disease-nonendemic areas because of a low index of suspicion among physicians. Individuals at risk of dissemination have suppressed cellular immunity, including those with advanced HIV infection, transplantation recipients, and those receiving chronic immunosuppressive medications such as glucocorticoids. Interestingly, this patient had no such risk factors, but the key in his case was obtaining travel/living history as it increased suspicion of coccidioidomycosis infection earlier. Unfortunately, in his case, this did not change his outcome. CONCLUSIONS: Although coccidioidomycosis is rare in non-endemic areas, physicians must keep it in mind when evaluating patients who have traveled or lived in endemic areas even without immunosuppression. Reference #1: Ramanathan D, Sahasrabudhe N, Kim E. Disseminated Coccidioidomycosis to the Spine-Case Series and Review of Literature. Brain Sci. 2019 Jul 7;9(7). doi: 10.3390/brainsci9070160. PubMed PMID: 31284663; PubMed Central PMCID: PMC6680672. DISCLOSURES: No relevant relationships by Alireza Nathani, source=Web Response No relevant relationships by Sean OConnor, source=Web Response No relevant relationships by Chhaya Patel, source=Web Response No relevant relationships by Jorge Velazco, source=Web Response

PET in the diagnostic management of infectious/inflammatory pulmonary pathologies: a revisit in the era of COVID-19.

PET in the diagnostic management of infectious/inflammatory pulmonary pathologies: a revisit in the era of COVID-19.

Spinal Coccidioidomycosis: A Complication From Medication Noncompliance

Spinal coccidioidomycosis is a rare disseminated form of coccidioidomycosis infection. According to the literature, majority of patients are African American males. We present a rare case of spinal coccidioidomycosis in a young, Caucasian female with coccidioidomycosis meningitis at age 16 years who presented with bilateral lower extremity weakness after antifungal medication lapse for one year. Imaging revealed cystic arachnoid formations along her thoracic spine. Pathology report confirmed spinal arachnoiditis with coccidioidomycosis. This case report details a rare incidence of spinal coccidioidomycosis and reviews previous literature.

Risk factors and outcomes of culture-proven acute Coccidioides spp. infection in San Diego, California, United States.

Coccidioides spp. are dimorphic fungi endemic to parts of the United States, Mexico, Central and South America. Infection can cause a range of disease from self-limited acute pneumonia to severe disseminated disease. We performed a retrospective chart review of medical records of cases of culture-proven acute coccidioidomycosis at the University of California San Diego between 1 April 2015 and 31 December 2019 and described the demographics, risk factors and outcomes of these cases. Over the study period, fifteen evaluable cases of culture-proven acute coccidioidomycosis were identified. Of these, 87% (13/15) had traditional risk factors for coccidioidomycosis infection while two lacked known risk factors, including one patient with cirrhosis and one with chronic hepatitis C infection. Seven of fifteen (47%) had primary coccidioidomycosis of the lungs without dissemination and 7/15 (47%) disseminated disease. Of those with disseminated disease, 6/7 (86%) had either high-risk ethnicity or blood type as their only risk factor. At 90days, 11/15 (73%) were alive, 3/15 (20%) deceased and 1/15 (7%) lost to follow-up. Of those not alive at 90days, 1/3 (33%) had disseminated disease and 2/3 (67%) primary coccidioidomycosis, both on immunosuppressive therapy. Coccidioides spp. infection occurs in a variety of hosts with varying underlying risk factors, with the majority in our cohort overall and 86% with disseminated disease lacking traditional risk factors for invasive fungal infection other than ethnicity and/or blood phenotype. Clinicians should be aware of these non-traditional risk factors in patients with coccidioidomycosis infection.