Coccidioidomycosis can manifest in acute, chronic, and disseminated forms, of which the latter is the most severe [1]. Overall, it is caused by airborne transmission of Coccidioides immitis spores. This endemic disease occurs in the southwestern region of the United States, Central America, and South America [2]. Coccidioidomycosis is more common during the summer time and late fall [1]. Risk factors for disseminated coccidioidomycosis include AIDS and other immunosuppressed states as a consequence of chronic steroid therapy, chemotherapy, diabetes, and lymphoma [2].

The majority of patients with coccidioidomycosis have a mild, self-limiting respiratory infection [3] [4]. Symptomatic patients with a primary disease may exhibit fever, cough, dyspnea, malaise, arthralgia, chest pain, chills, weight loss, night sweats, and erythema nodosum [5]. Susceptible patients are at risk for developing disseminated disease weeks or months following the initial infection, in which it spreads hematogenously from the lungs to the bone, joints, CNS, and skin [1]. Extrapulmonary dissemination may occur even after a year of primary infection or following therapy. Those affected with disseminated infection report fever, dyspnea, weight loss, and night sweats.

Disseminated coccidioidomycosis can affect any organ. Musculoskeletal involvement results in lytic or sclerotic bone lesions and arthritis. Additionally, meningitis develops in nearly half of all patients with disseminated disease, which is associated with morbidity and mortality frequency [6]. Specifically, meningitis is characterized by headaches, photophobia, and nuchal rigidity. Also, if present, increased intracranial pressure (ICP) leads to altered mental status and emesis. Patients may even develop cranial nerve palsies, seizures, and coma [7]. Skin features in primary infection are commonly notable for diffuse maculopapular rashes which may evolve into erythema nodosum. Spread to the heart, which is rare, causes pericardial effusions and even tamponade [8].

Poor prognosis is associated with immunocompromised states and untreated individuals [9]. Coccidioidal fungemia is a rare occurrence but involves spread to CNS, liver, and spleen. Acute respiratory distress syndrome (ARDS) and shock are other serious complications.

Patients could present with fever, splenomegaly, and lymphadenopathy. The clinical features will reflect affected organs or systems. Meningeal and other neurologic signs may be apparent. Also, skin infection may be remarkable for papules, plaques, or nodules. If present, pulmonary findings could include rales, rhonchi, and decreased breath sounds.

• Mediastinal Lymphadenopathy

  CT scan showed multiple bilateral focal opacities with hilar and mediastinal lymphadenopathy with no ductal dilation or gallbladder stones. [ncbi.nlm.nih.gov]

  The presence of paratracheal or mediastinal lymphadenopathy should suggest disseminated disease (Figure 10). [appliedradiology.com]

• Fever

  The patient was a 21-year-old, apparently immunocompetent, pregnant black woman who had fever of unknown origin for 6 weeks. She had recently moved from Arizona. [ncbi.nlm.nih.gov]

  The scientific name for Valley fever is “coccidioidomycosis,” and it’s also sometimes called “San Joaquin Valley fever” or “desert rheumatism.” [cdc.gov]

  The director of the University of Arizona Valley Fever Center for Excellence, John N. [deptmedicine.arizona.edu]

  Overview Valley fever is a fungal infection caused by coccidioides (kok-sid-e-OY-deze) organisms. It can cause fever, chest pain and coughing, among other signs and symptoms. Two species of coccidioides fungi cause valley fever. [mayoclinic.org]

  About Valley Fever Found mostly in the western United States, valley fever is caused by the fungus Coccidioides immitis, which thrive as microscopic spores in arid soil. [ucdmc.ucdavis.edu]

• Weight Loss

  A 50-year-old man presented with a 2-3 month history of left lower quadrant abdominal pain, right periorbital headache, blurry vision, tinnitus, polydipsia, right elbow pain, and a 32 kg weight loss over the past year. [ncbi.nlm.nih.gov]

  Soon after the primary infection, dissemination (extrapulmonary spread) could be first suspected in those patients with a history of weight loss, prolonged duration of generalized symptoms (malaise, FULL TEXT [annals.org]

  Patients develop chronic productive cough, haemoptysis, weight loss and chest pains. [life-worldwide.org]

  Patients with disseminated coccidioidomycosis may present with: Altered mental status Lymph node enlargement Neck stiffness Swelling/stiffness of the joints Light sensitivity Unexplained weight loss. [dermnetnz.org]

  The symptoms resemble tuberculosis and include: a cough chest pain a fever weight loss lung nodules blood in the sputum the development of pneumonia Disseminated coccidioidomycosis occurs when the infection spreads to other parts of the body from the [healthline.com]

• Chills

  The major signs and symptoms exhibited by Disseminated Coccidioidomycosis are fever and chills, cough, muscle stiffness and aches, altered mental status, and swelling of the joints. [dovemed.com]

  Patients with mild or self-limiting infections will present with: Low-grade fever with chills and night sweats Fatigue Pain (headaches, sore throat, chest pain) A cough, with possible sputum production and hemoptysis Lower limb/foot swelling Loss of appetite [dermnetnz.org]

  When the infection is in your lungs, it can cause flu-like symptoms, such as: a cough chest pain a fever chills night sweats fatigue joint aches a red, spotty rash shortness of breath This type of infection is commonly known as valley fever. [healthline.com]

  Other symptoms include night sweats, chest pain, chills, arthralgias, headaches, myalgias, wheezing, skin rashes, stiff neck, sore throat, weight loss, and hemoptysis. [clinicaladvisor.com]

  They tend to resemble those of the flu, and can range from minor to severe, including: Fever Cough Chest pain Chills Night sweats Headache Fatigue Joint aches Red, spotty rash The rash that sometimes accompanies valley fever is made up of painful red [mayoclinic.org]

• Malaise

  We report a case of disseminated coccidioidomycosis in an immunocompetent black male with cutaneous lesions, a flocculent neck mass, bilateral hilar adenopathy, persistent fever, night sweats and malaise. [ncbi.nlm.nih.gov]

  Soon after the primary infection, dissemination (extrapulmonary spread) could be first suspected in those patients with a history of weight loss, prolonged duration of generalized symptoms (malaise, FULL TEXT [annals.org]

  Symptomatic patients with a primary disease may exhibit fever, cough, dyspnea, malaise, arthralgia, chest pain, chills, weight loss, night sweats, and erythema nodosum. [symptoma.com]

  Primary infection is often complicated by prolonged cough, pleuritic chest pain, malaise, and fatigue, which can be prolonged and debilitating. [clinicaladvisor.com]

• Fever of Unknown Origin

  The patient was a 21-year-old, apparently immunocompetent, pregnant black woman who had fever of unknown origin for 6 weeks. She had recently moved from Arizona. [ncbi.nlm.nih.gov]

• Polydipsia

  A 50-year-old man presented with a 2-3 month history of left lower quadrant abdominal pain, right periorbital headache, blurry vision, tinnitus, polydipsia, right elbow pain, and a 32 kg weight loss over the past year. [ncbi.nlm.nih.gov]

  A 50-year-old man presented with a 2–3 month history of left lower quadrant abdominal pain, right periorbital headache, blurry vision, tinnitus, polydipsia, right elbow pain, and a 32 kg weight loss over the past year. [nature.com]

• Elbow Pain

  A 50-year-old man presented with a 2-3 month history of left lower quadrant abdominal pain, right periorbital headache, blurry vision, tinnitus, polydipsia, right elbow pain, and a 32 kg weight loss over the past year. [ncbi.nlm.nih.gov]

  A 50-year-old man presented with a 2–3 month history of left lower quadrant abdominal pain, right periorbital headache, blurry vision, tinnitus, polydipsia, right elbow pain, and a 32 kg weight loss over the past year. [nature.com]

• Neck Mass

  He subsequently developed a large neck mass and was found to have mediastinal and hilar adenopathy highly suspicious of a neoplastic process. Fine needle aspiration biopsy of the neck mass, followed by flexible bronchoscopy, was performed. [ncbi.nlm.nih.gov]

  There are case reports of neck masses due to cervical lymphadenopathy representing the only manifestation of disseminated disease. 37 Abdomen and pelvis The abdomen and pelvis are other potential sites for dissemination. [appliedradiology.com]

• Suggestibility

  The clinical illness and immunologic studies suggest subtle defects that may have existed antecedent to infection and, thus, provided an opportunity for widespread dissemination by these normally nonopportunistic organisms. [ncbi.nlm.nih.gov]

• Fear

  Corticosteroids have been avoided as adjunctive therapy to antifungals in the treatment of acute respiratory distress syndrome secondary to coccidioidomycosis because of the fear of enhancing fungal virulence, but they have been proven safe and effective [ncbi.nlm.nih.gov]

• Dark Urine

  A young man from California presented with acute onset of cough, fevers, night sweats and pruritus with dark urine. Laboratory studies were notable for moderate transaminitis with elevated bilirubin and eosinophilia. [ncbi.nlm.nih.gov]

• Headache

  Allogeneic epidural blood patches are an option for refractory dural puncture headaches when autologous blood may cause meningitis or malignant seeding of the central nervous system. [ncbi.nlm.nih.gov]

  If you have symptoms, they may include a flu-like illness, with fever, cough, headache, rash, and muscle aches. Most people get better within several weeks or months. A small number of people may develop a chronic lung or widespread infection. [icdlist.com]

  Within 1 year, the patient developed worsening headache, which was treated with increasing doses of fluconazole. By April 1997, he complained of worsening right frontal headaches and diplopia. [ajnr.org]

  Symptomatic persons (40% of cases) usually present 1 to 3 weeks after exposure with fatigue, cough, dyspnea, headache, night sweats, myalgias, and rash. 1 – 3 Primary pulmonary disease is often self-limiting, but some patients fail to recover and develop [cdc.gov]

• Intracranial Hemorrhage

  Fatal intracranial hemorrhage is a rare complication of disseminated coccidioidomycosis. [ncbi.nlm.nih.gov]

  Fatal intracranial hemorrhage is rare and, to our knowledge, has been reported as occurring in only one patient (4). [ajnr.org]

The diagnosis is based on the clinical manifestations, history including risk factors such as a recent travel to endemic areas and the patient's immunocompetence, physical exam, and the appropriate studies.

Laboratory studies should include complete blood count (CBC), which may be normal or significant for elevated lymphocytes, eosinophils, and monocytes. Additionally, there is an increase in erythrocyte sedimentation rate (ESR).

Diagnostic studies include serologic testing such as IgM and IgG antibodies as well as complement fixation techniques for IgG. Polymerase chain reaction (PCR), skin testing, blood cultures, and the urine antigen test are all helpful. Also, visualization of the fungus in body fluids such as blood, sputum, urine, or cerebrospinal fluid (CSF) is beneficial.

Patients with disseminated coccidioidomycosis could exhibit hilar and mediastinal adenopathy as well as the miliary pattern on chest X-ray. Other findings may also be present. Computed tomography (CT) scan reveals the morphology of the lesions more effectively [10].

Patients with suspected meningitis or other neurologic manifestations warrant assessment with CT and magnetic resonance imaging (MRI) of the brain, with the latter demonstrating better sensitivity for coccidioidal meningitis. Frequently observed abnormalities include basilar meningitis, vascular occlusion, and hydrocephalus.

Fluorodeoxyglucose positron emission tomography (FDG-PET) scans demonstrate diffuse intake reflective of disseminated disease and active infection. Also, bone scans are indicated in patients with osteomyelitis or suspected bone disease [11]. MRI can also display affected bone and tissue.

Lumbar puncture is necessary for assessment of meningitis [12]. Common findings in the CSF include lymphocytic and eosinophilic pleocytosis, increased protein, and low glucose levels. Complement-fixating antibodies in the CSF typically reveal elevated titers, which confirms the diagnosis of coccidioidal meningitis.

• Bilateral Hilar Adenopathy

  We report a case of disseminated coccidioidomycosis in an immunocompetent black male with cutaneous lesions, a flocculent neck mass, bilateral hilar adenopathy, persistent fever, night sweats and malaise. [ncbi.nlm.nih.gov]

• Bilateral Pulmonary Infiltrates

  Diffuse bilateral pulmonary infiltrates may be a result of a hematogenous spread. They may also be a result of a multiple foci of infection secondary to high innoculum exposure. [bmcinfectdis.biomedcentral.com]

• Liver Biopsy

  The diagnosis is readily made with liver biopsy, and the outcome may be more favorable than other forms of dissemination. [ncbi.nlm.nih.gov]

  The test is generally used to diagnose a suspected respiratory tract infection A tissue biopsy may be performed to determine the site of disseminated disease and it may include: Bone marrow biopsy Liver biopsy Open lung biopsy Skin lesion biopsy Family [dovemed.com]

Treatment trials with higher doses appear warranted. The relative efficacy of fluconazole versus other azoles or amphotericin B remains unknown. [ncbi.nlm.nih.gov]

Aspergillus was the second most common offender, and disseminated infection was associated with a very grave prognosis for the transplant recipient. Rare infections with Mucor and Cryptococcus neoformans are described in the literature. [ncbi.nlm.nih.gov]

The prognosis of the acute form is excellent, since it is self-limiting Who gets Disseminated Coccidioidomycosis? (Age and Sex Distribution) Any individual may be affected by coccidioidomycosis. [dovemed.com]

Treatment and prognosis The mainstay of medical treatment is with fluconazole 7. Surgical opinion may also be sought for CNS involvement or complications of pulmonary coccidioidomycosis if necessary 7. Promoted articles (advertising) [radiopaedia.org]

Outlook and prognosis Coccidioidal meningitis needs to be treated lifelong, as it is incurable. Complications including communicating hydrocephalus. [life-worldwide.org]

Poor prognosis is associated with immunocompromised states and untreated individuals. Coccidioidal fungemia is a rare occurrence but involves spread to CNS, liver, and spleen. [symptoma.com]

Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. [icd10coded.com]

The expression of PTHrP is a property of infectious granulomas regardless of etiology or the tissue involved, suggesting that PTHrP expression is part of the normal granulomatous immune response. [ncbi.nlm.nih.gov]

Both patients were later found to have disseminated Coccidioidomycosis, a rare diagnosis that is often mistaken for other etiologies. Both patients responded well to fluconazole therapy. [content.iospress.com]

April 06, 2015 ; 84 (14 Supplement) April 23, 2015 Rahul Shah, Bing Liao, Elena Shanina, Glenn Smith First published April 8, 2015, Abstract OBJECTIVE: To emphasize Coccidioidomycosis as an unusual etiology for brachial plexitis BACKGROUND: Coccidioidomycosis [neurology.org]

The epidemiology, diagnosis, and management of coccidioidomycosis are discussed. [ncbi.nlm.nih.gov]

Patient Population: Prevalence and Epidemiology Knee // Shoulder & Elbow // Hip // Spine // Foot & Ankle // Hand & Wrist Fragility Fractures: Diagnosis and Treatment Shoulder & Elbow The Characteristics of Surgeons Performing Total Shoulder Arthroplasty [mdedge.com]

Chapter 6: Epidemiology of coccidioidomycosis, pages 199-238. IN: McGinnis MR (editor). Current Topics in Medical Mycology, Volume 2. Springer-Verlag. 1988. Rosenstein NE, Emery KW, et al. [meducator3.net]

Epidemiologic, clinical, and diagnostic aspects of coccidioidomycosis. J Clin Microbiol. 2007;45:26-30. Williams PL. Coccidioidal meningitis. Ann NY Acad Sci. 2007; 1111:377-384. Davis LE, Porter BS. [appliedradiology.com]

Epidemiological, clinical, and diagnostic aspects of coccidioidomycosis. J. Clin. Microbiol. 45, 26–30 (2007). 4. Hector, R. F. & Laniado-Laborin, R. Coccidioidomycosis—a fungal disease of the Americas. PLoS Med. 2, e2 (2005). 5. Crum, N. [nature.com]

Cell-mediated immunity, which appears to be the relevant host defense mechanism, is impaired by the immunosupressive agents used to prevent allograft rejection. [ncbi.nlm.nih.gov]

They may also help in the development of preventative vaccines. [grantome.com]

SOURCE: Centers for Disease Control and Prevention (CDC) Impacts and Issues Coccidioidomycosis has plagued humans for many years. A cure has long been sought, but not yet attained. [encyclopedia.com]

Centers for Disease Control and Prevention. About 5-10 percent develop serious or long-term problems in their lungs. For about 1 percent, the infection spreads to other parts of the body. [deptmedicine.arizona.edu]

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