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  • • Infection occurs by inhalation of 1-10 spores, germination, and rupture causing spread of infection

    • Persistent infection 6-8 wks after primary classified into 5 types:

    • 1. Persistent pneumonia

      2. Chronic progressive pneumonia

      3. Miliary coccidioidomycosis

      4. Coccidioidal nodules

      5. Pulmonary cavities

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Epidemiology

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  • • Pulmonary fungal infections are rising due to widespread use of broad-spectrum antibiotics, immunosuppressive drugs, and HIV infection

    • Occur anywhere in world, some with characteristic endemic areas

    Coccidioides immitis is endemic to Sonoran life zone (UT, CA, AZ, NV, NM), associated with creosote brush

    • -Dry heat with brief intense rain essential for fungus

      -Spread by strong winds

      -In endemic areas, 30-50% of all pulmonary nodules are coccidiomas

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Symptoms and Signs

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  • • Primary infection is asymptomatic in 60%

    • "Desert fever": Fever, productive cough, pleuritic chest pain, pneumonitis, rash

    • "Desert rheumatism": Desert fever with arthralgias

    • Eosinophilia common (66%)

    • Persistent pneumonia

    • -Fever

      -Productive cough

      -Pleuritic chest pain

      -Consolidation on chest film

      -Resolves < 8 mos

    • Chronic progressive pneumonia

    • -Fever

      -Cough

      -Dyspnea

      -Hemoptysis

      -Weight loss

      -Bilateral apical nodules and multiple cavities

      -Lasting > 10 yrs

    • Miliary coccidioidomycosis: Occurs early and rapidly with bilateral diffuse infiltrates (mortality: 50%)

    • Coccidioidal nodules: 50% asymptomatic; coccidiomas (noncalcified nodular densities) in middle and upper lung fields range from 1 to 4 cm

    • Pulmonary cavities

    • -Affects 15% of patients

      -Typically solitary, thin-walled, located in upper lobes, and < 6 cm

      -50% close spontaneously within 2 yrs

    • Uncommonly, can disseminate in immunocompromised, third trimester pregnancy, darker-skinned people

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Laboratory Findings

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  • • Acutely elevated IgM titers

    • Rising serum IgG titers (seroconversion of 4× rise)

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Imaging Findings

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  • Chest film: Hilar adenopathy (20%), small pleural effusions (2-20%)

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  • • Acutely elevated IgM titers

    • Rising serum IgG titers (seroconversion of 4× rise)

    • Skin tests (coccidioidin and spherulin) good for epidemiologic studies, not for diagnosis of acute disease

    C immitis early to grow in culture but hazardous to handle

    • Spherule identification in tissue, lavage samples helpful in diagnosis

    • Pap staining most sensitive (Gram stains fail to demonstrate spherules)

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Rule Out

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  • • Histoplasmosis

    • TB

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  • • Chest x-ray

    • Chest CT scan

    • Sputum microscopy and culture

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  • • Medical therapy not indicated in asymptomatic patients

    • Persistent illness or those at risk for dissemination treat with antifungals

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Surgery

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  • • Resection all diseased tissue, usually with lobectomy

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Indications

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  • • Coccidiomas or cavities where cancer is concern on radiographic imaging

    • Complications of cavities: Hemoptysis, pyopneumothorax

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Medications

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  • • Amphotericin B is standard treatment

    • Fluconazole, ketoconazole, itraconazole for long-term maintenance

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Complications

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  • • 25-50% of those requiring antifungals relapse

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Prognosis

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  • • Disseminated and miliary coccidioidomycosis: Mortality, 50%

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