eMedicine Specialties > Pulmonology > Infectious Lung Diseases

Coccidioidomycosis: Follow-up

Author: John E Cho, MD, Fellow, Department of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center
Coauthor(s): Guy W Soo Hoo, MD, MPH, Clinical Professor of Medicine, Geffen School of Medicine at the University of California at Los Angeles; Director, Medical Intensive Care Unit, Pulmonary and Critical Care Section, West Los Angeles Healthcare Center, Veteran Affairs Greater Los Angeles Healthcare System
Contributor Information and Disclosures

Updated: Sep 17, 2009

Follow-up

Further Inpatient Care

  • The need for hospitalization in patients with coccidioidomycosis is dictated by symptoms and the severity of disease and does not differ from patients with any other respiratory condition.
  • Sepsis syndrome, respiratory distress, severe hypoxemia, or severe or unresolving pneumonia as manifestations of acute or disseminated coccidioidal infection are indications for inpatient management.
  • Refractory cases requiring intravenous amphotericin also require hospitalization; however, once the patient is stable, he or she can be treated d in an infusion center environment.
  • While patients with suspected coccidioidal meningitis can be treated adequately in an outpatient setting, hospitalization helps facilitate confirmation of diagnosis and initiation of therapy.
  • Coccidioidal disease that requires surgical intervention is best managed in an inpatient setting.

Further Outpatient Care

  • Oral azole therapy is effective; therefore, most coccidioidal infections can be managed in an outpatient setting.
  • Close follow-up is warranted to assess response to therapy (clinical, radiologic, serologic), monitor for complications of coccidioidal infection, and monitor toxicity of azole medications.

Inpatient & Outpatient Medications

  • Effective antifungal therapy can be given in an outpatient or inpatient setting. The initial use of amphotericin may require an inpatient stay, and long-term amphotericin therapy requires placement of an indwelling intravenous catheter, such as a peripherally inserted central catheter (PICC) line.

Transfer

  • Transfer of patients with coccidioidal infections to other facilities depends on the stability of the patient (hemodynamics and respiratory status). No restrictions or limitations are needed for stable patients. No specific respiratory precautions are required because coccidioidal disease is not a contagious condition.

Deterrence/Prevention

  • Individuals who live or travel to endemic areas should be aware that the risk of infection is related to exposure to disrupted soil and dust, as may occur around construction sites or during dust storms.
  • Certain groups of persons are at increased risk of disseminated or more severe disease, and these persons should be especially aware that exposures may occur in any dusty environment, especially in proximity to a construction site.
  • Occupational risk and exposure are highest among persons in close proximity to soil and dust, such as gardeners, farm workers, construction workers, and persons involved in archaeologic digs.
  • Laboratory personnel in microbiology laboratories should take proper precautions when handling cultures with possible growth of Coccidioides immitis.
  • Some protection may be afforded with a well-fitted dust face mask, but these are not always practical or available.

Complications

Complications related to coccidioidal infection are as follows:

  • Primary acute coccidioidal infection
    • Respiratory failure
    • Airway coccidioidal infection with local effects of obstructing lesions
  • Chronic progressive coccidioidal infection 
    • Hemoptysis
    • Respiratory failure
  • Pulmonary nodules - Progression to pulmonary cavities
  • Pulmonary cavities 
    • Hemoptysis
    • Secondarily infected cavities
    • Spontaneous rupture and pneumothorax
  • Disseminated coccidioidomycosis
    • Septic arthritis
    • Paraspinous abscess
    • Osteomyelitis (any location, vertebral osteomyelitis with local effects)
    • Peritonitis
    • Genitourinary involvement with associated dysfunction
    • Bone marrow involvement and pancytopenia
    • Acute and chronic meningitis
Complications related to antifungal medication are as follows:
  • Amphotericin
    • Renal toxicity
    • Bone marrow toxicity
    • Local systemic effects (fever, rigors)
  • Azoles - Hepatic dysfunction

Prognosis

  • The prognosis is excellent because most infections are self-limited and resolve without the need for medial intervention.
  • Treatment with antifungal therapy is effective in most of the defined clinical syndromes, and, therefore, the prognosis for recovery is also excellent.
  • Patients with suppressed immune systems or those taking immunosuppressant medications are especially at risk for progressive or disseminated disease, and their coccidioidal infections may be difficult to eradicate.
  • Disseminated disease may require months to years of antifungal therapy, and high-risk patients are at significant risk for relapse when treatment is stopped, even after extended courses (years) of treatment.
  • Coccidioidal immunodiffusion complement fixation titers may be useful to assess risk for dissemination (titers >1:16) and monitor response to therapy (4-fold or greater decline in titer).
  • Overall mortality is low and occurs most commonly in patients with disseminated disease, underlying risk factors, or immunosuppression. Of the clinical syndromes, mortality is highest in coccidioidal meningitis.

Patient Education

  • Residents of or travelers to endemic areas should be aware of the risk of coccidioidal infection with exposure to dust or soil. Infection may be acquired with exposure to dust from construction sites and any activities that increase the risk of dust inhalation (eg, recreational activities, occupational exposures).
  • A persistent or progressive febrile respiratory illness should prompt medical evaluation, as should other symptoms often associated with extrathoracic coccidioidal infection (eg, bony pain, monoarticular arthritis, persistent headache).
  • A travel history should always be obtained from a patient presenting with any pulmonary symptoms.
  • For excellent patient education resources, visit eMedicine's Procedures Center. Additionally, see eMedicine's patient education article Bronchoscopy.

Miscellaneous

Medicolegal Pitfalls

  • Potential problems may arise if coccidioidomycosis is not considered in residents of or travelers to endemic areas who manifest one of the clinical syndromes and who have continued or progressive symptoms.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Sat Sharma, MD, FRCPC, to the development and writing of this article.



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Multimedia: Coccidioidomycosis
References
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Further Reading

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Keywords

coccidioidomycosis, coccidioides infection, coccidioidal infection, cocci infection, coccidioidal pneumonia, coccidioidal lung infection, San Joaquin Valley fever, valley fever,

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Contributor Information and Disclosures

Author

John E Cho, MD, Fellow, Department of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center
John E Cho, MD is a member of the following medical societies: American College of Chest Physicians, California Medical Association, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Coauthor(s)

Guy W Soo Hoo, MD, MPH, Clinical Professor of Medicine, Geffen School of Medicine at the University of California at Los Angeles; Director, Medical Intensive Care Unit, Pulmonary and Critical Care Section, West Los Angeles Healthcare Center, Veteran Affairs Greater Los Angeles Healthcare System
Guy W Soo Hoo, MD, MPH is a member of the following medical societies: American Association for Respiratory Care, American College of Chest Physicians, American College of Physicians, American Thoracic Society, California Thoracic Society, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Medical Editor

Michael Peterson, MD, Chief of Medicine, Vice-Chair of Medicine, University of California at San Francisco; Endowed Professor of Medicine, University of California at San Francisco-Fresno
Michael Peterson, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Gregg T Anders, DO, Medical Director, Great Plains Regional Medical Command , Brook Army Medical Center; Clinical Associate Professor, Department of Internal Medicine, Division of Pulmonary Disease, University of Texas Health Science Center at San Antonio
Gregg T Anders, DO is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society
Disclosure: Nothing to disclose.

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD, Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center; Professor of Medicine, David Geffen School of Medicine at UCLA
Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society
Disclosure: Nothing to disclose.

 
 
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