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Valley Fever” COCCIDIOIDOMYCOSIS “Valley Fever” By: Pamela Galioto, Katie Olenick, and Troy Adamson Coccidioidomycosis • Also known as San Joaquin fever, valley fever, and desert rheumatism • Etiologic agents are ‐Coccidioides immitis ‐Coccidioides posadasii Coccidioidomycosis Classification • Kingdom: Fungi • Phylum: Ascomycota • Class: Euascomycetes • Order: Onygenales • Family: Onygenaceae • Genus: Coccidioides Coccidioides immitis/posadasii •California and Non‐California variants •Morphologically identical •Different rates of growth with high salt concentration ‐C. posadasii grows more slowly •Inhabits more alkaline soil •Truly pathogenic ‐ Causative agent of true endemic mycoses Geographical Distribution •High temperatures, dry, little rainfall, low altitude •C. immitis exclusive to San Joaquin valley (CA) •C. posadasii found in desert in southwestern US, Mexico, and South America •Approx. 10‐50% population exposure in endemic regions Life Cycle Phase 1 – Mycelial Arthrospore •Grow rapidly, but are less infectious •Soil dries, develop arthrospores •Disarticulate as a single arthroconidia •Become airborne when disturbed by wind or soil. Phase 2 – Spherule Endospore •After inhalation, in infected tissues •Thick‐walled spherule with endospores form •Release of endospores lead to new spherule formation •Proliferation of disease Epidemiology Risk Factors – •Live in endemic regions •Activities with exposure to dust and soil •Endemic regions with recent natural disasters •Laboratory work with fungus Prevention and Control – •Do not engage in activities •Proper handling of laboratory leading to exposure of dust and equipment soil or disturbed land in •Refrain from visiting endemic endemic regions areas Pathogenesis •Airborne fungal infection •Acquired by inhalation •Usually presents as pulmonary infection •Hematogenous spread causes infection in skin, bones, lymph nodes, adrenal glands, central nervous system •Most cases make full recovery within weeks or months, but some may develop chronic pulmonary infection •60% of cases will have no symptoms •Can also cause infection in animals Diagnosis • Blood – CBC w/ differential – Antibody titer • Imaging – Chest x‐ray or CT scan • Invasive Testing – Biopsy of lung or lymph node – Bronchoscopy Histopathology • Sputum microscopic analysis – Dimorphic fungus: filamentous in soil, but spherule in tissue – The spherule is filled with numerous spherical endospores – Special stains will enhance visualization • Silver stain • Periodic Acid Schiff (PAS) stain • KOH smear • Sputum culture – Gold standard of diagnosis – Coccidioides immitis Clinical Manifestations • Symptoms – Chest pain – Fever – Headache – Chest pain – Joint pain – Cough or hemoptysis – Erythema nodosum • Painful red, lumpy rash on legs • Can begin from a few days to a few weeks after exposure • Immunocompromised patients are susceptible to disseminated disease (spreads to skin, CNS or other organs) Treatment and Management • Pulmonary Coccidioidomycosis – Supportive measures are usually sufficient • Bed rest, fever reduction, symptomatic management – Antifungal medications usually not required • Disseminated Coccidiomycosis – Prevention is the best treatment! • Avoid AIDS and other causes of impaired immunity – Antifungal medications are a necessity • Itraconazole, Fluconazole – This form still caries a high mortality rate • Meningitis is most severe form of disseminated disease Case Report 1 • Immunocompetent patient, 9 months in Arizona • 28‐year‐old female • Inflammatory pain in thoracic and lumbar spine • Fever and severe weight loss • Spinal stiffness • MRI of spine disclosed lesions in vertebral bodies • Spinal tuberculosis suspected • Positive diagnosis on day 4 of Coccidioides immitis Case Report 2 • 58 year old Dutch male • Immunocompetent • Presented non productive coughing, fever, vomiting, and loss of appetite • Medical history revealed mitral valve prolapse and atrial fibrillation Case Report 2 (cont.) • A chest x‐ray, computer tomography and supraclavicular lymph node biopsy performed • Generally, healthy persons recover spontaneously • Immunocompromised patients need to continue with regular clinical visits Question #1 • What are the two life cycle phases of Coccidioides immitis called? – A. Mycelial Arthrospore and Spherule Exospore – B. Mycelial Arthrospore and Spherule Endospore – C. Vegetative hyphae and Spherule Endospore – D. Vegetative hyphae and Spherule Exospore Question #2 • All are risk factors of Coccidioides except: – A. Endemic regions with recent to natural disasters – B. Laboratory work with fungus – C. Animals – D. Activities with exposure to dust and soil Question #3 • Which person is least likely to experience disseminated Coccidioidomycosis? – A. Kidney transplant recipient – B. Leukemia patient – C. Patient with congestive heart failure – D. AIDS patient Question #4 • Which of the following is not used to diagnose Coccidioidomycosis? – A. Imaging studies – B. Skin test – C. Blood test – D. Sputum sample Question #5 • Which of the following stains is not used to visualize Coccidioidomycosis? – A. PAS stain – B. KOH smear – C. Silver stain – D. India ink References Choo, John, Guy Shoo Choo, Michael Peterson, Francisco Talavera, and Greg Anders. "Coccidiodomycosis in Pulmonology ." Medscape. N.p., 17 Sep 2009. Web. 24 Jul 2011. "Coccidioides Species." Doctor Fungus. N.p., n.d. Web. 24 Jul 2011. "Coccidiodomycosis: General Information." Center for Disease Control. USA.gov, 04 Mar 2010. Web. 24 Jul 2011. Reach P;Paugam A;Kahan A;Allanore Y;Wipff J. "Coccidioidomycosis of the spine in an immunocompetent patient." Joint, Bone, Spine: Revue Du Rhumatisme 77.6 (2010), 611‐3. Kok, Petra, et al. "Fungal disease of the Western hemisphere: A patient with coccidioidomycosis." European Journal of Internal Medicine 20.3 (2009), 319‐322. References (cont.) Cho M.D., John E. "Coccidioidomycosis in Pulmonology Workup." Medscape. Web. 20 July 2011. <http://emedicine.medscape.com/article/297976‐workup>. "Coccidioidomycosis ‐ Acute Pulmonary: MedlinePlus Medical Encyclopedia." National Library of Medicine ‐ National Institutes of Health. Web. 20 July 2011. <http://www.nlm.nih.gov/medlineplus/ency/article/000094.htm>. "DermAtlas: Online Dermatology Image Library Dermatology Image,folliculitis, Demodex,folliculitis, Demodex,coccidioidomycosis,fungal Infection, Deep,pemphigus Vulgaris,xanthogranuloma, Juvenile,xanthogranuloma, Juvenile,xanthogranuloma, Juvenile,xanthogranuloma, Juvenile." Dermatlas: Dermatology Image Atlas with 12474 Dermatology Images. Web. 20 July 2011. <http://dermatlas.med.jhmi.edu/derm/result.cfm?Author=434027 241>. Rosenthal, Ken S., and James S. Tan. Rapid Review Microbiology and Immunology. Philadelphia, PA: Mosby/Elsevier, 2007. Print. References (cont.) http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5805a1.htm http://www.medversation.com/medversation/hcp/section/PGL/S0716A4CD‐ 892E‐4BF7‐CC8C‐4435811AA9C9.html http://www.corbisimages.com/stock‐photo/rights‐managed/42‐ 26636219/spherule‐with‐endospores‐of‐the‐coccidioides‐immitis/?ext=1 http://www.nlm.nih.gov/medlineplus/mobileimages/ency/fullsize/17157_lafs.p ng http://www.valley‐can.org/fact_sheets_info/sjv_fact_sheet.php http://www.isradiology.org/tropical_deseases/tmcr/chapter6/clinical37.htm References (cont.) http://www.mayoclinicproceedings.com/content/83/3/343.full http://pathmicro.med.sc.edu/mycology/mycology‐6.htm http://www.flickr.com/photos/pulmonary_pathology/5286000370/ http://ohacmed.oxfordtextbookofmedicine.com/cgi/content/citation/3/1/me d‐9780199230921‐div1‐07002 http://findlaw.doereport.com/generateexhibit.php?ID=8899&ExhibitKeyword sRaw=&TL=&A=42409 http://www.cdc.gov/ncidod/eid/vol2no3/kirkland.htm.
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