eMedicine Specialties > Dermatology > Fungal Infections

Coccidioidomycosis: Follow-up

Author: Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Coauthor(s): Linas Riauba, MD, Assistant Professor of Clinical Medicine, Department of Medicine, Section of Infectious Disease, University Hospital, University of Medicine and Dentistry of New Jersey
Contributor Information and Disclosures

Updated: Jun 12, 2009

Follow-up

Further Outpatient Care

  • Monitor CF titers after the treatment is completed.
  • Increasing titers warrant repeat therapy.
  • Lifetime suppression therapy is necessary in patients infected with HIV.

Deterrence/Prevention

  • Because coccidioidomycosis cannot yet be prevented in endemic regions, the single most important activity is to develop educational programs for construction and agriculture employees, military personnel, students, and other groups.
  • People who live in or visit endemic regions who are also aware of the medical problems that C immitis infection can produce may be more likely to seek medical attention when symptoms arise, resulting in earlier and more effective diagnosis and management.

Complications

  • Mycetoma may develop within cavities, either from mycelia due to infection with C immitis or other fungi such as Aspergillus species.
  • The rupture of a peripheral coccidioidal cavity into the pleural space is a complication that is most common in young male patients.
  • Hydrocephalus is a common complication, especially in children.
  • Cerebral vasculitis and focal intracerebral coccidioidal abscesses are less common complications.
  • In rare occurrences, an inoculation of C immitis causes primary cutaneous coccidioidomycosis with lymphatic extension to regional lymph nodes; these cases resolve without treatment.
  • Approximately 5-10% of infections due to C immitis result in residual pulmonary sequelae.

Prognosis

  • In the absence of immunosuppressive disease or therapy, patients with primary pulmonary infections do not need antifungal therapy.
    • The solitary pulmonary nodules resolve by themselves.
    • Moderate and severe cases of airway coccidioidomycosis may be treated with azoles.
  • Medical treatment in immunocompromised patients is more challenging. Complete response rates vary from 50-63% in soft tissue and pulmonary infections, and 26-52% in bone or joint infections.
  • Coccidioidomycosis infections involving the central nervous system require lifelong suppressive therapy with azoles.
  • Coccidioidal meningitis is the most serious form of disseminated infection. Untreated, it is almost always fatal within 2-3 years of diagnosis.

Miscellaneous

Medicolegal Pitfalls

  • The failure to provide special laboratory containment facilities for culturing C immitis is a pitfall because of the risk of infecting laboratory personnel with airborne arthrospores
  • The failure to prevent the spread of C immitis infection from an osteomyelitis to a plaster cast is a pitfall because airborne arthrospores from such growth pose a substantial risk to hospital personnel.

Special Concerns

  • Pregnant women are more likely to acquire disseminated coccidioidal infection, especially in the third trimester or in the immediate postpartum period.
    • A diagnosis of primary infection during the third trimester of pregnancy or in the period immediately after delivery should prompt consideration for treatment.
    • During pregnancy, amphotericin B is the treatment of choice because fluconazole medications, and probably other azole antifungals, are teratogenic.
  • Coccidioidomycosis may be imported worldwide from endemic areas. A recent patient in France acquired it during a visit to California.27 A careful travel history is essential.
 


More on Coccidioidomycosis

Overview: Coccidioidomycosis
Differential Diagnoses & Workup: Coccidioidomycosis
Treatment & Medication: Coccidioidomycosis
Follow-up: Coccidioidomycosis
References
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Further Reading

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Keywords

Valley fever, San Joaquin Valley fever, Coccidioides immitis, C immitis, arthroconidia, primary cutaneous coccidioidomycosis, respiratory infection, coccidioidal pneumonia, coccidioidal meningitis

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Contributor Information and Disclosures

Author

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

Coauthor(s)

Linas Riauba, MD, Assistant Professor of Clinical Medicine, Department of Medicine, Section of Infectious Disease, University Hospital, University of Medicine and Dentistry of New Jersey
Linas Riauba, MD is a member of the following medical societies: American Medical Association and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Medical Editor

Janet Fairley, MD, Professor and Head, Department of Dermatology, University of Iowa
Janet Fairley, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, American Federation for Medical Research, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

Van Perry, MD, Assistant Professor, Department of Medicine, Division of Dermatology, University of Texas Health Science Center
Van Perry, MD is a member of the following medical societies: American Academy of Dermatology and American Society for Laser Medicine and Surgery
Disclosure: Nothing to disclose.

CME Editor

Catherine M Quirk, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania
Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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