Disseminated Coccidioidomycosis Research Articles

Two lateral flow assays for detection of anti-coccidioidal antibodies show similar performance to immunodiffusion in dogs with coccidioidomycosis.

To compare 2 point-of-care lateral flow assays (LFAs) with immunodiffusion (ID) IgG results for anti-coccidioidal antibody detection in dogs with coccidioidomycosis. A further aim was to compare the quantifiable output of 1 of the LFAs to ID antibody titers. Serum banked from 73 client-owned dogs diagnosed with pulmonary or disseminated coccidioidomycosis. ID was used to determine antibody presence and titer against a coccidioidal antigen preparation. All sera were subsequently tested on an LFA based on recombinant chitinase 1 (CTS1) and the commercially available sōna LFA. LFA results were analyzed and compared to ID IgG results and clinical diagnosis. All assays showed similar sensitivities in detecting anti-coccidioidal antibodies (83.6% to 89.0%). When compared with ID IgG, the CTS1 LFA had a positive percent agreement of 100%, while the sōna LFA had a positive percent agreement of 91.4%. Since the CTS1 LFA is semiquantitative, we were able to compare test line densities with ID titers and found a strong correlation between the 2 assays (Spearman ρ = 0.82). This is the first side-by-side evaluation of a commercially available LFA (sōna) and a newer more rapid anti-CTS1 antibody LFA using serum from dogs with coccidioidomycosis. Both LFAs tested have similar sensitivity to ID IgG results. The CTS1 LFA can be read after 10 minutes and is semiquantitative, while the sōna LFA is read after 30 minutes, and the results are subject to interpretation. Accurate and fast detection of anti-coccidioidal antibodies allows clinicians to initiate appropriate treatment without diagnostic delay.

Immunogenetics associated with severe coccidioidomycosis.

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

Contribution of Biologic Response Modifiers to the Risk of Coccidioidomycosis Severity.

The risk of coccidioidomycosis (CM) as a life-threatening respiratory illness or disseminated CM (DCM) increases as much as 150-fold in immunosuppressed patients. The safety of biologic response modifiers (BRMs) as treatment for patients with autoimmune disease (AI) in CM-endemic regions is not well defined. We sought to determine that risk in the Tucson and Phoenix areas. We conducted a retrospective study reviewing demographics, Arizona residency length, clinical presentations, specific AI diagnoses, CM test results, and BRM treatments in electronic medical records of patients ≥18 years old with International Classification of Diseases (ICD-10) codes for CM and AI from 1 October 2017 to 31 December 2019. We reviewed 944 charts with overlapping ICD-10 codes for CM and AI, of which 138 were confirmed to have both diagnoses. Male sex was associated with more CM (P=.003), and patients with African ancestry were 3 times more likely than those with European ancestry to develop DCM (P<.001). Comparing CM+/AI+ (n = 138) with CM+/AI- (n = 449) patients, there were no significant differences in CM clinical presentations. Patients receiving BRMs had 2.4 times more DCM compared to pulmonary CM (PCM). AI does not increase the risk of any specific CM clinical presentation, and BRM treatment of most AI patients does not lead to severe CM. However, BRMs significantly increase the risk of DCM, and prospective studies are needed to identify the immunogenetic subset that permits BRM-associated DCM.

Vaccine Protection of Mice With Primary Immunodeficiencies Against Disseminated Coccidioidomycosis.

Disseminated coccidioidomycosis (DCM), often a severe and refractory disease leading to poor outcomes, is a risk for people with certain primary immunodeficiencies (PID). Several DCM-associated PID (STAT4, STAT3, IFNγ, and Dectin-1) are modeled in mice. To determine if vaccination could provide these mice protection, mice with mutations in Stat4, Stat3, Ifngr1, Clec7a (Dectin-1), and Rag-1 (T- and B-cell deficient) knockout (KO) mice were vaccinated with the live, avirulent, Δcps1 vaccine strain and subsequently challenged intranasally with pathogenic Coccidioides posadasii Silveira strain. Two weeks post-infection, vaccinated mice of all strains except Rag-1 KO had significantly reduced lung and spleen fungal burdens (p<0.05) compared to unvaccinated control mice. Splenic dissemination was prevented in most vaccinated immunodeficient mice while all unvaccinated B6 mice and the Rag-1 KO mice displayed disseminated disease. The mitigation of DCM by Δcps1 vaccination in these mice suggests that it could also benefit humans with immunogenetic risks of severe disease.

42. Common Population Variants Cause Susceptibility to Disseminated Coccidioidomycosis

Background Coccidioides are endemic, dimorphic fungi found in soils of southwestern United States, Mexico and Central America. Infection occurs via inhalation of arthroconidia which swell, differentiate into spherules and rupture releasing endospores. While the majority of infected individuals will never report illness, roughly 1/3 seek medical attention for fungal pneumonia and ~1% of those present with disseminated coccidioidomycosis (DCM). IL12-IFNγ pathway mutations have been reported in DCM but are exceedingly rare and cannot account for the ~500–600 cases of DCM/year.MethodsWe performed whole exome sequencing on 66 individuals with DCM, retaining variants predicted damaging (CADD >15) with a population frequency < 10%.ResultsHomozygous CLEC7A c.714T >G; p.Y238* causing a truncated Dectin-1 receptor was overrepresented (OR=9.8449, 95% CI 3.0841 to 31.4260, P=0.0001). Dectin-1 signaling pathway variants included 3 homozygous and 11 heterozygous CLEC7A p.Y238* individuals, one each CLEC7A p.I223S and MALT1 p.R149Q and five PLCG2 p.R268W. Since Dectin-1 is the receptor for b-glucan, a major Coccidioides cell-wall component, we hypothesized that Dectin-1 pathway variants could affect fungal recognition and cellular response. Healthy control PBMCs stimulated with purified β-glucan or heat-killed Candida albicans induced 6-fold more TNFα than patients with homozygous or heterozygous CLEC7A, PLCG2 or MALT1 variants (P=0.0022, Ordinary one-way ANOVA). Additionally, one patient with a family history of DCM but lacking a defined mutation also failed to up-regulate TNFα after stimulation.Normalized TNF production from healthy control and DCM patient’s peripheral blood mononuclear cellsConclusion These data are consonant with increased dissemination in Clec7a-/- mice as well as in patients receiving anti-TNF biologics. These gene variants accounted for 31% of our DCM cohort (21/66 patients). This is the first demonstration of variants outside the IL12-IFNg pathway impairing fungal recognition and cellular response in coccidioidomycosis. Common heterozygous variants may be sufficient for disease susceptibility to highly pathogenic organisms.Disclosures Michail Lionakis, MD, ScD, Matinas BioPharma (Research Grant or Support)

Natural History of Disseminated Coccidioidomycosis: Examination of the Veterans Affairs-Armed Forces Database.

The natural history of non-central nervous system (non-CNS) disseminated coccidioidomycosis (DCM) has not been previously characterized. The historical Veterans Affairs (VA)-Armed Forces coccidioidomycosis patient group provides a unique cohort of patients not treated with standard antifungal therapy, allowing for characterization of the natural history of coccidioidomycosis. We conducted a retrospective study of 531 VA-Armed Forces coccidioidomycosis patients diagnosed between 1955-1958 and followed to 1966. Groups were identified as non-DCM (462 patients), DCM (44 patients), and CNS (25 patients). The duration of the initial infection, fate of the primary infection, all-cause mortality, and mortality secondary to coccidioidomycosis were assessed and compared between groups. Mortality due to coccidioidomycosis at the last known follow-up was significantly different across the groups: 0.65% in the non-DCM group, 25% in the DCM group, and 88% in the CNS group (P < .001). The primary fate of pulmonary infection demonstrated key differences, with pulmonary nodules observed in 39.61% of the non-DCM group, 13.64% of the DCM group, and 20% of the CNS group (P < .001). There were differences in cavity formation, with 34.20% in the non-DCM group, 9.09% in the DCM group, and 8% in the CNS group (P < .001). Dissemination was the presenting manifestation or was concurrent with the initial infection in 41% and 56% of patients in the non-CNS DCM and CNS groups, respectively. This large, retrospective cohort study helps characterize the natural history of DCM, provides insight into the host immunologic response, and has direct clinical implications for the management and follow-up of patients.

Primary Cutaneous Coccidioidomycosis: An Update.

Coccidioidomycosis is an endemic mycosis of the southern United States, Northern Mexico, and South America. Primary cutaneous coccidioidomycosis, despite being a very rare clinical presentation, has shown an increasing incidence. An extensive literature search for cutaneous coccidioidomycosis cases was performed using the OLDMEDLINE, PubMed, Cochrane, LILACS and Google Scholar databases for studies published from January 1927 through December 21, 2019. Forty-two observational studies were included totaling 82 cases of primary cutaneous coccidioidomycosis. Narrative reviews, systematic reviews, and meta-analyses were also included. Additionally, an original case was included. Patients with primary cutaneous coccidioidomycosis share the same geographical and epidemiological characteristics as those with pulmonary or disseminated coccidioidomycosis. Most of the imported cases came from endemic areas. A large portion of cases had prior local skin trauma. Tissue culture is still the leading diagnostic method; nevertheless, molecular techniques such as polymerase chain reaction (PCR) are currently relevant to differentiate between species. First-line treatment consists of azoles; however, it has an excellent prognosis even without treatment. Primary cutaneous coccidioidomycosis should be considered a differential diagnosis of unusual infections or neoformations in any part of the body in resident populations of endemic areas or in patients with a previous history of travel to these areas.

Cytokine and Anticytokine Therapy for Disseminated Coccidioidomycosis

A 4-year-old child was found to have multisite disseminated coccidioidomycosis that was unresponsive to antifungal therapy and only partially

Modeling a human STAT4 mutation that predisposes to disseminated Coccidioidomycosis in mice

Abstract Coccidioidomycosis is a common fungal respiratory disease caused by the fungus Coccidioides spp. fungi in Arizona and the central valley of California. Disseminated Coccidioidomycosis (DCM) occurs in 8% of identified cases, causing significant morbidity and mortality. DCM occurred in 3 generations of a family in Tucson, Arizona who all shared a heterozygous missense mutation (p.E626G) in STAT4. Transfection of STAT4 E626G in WT human cells showed dampened responses to STAT4-dependent cytokine gene induction, suggesting the mutation is a dominant negative. To understand the function of E626G mutation, we generated the homologous mutation in Stat4 in B6 mice. Mice carrying E626G were grossly normal with normal numbers of innate and adaptive immune cells in primary and secondary lymphoid organs. To examine the effect of E626G on susceptibility to Coccidioides infection, we infected mice with C. posadasii strain 1038 intranasally. After infection E626G heterozygous mice all died by 50 days post infection (dpi), median time to death 45.5 days; range 30–50 dpi. 87% of WT B6 controls were alive when the experiment ended at a predetermined 70 dpi, resulting in a median time to death of &amp;gt;70 days. Mediastinal lymph nodes in E626G heterozygous mice had reduced numbers of B cells and activated (CD62Llow) T cells compared to B6 controls on 14 dpi. Cells from infected lungs from E626G heterozygotes produced less IFN-gamma after infection on 28, 35 and 42 dpi. Interferon stimulated cytokines (IP-10, MIG, MIP-2) were also significantly reduced compared to WT controls. Ongoing work includes examining the cells requiring STAT4 signaling and IFN-gamma production as well as the mechanism of reduced accumulation of immune cells in the draining lymph nodes.

2888. STAT4 Mutation in Three Generations with Disseminated Coccidioidomycosis (DCM) also Exhibits Increased Susceptibility to Coccidioidal Infection in Transfected Mice

BackgroundReported coccidioidomycosis has increased with case rates of 198/100,000 in Arizona (2012). In California alone, 2000–2011 hospitalizations were $2.2B. Dissemination occurs in 8% of reports with significant morbidity and occasional deaths. DCM was found in 3 generations: grandmother (skin), mother (skin), and son (bone). Whole exome sequencing identified a heterozygous (het) STAT4 mutation (p.E626G) in all three. This mutation alters the phosphotyrosine binding pocket and is predicted to impair STAT4 function, interfering with (i) receptor binding and phosphorylation, (ii) nuclear localization, and/or (iii) transcription. Expression profiling of antigen-stimulated peripheral blood mononuclear cells from one patient showed dampening of known STAT4 targets compared with controls.MethodsSTAT4 p.E626G was generated and confirmed in C57BL/6NJ (WT) mice using CRISPR-Cas9. With continued breeding, neither homozygous (hom) nor het mice had gross abnormalities. There were normal spleen and lung lymphoid cell numbers. Thymus and bone marrow had normal development of lymphoid subsets. We performed intranasal infection with reduced virulence C. posadasii strain 1038 or with F. tularensis live vaccine- strain (LVS). Naïve or Δcps1-vaccinated mice were tested for resistance to C. posadasii strain Silveira.ResultsAt day 21 post Cp 1038 infection, hom, het, and WT mice had similar lung fungal burdens (~104.7 cfu). All p.E626G mice died between days 31 and 39 with lung burden significantly higher (~9 × 106 cfu) than WT sacrificed on day 44 (7 × 105 cfu, P = 0.015). After LVS infection, p.E626G mice had increased lung bacterial cfu and all had dissemination to the spleen compared with WT lung bacterial burden and no splenic dissemination. Immunized het and WT mice all had significantly reduced lung cfu 14 days following C. posadasii infection compared with unvaccinated WT mice.ConclusionThe STAT4 p.E626G mutated mouse recapitulated patients’ increased susceptibility to coccidioidal infection. The decreased fungal burdens seen in Δcps1-vaccinated mice suggest that vaccination may be effective in those persons genetically susceptible to DCM. Given the increasing frequency and economic burdens of coccidioidomycosis, pursuit of vaccination strategies should continue. Disclosures All Authors: No reported Disclosures.

263. Advances in Diagnosis of Progressive Coccidioidomycos: Experience in 164 Cases and 508 Controls

BackgroundAntibody detection is the main method for diagnosis of coccidioidomycosis but has limitations including sensitivity and turnaround time. The MVISTA Coccidioides antigen enzyme immunoassay (EIA) is recommended for testing CSF in suspected Coccidioides meningitis. The early reports on urine and serum antigen testing evaluated small numbers of patients who were mostly immunocompromised with advanced disease.MethodsA retrospective study, including all patients in whom Coccidioides antigen testing was performed between January 2013 and May 2017, was conducted at Maricopa Integrated Health System (MIHS). Sensitivity and specificity of antigen testing at MiraVista Diagnostics and antibody testing at MIHS or commercial laboratories were evaluated in 164 cases and 508 controls.ResultsThe sensitivity of antigen testing was 51% and specificity was 99%. The sensitivity of antigen detection was highest if both urine and serum were tested (57%) than if only urine was tested (38%). The sensitivity of antibody testing was 84% and the specificity was 94% by immunodiffusion (ID). The sensitivity and specificity of antigen or ID antibody testing both were 94%. Sensitivity of antigen testing was 57% in proven and 58% in probable cases, ID antibody in 85% of proven and 75% of probable and antigen or ID antibody in 93% of proven and 95% of probable cases. Antigen was detected more often in disseminated (79%) than pulmonary cases (42%) as was ID antibody, 91% and 79%, respectively. Antigen testing was more sensitive in immunocompromised (76%) than non-immunocompromised patients (41%) while ID antibody was less sensitive in immunocompromised (74%) than in non-immunocompromised patients (93%). Combined antigen and ID antibody testing provided the highest sensitivity, 94% in all cases, 94% in immunocompromised and 95% in non-immunocompromised patients.ConclusionThese findings support testing urine and serum for Coccidioides antigen and serum for ID antibodies for diagnosis of progressive pulmonary or disseminated coccidioidomycosis. Disclosures All authors: No reported disclosures.

THE INDOLENT SANDSTORM: A RARE CASE OF MULTIFOCAL DISSEMINATED COCCIDIOIDOMYCOSIS

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Coccidioidomycosis is a highly variable disease endemic in the southwest with 60% of infected individuals remaining asymptomatic or suffer mild respiratory illness. Less than 1% result in life-threatening dissemination with immunocompromised hosts being most at risk. We present a rare case of multifocal disseminated coccidioidomycosis (DC) in an immunocompetent young male from a non-endemic region. CASE PRESENTATION: A 35 year old previously healthy African American male presented with persistent multiple skin abscesses on his face and neck with purulent drainage, neck pain and right foot pain for 2 months accompanied by a 20 lb weight loss. Upon examination he was febrile with a temperature of 102.8F and tachycardic. There was localized crusting and purulent drainage at the right mandibular body and anterior neck. Large, tender fluctuant masses were noted throughout the anterior neck coupled with cervical lymphadenopathy. A neck Computed Tomography (CT) scan revealed a large retropharyngeal abscess extending from C2-T1 vertebrae, osseous erosion into cervical spine C2-C6 with anterior cervical and ventral epidural abscesses, and multiple bilateral neck abscesses. Patient underwent a C3-C6 decompressive laminectomy and bilateral neck exploration with washout of abscesses. Subsequent imaging identified bony destruction of several ribs and abscessed tenosynovitis of the right ankle. Fungal culture from neck and ankle abscess grew Coccidioides immitis. An acquired immunodeficiency syndrome and immunoglobulin workup was negative. Liposomal amphotericin B, itraconazole, and interferon gamma 1b (INF-y) were used as treatment for multifocal DC. A 7 week hospital course was complicated by recurrent and metastatic C. immitis infections involving widespread multifocal areas of bony destruction and isolated cutaneous lesions. Despite aggressive treatment our patient passed from overwhelming infection. DISCUSSION: Our case illustrates the unexpected presentation of DC - an immunocompetent patient from a non-endemic region. Male gender, African American or Filipino race, and those living in endemic areas have a much higher incidence of dissemination. The skin is the most common extrapulmonary site of endemic mycosis with systemic symptoms being largely absent as seen in our patient. Rare genetic defects in the STAT3 family of proteins coding for INF-y have been implicated in this process. Combination therapy with antifungals and IFN-y has been reported with success in a small case series. A genetic testing panel yielded negative results. CONCLUSIONS: Our case represents an exceedingly rare presentation of an uncommon illness in an unlikely clinical setting - and stresses the importance of a robust differential diagnosis. Reference #1: Odio CD, Marciano BE, Galgiani JN, Holland SM. Risk Factors for Disseminated Coccidioidomycosis, United States. Emerg Infect Dis. 2017;23(2):308–311. Reference #2: Stockamp NW, Thompson GR. Coccidioidomycosis. Infect Dis Clin North Am. 2016 Mar;30(1):229-46. Reference #3: Hung CY. Castro-Lopez N. Cole GT. Card9- and MyD88-Mediated Gamma Interferon and Nitric Oxide Production is Essential for Resistance to Subcutaneous Coccidioides posadasii Infection. Infect Immun. 2016 Mar 24;84(4):1166-75. DISCLOSURES: No relevant relationships by Amy Goodrich-Harris, source=Web Response No relevant relationships by Paul Marik, source=Web Response No relevant relationships by Mit Patel, source=Web Response No relevant relationships by Timothy Walls, source=Web Response

An Analysis of Skin Test Responses to Spherulin-Based Coccidioidin (Spherusol®) Among a Group of Subjects with Various Forms of Active Coccidioidomycosis

A reformulated skin test for coccidioidomycosis, Spherusol®, was recently approved for use in the USA. We hypothesized that it could be useful in predicting severity of illness and outcome in various types of coccidioidomycosis. Subjects with non-meningeal coccidioidomycosis attending a clinic in the coccidioidal endemic region were skin tested with Spherusol® and clinical data were collected at the time of testing and at follow-up. Twenty-seven subjects were studied, eight of whom had extrathoracic dissemination. A total of 15 subjects had positive tests, including 11 of 19 subjects with non-disseminated pulmonary disease and four with extrathoracic disseminated coccidioidomycosis. Among those with non-disseminated pulmonary disease, age ≥ 65years, female sex, and antifungal therapy were significantly associated with a negative test on univariate but not multivariate analysis. For 23 subjects, there was a trend for those not on antifungal therapy at the time of follow-up to have a positive test but no association with coccidioidal complement-fixation titer or overall outcome. Not all subjects with non-disseminated pulmonary coccidioidomycosis were found to be skin test positive and half of those with extrathoracic disseminated disease manifested dermal hypersensitivity. In this small study, the results of the skin test were not clinically predictive of disease severity or outcome.

Curious Case of a Year-Long History of Cold Subcutaneous Abscesses

Abstract Cold subcutaneous abscess (CSA) is an abscess lacking classic inflammatory signs. This is a case of a 27-year-old incarcerated African American man who presented with 1-year history of soft, painless, mobile, masses on his limbs. Chest computed tomography scan showed diffuse reticulonodular infiltrates with right lower lobe mass. Computed tomography scan of the right upper extremity showed fluid density with no deep tissue involvement. Coccidioides complement fixation titers are 1:64, IgG 1.315, and IgM 0.242. Lung biopsy and CSA aspiration showed thick walled black spherules with endospores consistent with disseminated coccidioidomycosis (DCM). Cold subcutaneous abscess is a rarely reported manifestation of DCM. Defective cell-mediated immunity and inhibition of inflammation were thought to play a role in DCM and CSA pathogenesis. Cold subcutaneous abscess can remain unnoticed because of lack of inflammation. Our patient has longest time a CSA lasted without other symptoms of DCM. It is important to recognize it early to uncover a potentially dangerous disease.

386. A Reexamination of Disseminated Coccidioidomycosis: The Natural History in the Pre-Antifungal Era

BackgroundWhile it has been previously well described that central nervous system (CNS) coccidioidomycosis (CM) is nearly always fatal without treatment, the natural history of non-CNS disseminated coccidioidomycosis (DCM) infections is not well characterized. The historical VA-Armed forces CM patient group provides a unique cohort of patients not treated with standard antifungals to characterize the natural history of non-CNS DCM.MethodsWe conducted a retrospective study of 595 VA-Armed forces CM patients diagnosed between 1955 and 1958 and followed to 1966. Cohorts were identified as non-disseminated disease (487 patients), non-CNS DCM (72 patients), and CNS DCM (36). A combination of statistical analyses were used to compare demographic information, laboratory data including serologies and complete blood count data, symptom severity, fate of primary infection, and mortality.ResultsThere were significant differences in the ethnicity between the cohorts with trends toward increased Black and Filipino patients in the disseminated cohorts (P < 0.001). There was a trend showing increased frequency of leukocytosis regardless of eosinophilia in the disseminated cohorts (P = 0.009). Patients with disseminated disease presented with more severe symptoms (P = 0.006). Primary fate of infection demonstrated decreased rates of residual pulmonary nodule in DCMs: 38.19% in non-DCM, 13.89% in non-CNS DCM, and 19.44% in CNS DCM (P < 0.001). In addition, there were decreased rates of residual cavities in DCM: 33.26% in non-DCM, 8.33% in non-CNS DCM, and 8.33% in CNS DCM (P < 0.001). Forty-five percent and 53% of patients in the non-CNS DCM and CNS DCM cohorts, respectively, developed dissemination with initial infection. Mortality at last known follow-up due to CM was significantly different across the cohorts: 1.03% in non-DCM, 15.28% in non-CNS DCM, and 77.78% in CNS DCM (P < 0.001).ConclusionThis large retrospective cohort study helps further characterize the natural history of non-CNS DCM in comparison to CNS DCM in a population that was not treated with conventional antifungal therapy. While not as fatal as CNS DCM, non-CNS DCM shares many characteristics and has a high associated morbidity.Disclosures All authors: No reported disclosures.

Disseminated Coccidioidomycosis Among Children in Central California: A Retrospective Review

BackgroundThe burden of coccidioidomycosis in central California is significant among children. Yet, the literature on such infection is limited, particularly on disseminated coccidioidomycosis (DC) in children. ObjectivesReview the natural history, treatment and outcomes of DC in a tertiary children’s hospital.Methods Retrospective review of patients ≤21 years old with DC seen at our facility during 1/1/07–12/31/16.ResultsEighty cases were identified. Median age was 8.5 years (IQR 4.3–14.6); majority was hispanic (66%) and without comorbid conditions (85%). Pulmonary disease with other organ involvement occurred in 69%; 19% had meningitis. Overall, 82% had resolved and/or stable disease (RS), whereas 14% experienced relapse and/or progressive disease (RP). Meningitis more commonly seen in older age group (14.3 vs. 6.9 years, P = 0.04) and had low eosinophil’s (0.8 vs. 2.1%, P < 0.01). More organ involvement (64% vs. 35%, P = 0.03) and RP disease (22% vs. 5%, P = 0.04) commonly seen in children 10 years or older. Non-Hispanics also found to be older than Hispanics (12.2 vs. 7.4 years, P < .01); received multiple drug therapy (48% vs. 18%, P = 0.02). Although not significant, Non-Hispanics were more likely to have meningitis (30% vs. 13%, P = 0.07), coccidioidal complement fixation (CF) titers ≥ 32 (92% vs. 73%, P = 0.07), and RP disease (24% vs. 7%, P = 0.06) than Hispanics. No significant association was found between gender and age, CF titers, and/or outcomes. Higher CF titers were seen with >1 organ involvement (1:256 vs. 1;64, P < 0.01) and more antifungal therapy (1:256 vs. 1:32, P < 0.01). Coccidioides EIA antibody was positive in 50% of cases and 48% with negative/indeterminate results were positive by Immunodiffusion. On multivariate analysis, age remained independently associated with RP (OR = 1.2, 95% CI 1.0–1.5, P = 0.02); age (OR = 1.1, 95% CI 1.0–1.3, P = 0.01) and more antifungal therapy (OR = 3.7, 95% CI 1.4–9.5, P < 0.01) with non-Hispanics.Conclusion To our knowledge this is the largest series for pediatric DC. We identify older age group, non-Hispanics and higher CF titers as potential risk factors for DC, which require early intervention. Prospective studies are needed to identify predictors for adverse outcomes in pediatric DC.Disclosures All authors: No reported disclosures.

CD-4/CD-8 lymphocytopenia in HIV negative patients with severe, chronic granulomatous infections

Background: CD-4 lymphocytopenia can occur in acquired immunodeficiency syndrome(AIDS), in severe combined immunodeficiency, with the use of corticosteroids and/or immunosuppressive drugs, and in patients with idiopathic CD-4 lymphocytopenia. The mechanism for the lymphocytopenia is different in each of these illnesses. Objective: Description of HIV-negative patients with severe disseminated tuberculosis or coccidioidomycosis and lymphocytopenia. Settings and patients: All patients were referred to a University Medical Center in Northwest Texas, USA. Four had disseminated tuberculosis, and three had disseminated coccidioidomycosis. Main outcome measures: Follow-up of lymphocyte subset counts and clinical improvement with the treatment of the underlying granulomatous infection. Results: Five patients had an increase in both CD-4 and CD-8 lymphocyte subset counts with treatment of the underlying granulomatous infection. All patients had clinical improvement with initial therapy of the granulomatous infection. One patient succumbed to disseminated tuberculosis (meningitis) and two to disseminated coccidioidomycosis. One patient was lost to follow up. Conclusions: We report a group of HIV-negative patients who had CD-4 lymphocytopenia in response to severe, disseminated, chronic granulomatous infections. With the treatment of the granulomatous infection the lymphocytopenia improved. This finding, coupled with preserved CD-4/CD-8 ratios, can help to differentiate these patients from those with other causes of lymphocytopenia or AIDS.

Cytokine Profiles from Antigen-Stimulated Whole-Blood Samples among Patients with Pulmonary or Nonmeningeal Disseminated Coccidioidomycosis.

The outcome of coccidioidomycosis depends on a robust specific cellular immune response. A T-helper type 1 (Th1) cellular immune response has been previously associated with resolution of clinical illness. However, the precise elements of this response and whether cytokines not involved with the Th1 response play a role in coccidioidomycosis are not known. Whole-blood samples were obtained from subjects with active coccidioidomycosis and controls and incubated for 18 h with T27K, a coccidioidal antigen preparation. The supernatant was then assayed for gamma interferon (IFN-γ), interleukin-2 (IL-2), tumor necrosis factor alpha (TNF-α), IL-4, IL-6, IL-10, and IL-17A. A total of 43 subjects, 16 with acute pneumonia, 9 with pulmonary sequelae of nodules and cavities, and 18 with nonmeningeal disseminated coccidioidomycosis, were studied. Compared to concentrations in healthy immune and nonimmune donors, the median concentration of IL-17A was significantly higher in those with active coccidioidomycosis (for both, P < 0.01). In addition, IL-6 concentrations were higher while IL-2 and IFN-γ concentrations were significantly lower in those with nonmeningeal disseminated disease diagnosed within 12 months than in those with acute pneumonia (for all, P < 0.05). The cytokine profile among patients with active coccidioidomycosis is distinct in that IL-17A is persistently present. In addition, those with nonmeningeal disseminated disease have an increased inflammatory cytokine response and diminished Th1 responses that modulate over time.

Coccidioidomycosis: epidemiology

Coccidioidomycosis consists of a spectrum of disease, ranging from a mild, self-limited, febrile illness to severe, life-threatening infection. It is caused by the soil-dwelling fungi, Coccidioides immitis and C. posadasii, which are present in diverse endemic areas. Climate changes and environmental factors affect the Coccidioides lifecycle and influence infection rates. The incidence of coccidioidomycosis has risen substantially over the past two decades. The vast majority of Coccidioides infections occur in the endemic zones, such as California, Arizona, Mexico, and Central America. Infections occurring outside those zones appear to be increasingly common, and pose unique clinical and public health challenges. It has long been known that elderly persons, pregnant women, and members of certain ethnic groups are at risk for severe or disseminated coccidioidomycosis. In recent years, it has become evident that persons with immunodeficiency diseases, diabetics, transplant recipients, and prisoners are also particularly vulnerable.

Effect of Farnesol on Growth, Ergosterol Biosynthesis, and Cell Permeability in Coccidioides posadasii

Coccidioidomycosis is a systemic mycosis caused by the dimorphic fungi Coccidioides spp. The treatment for chronic and/or disseminated coccidioidomycosis can be prolonged and complicated. Therefore, the search for new drugs is necessary. Farnesol is a precursor in the sterol biosynthesis pathway that has been shown to present antifungal activity. Thus, the objective of this study was to evaluate the in vitro antifungal activity of farnesol alone and in combination with antifungal agents against clinical and environmental strains of Coccidioides posadasii as well as to determine their effect on the synthesis of ergosterol and on cell permeability. This study employed the broth macrodilution method to determine the MIC of farnesol against 18 strains of C. posadasii. Quantification of ergosterol was performed with 10 strains of C. posadasii after exposure to subinhibitory concentrations of farnesol. Finally, the activity of farnesol was evaluated in the presence of osmotic stress, induced by the addition of NaCl to the culture medium, during the susceptibility tests. The results showed that farnesol exhibited low MICs (ranging from 0.00171 to 0.01369 mg/liter) against all tested strains. The combination of farnesol with the antifungals showed synergistic effects (fractional inhibitory concentration index [FICI] ≤ 0.5). As for the ergosterol quantification, it was observed that exposure to subinhibitory concentrations of farnesol decreased the amount of ergosterol extracted from the fungal cells. Furthermore, farnesol also showed lower MIC values when the strains were subjected to osmotic stress, indicating the action of this compound on the fungal membrane. Thus, due to the high in vitro antifungal activity, this work brings perspectives for the performance of in vivo studies to further elucidate the effects of farnesol on the host cells.