eMedicine Specialties > Pulmonology > Infectious Lung Diseases

Coccidioidomycosis: Treatment & Medication

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

Treatment

Medical Care

Most patients infected with Coccidioides are asymptomatic or have self-limited symptoms that do not require more than supportive care. Symptomatic patients usually come to medical attention because of respiratory tract or systemic symptoms. Management is outlined based on previously described clinical syndromes. Most treatment recommendations represent consensus guidelines because prospective, randomized trials are lacking.

Also see the clinical guideline summary from the Infectious Diseases Society of America, Coccidioidomycosis.6

Primary pulmonary coccidioidomycosis/acute pneumonia

  • No consensus has been reached on antifungal treatment for symptomatic patients.
  • In endemic areas, patients with symptoms consistent with community-acquired pneumonia were found to have diagnostic coccidioidal serologies in approximately 30% of patients.7
  • Patients with a higher clinical severity score and symptom score are more likely to be treated, but outcomes are not significantly different, although more complications have been seen in those with cessation of treatment.8,9
  • No consensus has been reached on the duration of therapy, but 6 months of treatment is most common, and CF titers are used to monitor response to therapy.
  • Risk factors for dissemination may sway the decision to treat patients, as may findings of elevated CF titers and ethnicity.
  • Diffuse pneumonia warrants antifungal therapy.
Chronic progressive coccidioidal pneumonia
  • Treatment is recommended with an oral azole for at least a year.
  • Fluconazole at 400 mg/d and itraconazole at 200 mg twice daily appear to be equivalent in efficacy, but more patients demonstrate a response with itraconazole, which becomes evident at 12 months of therapy.
  • Amphotericin B can be used for refractory infections unresponsive to oral therapy.
  • Surgical resection is an option reserved for patients with refractory disease, usually those with persistent hemoptysis.
Pulmonary nodules

  • Antifungal therapy is not typically recommended.
  • Most lesions do not require any further investigation, especially if they are unchanged on serial imaging for 2 or more years.
  • However, lesions may undergo resection if no diagnosis is established and malignancy is a concern.

Pulmonary cavities

  • Asymptomatic patients often are noted incidentally. No evidence supports instituting antifungal therapy. Many resolve without specific therapy. Serial imaging can be performed to confirm stability.
  • Symptomatic patients are defined by local discomfort, hemoptysis, the presence of mycetoma, or local infection. Consider treatment with oral azoles as outlined previously. Large (>5 cm) or enlarging cavities were previously treated with surgical resection after amphotericin treatment, but in current practice a trial of oral azole therapy is warranted. Surgical resection is reserved for cavities refractory to therapy or for patients with persistent complications such as hemoptysis.
  • Ruptured cavities are often present as a hydropneumothorax or empyema. Chest tube drainage (if indicated) and antifungal therapy (azoles or amphotericin) are recommended in anticipation of eventual surgical resection.

Disseminated coccidioidomycosis

  • Nonmeningeal coccidioidomycosis is treated with oral azoles as outlined previously. Some authors use higher doses of fluconazole (800 mg/d). Amphotericin B is recommended for rapidly progressive lesions or disease with vertebral body involvement. Vertebral involvement may also require surgical debridement and stabilization. The duration of therapy is at least a year and often longer. Changes in CF titers can help with decisions on the duration of therapy.
  • Meningeal coccidioidomycosis is treated with oral fluconazole as the preferred agent. Although 400 mg/d has been reported, many treat with 800-1000 mg/d. The range for itraconazole doses is 400-600 mg. Treatment with azoles is usually life long. Hydrocephalus requires a shunt for decompression. Intrathecal amphotericin was previously used in refractory cases and initial therapy by some. The optimal dose and duration of intrathecal amphotericin unknown.

Surgical Care

Surgical resection is reserved for chronic pulmonary coccidioidal infection with severe, refractory complications including hemoptysis, bronchopleural fistula, or a failure of antifungal therapy to control symptoms.

Surgery in patients with chronic pulmonary coccidioidal infection is not uniformly curative and may result in serious complications. The potential complications of surgery include the development of postoperative bronchopleural fistula and postoperative cavity formation.

Surgical indications

  • Persistent or massive hemoptysis
  • Enlarging cavities (>5 cm) close to visceral pleural with high risk of rupture
  • Spontaneous pneumothorax with persistent lung collapse
  • Empyema drainage not amenable to chest tube drainage
  • Bronchopleural fistula closure
  • Expansion of lungs restricted by residual pleural disease
  • Symptomatic fungus ball
Limitations to surgical treatment
  • High complication rate with closure of bronchopleural fistula (30%)
  • Recurrent disease (cavitation) in 18%
  • Reduced postoperative risk seen with preoperative amphotericin B therapy, but experience with azole therapy unknown

Consultations

  • Pulmonary and infectious disease specialists
  • Surgeon in select cases

Diet

No specific diet is necessary for patients with coccidioidal infection.

Activity

No specific limitations in activity are necessary for patients with coccidioidal infection. Any limitations would be as a result of the adverse effects of the infection as it relates to hemodynamics, respiratory status, stamina, and ambulation.

Medication

Amphotericin B, fluconazole, and itraconazole are the antifungal agents currently recommended as first-line agents for the treatment of coccidioidal infection. Ketoconazole is efficacious, but has been largely replaced by fluconazole. Relapses have been reported in 7-39% of patients. Initial oral therapy should be with either fluconazole (400 mg/d) or itraconazole (200 mg bid), with higher doses in patients with disseminated disease or meningitis.

The duration of therapy is dictated by the clinical course of the illness, but it should be at least 6 months in all patients and often a year or longer in others. Therapy is tailored based on a combination of resolution of symptoms, regression of radiographic abnormalities, and changes in CF titers. Patients with a history of meningeal involvement require lifelong treatment.

No studies have directly compared amphotericin B with azole therapy. Amphotericin B should be considered as initial therapy in patients with rapidly progressive or life-threatening disease and in pregnant patients. Posaconazole, voriconazole, and caspofungin are under investigation as alternative agents and as possible alternatives for refractory coccidioidal infection.

  • Ketoconazole
    • First oral broad-spectrum antifungal medication
    • Moderate activity for coccidioidomycosis
    • Treatment response rate of 12-32%
    • High rate of recurrence with medication discontinuation
    • Higher dose with significant adverse effects
    • Risk for reduced testosterone synthesis
  • Itraconazole
    • Variable absorption levels depending on acidic gastric pH
    • Absorption impaired by agents that alter gastric pH such as proton pump inhibitors
    • Itraconazole study group with skeletal infections responded twice as fast as fluconazole group; difference between groups not statistically significant[19]
  • Fluconazole
    • Standard treatment used in coccidioidal infection
    • Efficacy in life-long treatment of coccidioidal meningitis
    • Sometimes used in combination with intrathecal amphotericin B for treatment of coccidioidal meningitis
  • Amphotericin B
    • Lipid-based formulation preferred because of reduced renal toxicity
    • Indicated in rapidly progressive disease
    • Indicated in pregnancy because of the presumed teratogenicity of azoles
  • Posaconazole
    • Structurally similar to itraconazole
    • Highly active in vitro against C immitis
    • Trial information: In an open-label, multicenter, international study, patients with invasive coccidioidal disease refractory to standard therapy (amphotericin with or without azoles) were treated with posaconazole; 11 of 15 patients had treatment success.10 The study was limited by a small sample size, poor patient compliance, significant baseline treatment differences, and nonrandomized study design.
    • Trial information: A small study in an open-label trial showed 5 of 6 successful treatment outcomes in patients with disseminated coccidioidomycosis in whom conventional antifungal treatment failed.11
    • Other cases of treatment success reported12
    • More study needed prior to consideration for treatment of refractory coccidioidal infection
  • Voriconazole
    • Few reported cases of use in salvage therapy13
    • More study needed prior to consideration
  • Caspofungin
    • Echinocandin
    • Few reported cases of success14
    • More study needed prior to consideration

Antifungals

Their mechanism of action may involve increasing the permeability of the cell membrane, which in turn causes intracellular components to leak.


Posaconazole (Noxafil)

Triazole antifungal agent. Blocks ergosterol synthesis by inhibiting the enzyme lanosterol 14-alpha-demethylase and sterol precursor accumulation. This action results in cell membrane disruption. Available as oral susp (200 mg/5 mL). Indicated for prophylaxis of invasive Aspergillus and Candida infections in patients at high risk because of severe immunosuppression.

Adult

400 mg PO qd with food or liquid nutritional supplement to enhance absorption

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Metabolized via UDP glucuronidation; P-gp efflux substrate; CYP3A4 inhibitor
UDP-G inducers (eg, rifabutin, phenytoin) and drugs that increase gastric pH (eg, cimetidine) decrease serum levels (avoid concomitant use unless benefit outweighs risk)
Inhibits CYP3A4 and may elevate serum levels of cyclosporine, tacrolimus, sirolimus, rifabutin, midazolam, phenytoin, calcium channel blockers (eg, nifedipine, bepridil), HMG-CoA reductase inhibitors (eg, lovastatin, pravastatin), ergot alkaloids, terfenadine, astemizole, cisapride, pimozide, halofantrine, quinidine, or vinca alkaloids (eg, vincristine, vinblastine)

Documented hypersensitivity; coadministration with ergot alkaloids; coadministration with CYP3A4 substrates (eg, terfenadine, astemizole, cisapride, pimozide, halofantrine, quinidine) likely to result in serious toxicities

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Common adverse effects include nausea, vomiting, diarrhea, rash, hypokalemia, thrombocytopenia, and elevated liver enzyme levels; closely monitor patients with severe diarrhea or vomiting for breakthrough fungal infections; rare adverse events include arrhythmias caused by QTc prolongation, bilirubinemia, or liver function impairment; caution with preexisting cardiac risk factors (eg, history of arrhythmia, hypokalemia, hypomagnesemia); food improves absorption and provides optimal serum concentration; shake well before use; administer with measuring spoon provided in package; avoid if breastfeeding


Voriconazole (VFEND)

Used for primary treatment of invasive aspergillosis and salvage treatment of Fusarium species or Scedosporium apiospermum infections. A triazole antifungal agent that inhibits fungal CYP450-mediated 14 alpha-lanosterol demethylation, which is essential in fungal ergosterol biosynthesis.

Adult

Loading dose: 6 mg/kg IV q12h infused over 2 h for 2 doses
Maintenance: 4 mg/kg IV q12h infused over 2 h, when able to tolerate PO may switch to 200 mg PO q12h
Note: For inadequate response, may increase to 300 mg PO q12h; <40 kg administer oral maintenance dose of 100 mg PO q12h (may increase to 150 mg PO q12h)

Pediatric

Not established

CYP450 2C19 (highest affinity), 2C9, and 3A4 (minor) substrate and inhibitor; CYP450 inducers (eg, rifampin) have shown to decrease steady state peak plasma levels by up to 93%; may increase serum levels of drugs metabolized by CYP450 2C19 or 2C9, of which some are contraindicated (eg, sirolimus, pimozide, quinidine, cisapride, ergot alkaloids), other may need more frequent monitoring (eg, cyclosporine, tacrolimus, warfarin, HMG CoA inhibitors, benzodiazepines, calcium channel blockers)

Documented hypersensitivity; do not administer IV form with CrCl <50 mL/min (decreased excretion of IV vehicle); coadministration with rifampin, rifabutin, carbamazepine, barbiturates, sirolimus, pimozide, quinidine, cisapride, ergot alkaloids

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Decrease maintenance dose with hepatic dysfunction; common adverse effects include visual disturbances, fever, rash, vomiting, nausea, diarrhea, headache, sepsis, peripheral edema, abdominal pain, rash (including Stevens-Johnson Syndrome and phototoxicity), and respiratory disorder; rare cases of severe hepatotoxicity have been reported; administer PO 1 h ac or pc


Caspofungin (Cancidas)

Used to treat refractory invasive aspergillosis. First of a new class of antifungal drugs (glucan synthesis inhibitors). Inhibits synthesis of beta-(1,3)-D-glucan, an essential component of fungal cell wall.

Adult

70 mg IV infused over 1 h on day 1; 50 mg IV qd thereafter

Pediatric

<3 months: Not established
3 months to 18 years: 70 mg/m2 IV infused over 1 h on day 1; 50 mg/m2/d IV thereafter; not to exceed 70 mg/d for either loading dose or maintenance dose
>18 years: Administer as in adults

Coadministration with cyclosporine may increase risk of hepatotoxicity; carbamazepine, nelfinavir, efavirenz, or dexamethasone may decrease levels of caspofungin; caspofungin may decrease levels of tacrolimus; rifampin decreases caspofungin levels by 30% (ie, adjust dose to 70 mg/d)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in moderate hepatic dysfunction (ie, decrease dose to 35 mg/d); may exacerbate preexisting renal dysfunction or myelosuppression


Ketoconazole (Nizoral)

Imidazole broad-spectrum antifungal agent. Inhibits synthesis of ergosterol, causing cellular components to leak, resulting in fungal cell death.

Adult

200-400 mg PO qd

Pediatric

Not established

Isoniazid may decrease bioavailability; coadministration decreases effects of either rifampin or ketoconazole; may increase effect of anticoagulants; may increase toxicity of corticosteroids and cyclosporine (cyclosporine dosage can be adjusted); may decrease theophylline levels

Documented hypersensitivity; fungal meningitis

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Hepatotoxicity may occur; may reversibly decrease corticosteroid serum levels (adverse effects avoided with dose of 200-400 mg/d); administer antacids, anticholinergics, or H2 blockers at least 2 h after taking ketoconazole


Itraconazole (Sporanox)

Oral antifungal agent with broad-spectrum antifungal activity. Decreases ergosterol synthesis and inhibits cell membrane formation.

Adult

200 mg PO bid

Pediatric

Not established

Antacids may reduce absorption; edema may occur with coadministration of calcium channel blockers (eg, amlodipine, nifedipine); hypoglycemia may occur with sulfonylureas; may increase tacrolimus and cyclosporine plasma concentrations when high doses are used; rhabdomyolysis may occur with coadministration of HMG-CoA reductase inhibitors (lovastatin, simvastatin); coadministration with cisapride can cause cardiac rhythm abnormalities and death; may increase digoxin levels; coadministration may increase plasma levels of midazolam or triazolam; phenytoin and rifampin may reduce itraconazole levels (phenytoin metabolism may be altered)

Documented hypersensitivity; coadministration with cisapride may cause adverse cardiovascular effects (possibly death)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hepatic insufficiencies; adverse effects include nausea (common), fatigue, malaise, rash, abdominal pain, and hepatitis


Fluconazole (Diflucan)

Synthetic oral antifungal (broad-spectrum bistriazole) that selectively inhibits fungal cytochrome P-450 and sterol C-14 alpha demethylation.

Adult

200-400 mg PO qd

Pediatric

3-6 mg/kg PO qd for 14-28 d depending on severity of infection

Levels may increase with hydrochlorothiazides; fluconazole levels may decrease with long-term coadministration of rifampin; may increase concentrations of theophylline, phenytoin, tolbutamide, cyclosporine, glyburide, and glipizide; effects of anticoagulants may increase with fluconazole coadministration

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Closely monitor patients who develop rashes during treatment and discontinue if lesions progress; may cause clinical hepatitis, cholestasis, and fulminant hepatic failure (including fatalities), especially when a serious underlying medical condition (eg, AIDS, malignancy) is present and often while taking multiple concomitant medications


Amphotericin B (AmBisome)

Depending on the concentration attained in body fluids and on fungal susceptibility, can be fungistatic or fungicidal. Polyene antibiotic produced by a strain of Streptomyces nodosus that changes membrane permeability by binding to sterols in the fungal cell membrane. Fungal cell death results.

Adult

0.5-1 mg/kg/d IV; not to exceed 2-4 g/dose

Pediatric

2.5 mg/kg/d IV

Antineoplastic agents may enhance potential of amphotericin B for renal toxicity, bronchospasm, and hypotension; corticosteroids, digitalis, and thiazides may potentiate hypokalemia; risk of renal toxicity is increased with cyclosporine

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Monitor renal function, serum electrolyte levels (eg, magnesium, potassium), liver function, CBC count, and hemoglobin concentrations; resume therapy at lowest level (eg, 0.25 mg/kg) when therapy is interrupted for longer than 7 d; hypoxemia, acute dyspnea, and interstitial infiltrates may occur in patients who are neutropenic who are receiving leukocyte transfusions (separate time of amphotericin infusion from time of leukocyte transfusion)

More on Coccidioidomycosis

Overview: Coccidioidomycosis
Differential Diagnoses & Workup: Coccidioidomycosis
Treatment & Medication: Coccidioidomycosis
Follow-up: Coccidioidomycosis
Multimedia: Coccidioidomycosis
References
[ CLOSE WINDOW ]

References

  1. Polesky A, Kirsch CM, Snyder LS, et al. Airway coccidioidomycosis--report of cases and review. Clin Infect Dis. Jun 1999;28(6):1273-80. [Medline].

  2. Increase in Coccidioidomycosis - California, 2000-2007. MMWR Morb Mortal Wkly Rep. Feb 13 2009;58(5):105-9. [Medline].

  3. Durkin M, Connolly P, Kuberski T, et al. Diagnosis of coccidioidomycosis with use of the Coccidioides antigen enzyme immunoassay. Clin Infect Dis. Oct 15 2008;47(8):e69-73. [Medline].

  4. Bialek R, Gonzalez GM, Begerow D, Zelck UE. Coccidioidomycosis and blastomycosis: advances in molecular diagnosis. FEMS Immunol Med Microbiol. Sep 1 2005;45(3):355-60. [Medline].

  5. Valdivia L, Nix D, Wright M, et al. Coccidioidomycosis as a common cause of community-acquired pneumonia. Emerg Infect Dis. Jun 2006;12(6):958-62. [Medline].

  6. Winn RE, Johnson R, Galgiani JN, Butler C, Pluss J. Cavitary coccidioidomycosis with fungus ball formation. Diagnosis by fiberoptic bronchoscopy with coexistence of hyphae and spherules. Chest. Feb 1994;105(2):412-6. [Medline].

  7. Tucker RM, Denning DW, Arathoon EG, Rinaldi MG, Stevens DA. Itraconazole therapy for nonmeningeal coccidioidomycosis: clinical and laboratory observations. J Am Acad Dermatol. Sep 1990;23(3 Pt 2):593-601. [Medline].

  8. Ampel NM. Coccidioidomycosis: a review of recent advances. Clin Chest Med. Jun 2009;30(2):241-51, v. [Medline].

  9. Ampel NM, Giblin A, Mourani JP, Galgiani JN. Factors and outcomes associated with the decision to treat primary pulmonary coccidioidomycosis. Clin Infect Dis. Jan 15 2009;48(2):172-8. [Medline].

  10. Stevens DA. Coccidioidomycosis. N Engl J Med. Apr 20 1995;332(16):1077-82. [Medline].

  11. Anstead GM, Corcoran G, Lewis J, Berg D, Graybill JR. Refractory coccidioidomycosis treated with posaconazole. Clin Infect Dis. Jun 15 2005;40(12):1770-6. [Medline].

  12. Catanzaro A, Cloud GA, Stevens DA, et al. Safety, tolerance, and efficacy of posaconazole therapy in patients with nonmeningeal disseminated or chronic pulmonary coccidioidomycosis. Clin Infect Dis. Sep 1 2007;45(5):562-8. [Medline].

  13. Crum-Cianflone NF, Truett AA, Teneza-Mora N, et al. Unusual presentations of coccidioidomycosis: a case series and review of the literature. Medicine (Baltimore). Sep 2006;85(5):263-77. [Medline].

  14. Antony S. Use of the echinocandins (caspofungin) in the treatment of disseminated coccidioidomycosis in a renal transplant recipient. Clin Infect Dis. Sep 15 2004;39(6):879-80. [Medline].

  15. Anstead GM, Graybill JR. Coccidioidomycosis. Infect Dis Clin North Am. Sep 2006;20(3):621-43. [Medline].

  16. Batra P, Batra RS. Thoracic coccidioidomycosis. Semin Roentgenol. Jan 1996;31(1):28-44. [Medline].

  17. Bayer AS. Fungal pneumonias: pulmonary coccidioidal syndromes (Part 2). Miliary, nodular, and cavitary pulmonary coccidioidomycosis; chemotherapeutic and surgical considerations. Chest. Jun 1981;79(6):686-91. [Medline].

  18. Bayer AS. Fungal pneumonias; pulmonary coccidioidal syndromes (Part I). Primary and progressive primary coccidioidal pneumonias -- diagnostic, therapeutic, and prognostic considerations. Chest. May 1981;79(5):575-83. [Medline].

  19. Castellino RA, Blank N. Pulmonary coccidioidomycosis. The wide spectrum of roentgenographic manifestations. Calif Med. Jul 1968;109(1):41-9. [Medline].

  20. Catanzaro A, Galgiani JN, Levine BE, et al. Fluconazole in the treatment of chronic pulmonary and nonmeningeal disseminated coccidioidomycosis. NIAID Mycoses Study Group. Am J Med. Mar 1995;98(3):249-56. [Medline].

  21. Como JA, Dismukes WE. Oral azole drugs as systemic antifungal therapy. N Engl J Med. Jan 27 1994;330(4):263-72. [Medline].

  22. Crum-Cianflone NF. Voriconazole in combination with amphotericin B for salvage therapy of coccidioidomycosis: Case report and review of literature. Infectious Diseases in Clinical Practice. July 2007;15(4):265-268.

  23. DiTomasso JP, Ampel NM, Sobonya RE, Bloom JW. Bronchoscopic diagnosis of pulmonary coccidioidomycosis. Comparison of cytology, culture, and transbronchial biopsy. Diagn Microbiol Infect Dis. Feb 1994;18(2):83-7. [Medline].

  24. Galgiani JN, Ampel NM, Blair JE, et al. Coccidioidomycosis. Clin Infect Dis. Nov 1 2005;41(9):1217-23. [Medline].

  25. [Guideline] Galgiani JN, Ampel NM, Blair JE, et al. Coccidioidomycosis. Clin Infect Dis. Nov 1 2005;41(9):1217-23. [Medline].

  26. Galgiani JN, Catanzaro A, Cloud GA, et al. Comparison of oral fluconazole and itraconazole for progressive, nonmeningeal coccidioidomycosis. A randomized, double-blind trial. Mycoses Study Group. Ann Intern Med. Nov 7 2000;133(9):676-86. [Medline].

  27. Hirschmann JV. The early history of coccidioidomycosis: 1892-1945. Clin Infect Dis. May 1 2007;44(9):1202-7. [Medline].

  28. Hyde L. Coccidioidal pulmonary cavitation. Dis Chest. Oct 1968;54:Suppl 1:273-7. [Medline].

  29. Johnson RH, Caldwell JW, Welch G. The great Coccidiodomycosis epidemic: Clinical Features. Coccidiodomycosis. Einstein HE, Catanzaro A. Bethesda, MD. 1996;Proceedings of Fifth International Conference:77-87.

  30. Johnson RH, Einstein HE. Coccidioidal meningitis. Clin Infect Dis. Jan 1 2006;42(1):103-7. [Medline].

  31. Kim KI, Leung AN, Flint JD, Muller NL. Chronic pulmonary coccidioidomycosis: computed tomographic and pathologic findings in 18 patients. Can Assoc Radiol J. Dec 1998;49(6):401-7. [Medline].

  32. Lonky SA, Catanzaro A, Moser KM, Einstein H. Acute coccidioidal pleural effusion. Am Rev Respir Dis. Oct 1976;114(4):681-8. [Medline].

  33. Martins TB, Jaskowski TD, Mouritsen CL, Hill HR. Comparison of commercially available enzyme immunoassay with traditional serological tests for detection of antibodies to Coccidioides immitis. J Clin Microbiol. Apr 1995;33(4):940-3. [Medline].

  34. Marty F, Mylonakis E. Antifungal use in HIV infection. Expert Opin Pharmacother. Feb 2002;3(2):91-102. [Medline].

  35. McGahan JP, Graves DS, Palmer PE, Stadalnik RC, Dublin AB. Classic and contemporary imaging of coccidioidomycosis. AJR Am J Roentgenol. Feb 1981;136(2):393-404. [Medline].

  36. Merchant M, Romero AO, Libke RD, Joseph J. Pleural effusion in hospitalized patients with Coccidioidomycosis. Respir Med. Apr 2008;102(4):537-40. [Medline].

  37. Mortara L, Bayer AS. Fever, cough, pleuritic chest pain, and pleural fluid eosinophilia in a 30-year-old man. Chest. Mar 1994;105(3):918-9. [Medline].

  38. Pappagianis D, Zimmer BL. Serology of coccidioidomycosis. Clin Microbiol Rev. Jul 1990;3(3):247-68. [Medline].

  39. Parish JM, Blair JE. Coccidioidomycosis. Mayo Clin Proc. Mar 2008;83(3):343-48; quiz 348-9. [Medline].

  40. Park BJ, Sigel K, Vaz V, et al. An epidemic of coccidioidomycosis in Arizona associated with climatic changes, 1998-2001. J Infect Dis. Jun 1 2005;191(11):1981-7. [Medline].

  41. Patel S, Snyder L. A sore throat in the southwest. Am J Med. Mar 2009;122(3):233-5. [Medline].

  42. Read CT. Coin lesion, pulmonary: in the Southwest. (Solitary pulmonary nodules). Ariz Med. Oct 1972;29(10):775-81. [Medline].

  43. Ryu JH, Swensen SJ. Cystic and cavitary lung diseases: focal and diffuse. Mayo Clin Proc. Jun 2003;78(6):744-52. [Medline].

  44. Sarosi GA, Parker JD, Doto IL, Tosh FE. Chronic pulmonary coccidioidomycosis. N Engl J Med. Aug 13 1970;283(7):325-9. [Medline].

  45. Spinello IM, Munoz A, Johnson RH. Pulmonary coccidioidomycosis. Semin Respir Crit Care Med. Apr 2008;29(2):166-73. [Medline].

  46. Spivey CG Jr, Jones FL, Bopp RK. Cavitary coccidioidomycosis: experience in a tuberculosis hospital outside the endemic area. Dis Chest. Jul 1969;56(1):13-8. [Medline].

  47. Stevens DA, Rendon A, Gaona-Flores V, et al. Posaconazole therapy for chronic refractory coccidioidomycosis. Chest. Sep 2007;132(3):952-8. [Medline].

  48. Timmes JJ, Baum GL. Surgery in pulmonary coccidioidomycosis. Dis Chest. Mar 1957;31(3):308-15. [Medline].

  49. Trimble HG. Coccidioidomycosis; a review. Dis Chest. Dec 1951;20(6):588-610. [Medline].

  50. Wallace JM, Catanzaro A, Moser KM, Harrell JH 2nd. Flexible fiberoptic bronchoscopy for diagnosing pulmonary coccidioidomycosis. Am Rev Respir Dis. Mar 1981;123(3):286-90. [Medline].

  51. Williams PL, Sable DL, Mendez P, Smyth LT. Symptomatic coccidioidomycosis following a severe natural dust storm. An outbreak at the Naval Air Station, Lemoore, Calif. Chest. Nov 1979;76(5):566-70. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

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

[ CLOSE WINDOW ]

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.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.