eMedicine Specialties > Emergency Medicine > Infectious Diseases

Coccidioidomycosis: Differential Diagnoses & Workup

Author: James de la Torre, MD, Staff Physician, Resident Emergency Medicine, Department of Emergency Medicine, University of Southern California/Los Angeles County Medical Center
Coauthor(s): Allison J Richard, MD, Instructor of Clinical Emergency Medicine, Keck School of Medicine, University of Southern California; Consulting Staff, Department of Emergency Medicine, LAC-USC Medical Center; Joseph Kim, MD, Chairman, Department of Emergency Medicine, Western Medical Center; Clinical Instructor, University of California at Irvine
Contributor Information and Disclosures

Updated: May 27, 2008

Differential Diagnoses

Babesiosis
Pneumonia, Empyema and Abscess
Erythema Multiforme
Pneumonia, Immunocompromised
Granuloma, Annulare and Pyogenic
Pneumonia, Mycoplasma
Meningitis
Pneumonia, Viral
Neoplasms, Lung
Sarcoidosis
Pleural Effusion
Tuberculosis
Pneumonia, Aspiration
Pneumonia, Bacterial

Other Problems to Be Considered

Histoplasmosis
Blastomycosis
Paracoccidioidomycosis
Other fungi
Lung abscess
Lymphoma
Other causes of cough, fever, and fatigue
Old granuloma

Workup

Laboratory Studies

Guide diagnostic evaluation by index of suspicion and patient's clinical presentation. Various tests may aid or confirm the diagnosis.

  • CBC count: CBC count may reveal leukocytosis with eosinophilia, lymphocytosis, or monocytosis.
  • Direct observation: Observe for direct evidence of spherules of C immitis from various aspirates, body fluids, or biopsy samples. Various fungal stains may increase sensitivity.
  • Skin testing: Delayed-type hypersensitivity test results may become positive as early as 1-3 weeks. Although reactivity may endure for a lifetime, it may wane in some individuals, particularly those who may be anergic.
  • Immunoglobulin testing: Serology tube precipitin assays for immunoglobulin (Ig) M may detect acute infection. IgM reactivity usually does not persist for more than 6 months. Complement fixation is useful in detecting IgG immunity and is particularly useful in evaluating the extent and response to meningeal disease.
  • Culture: Culture may be performed, but results are usually delayed because of a 5- to 7-day incubation period.
  • Immunoprecipitant assays
  • Immunodiffusion

Imaging Studies

  • Chest radiography should be routinely performed to check for signs of pulmonary infection. Findings may be normal or may include the following:
    • Infiltrates
    • Nodules
    • Cavity
    • Mediastinal or hilar adenopathy
    • Pleural effusion
  • Radiography of affected areas is performed to check for osteomyelitis.

Procedures

If unable to obtain a diagnosis by skin testing or serology, consider performing the following:

  • Bronchoscopy
  • Fine-needle biopsy
  • Open-lung biopsy
  • Pleural biopsy
  • Bone/skin/node biopsy

More on Coccidioidomycosis

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

  1. Ampel NM. Combating opportunistic infections: coccidioidomycosis. Expert Opin Pharmacother. Feb 2004;5(2):255-61. [Medline].

  2. CDC. Coccidioidomycosis following the Northridge earthquake--California, 1994. JAMA. Jun 8 1994;271(22):1735. [Medline].

  3. Schneider E, Hajjeh RA, Spiegel RA, et al. A coccidioidomycosis outbreak following the Northridge, Calif, earthquake. JAMA. Mar 19 1997;277(11):904-8. [Medline].

  4. Bergstrom L, Yocum DE, Ampel NM. Increased risk of coccidioidomycosis in patients treated with tumor necrosis factor alpha antagonists. Arthritis Rheum. Jun 2004;50(6):1959-66. [Medline].

  5. CDC. Increase in coccidioidomycosis--Arizona, 1998-2001. MMWR Morb Mortal Wkly Rep. Feb 14 2003;52(6):109-12. [Medline].

  6. Louie L, Ng S, Hajjeh R, et al. Influence of host genetics on the severity of coccidioidomycosis. Emerg Infect Dis. Sep-Oct 1999;5(5):672-80. [Medline].

  7. Galgiani JN, Catanzaro A, Cloud GA. 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].

  8. Prabhu RM, Bonnell M, Currier BL. Successful treatment of disseminated nonmeningeal coccidioidomycosis with voriconazole. Clin Infect Dis. Oct 1 2004;39(7):e74-7. [Medline].

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

  10. Park DW, Sohn JW, Cheong HJ. Combination therapy of disseminated coccidioidomycosis with caspofungin and fluconazole. BMC Infect Dis. 2006;6:26. [Medline].

  11. Deresinski S. Coccidioides immitis as a potential bioweapon. Semin Respir Infect. Sep 2003;18(3):216-9. [Medline].

  12. Blair JE, Smilack JD, Caples SM. Coccidioidomycosis in patients with hematologic malignancies. Arch Intern Med. Jan 10 2005;165(1):113-7. [Medline].

  13. Catanzaro A. Coccidioidomycosis. In: Manual of Clinical Problems in Pulmonary Medicine. 5th ed. Lippincott Williams & Wilkins; 2000.

  14. Comrie AC. Climate factors influencing coccidioidomycosis seasonality and outbreaks. Environ Health Perspect. Jun 2005;113(6):688-92. [Medline].

  15. Deresinski SC, Mirels LF, Kemper CA. Coccidioides immitis. In: Infectious Diseases. Philadelphia, PA: Lippincott Williams & Wilkins; 2004:2227-46.

  16. Galgiani J. Coccidioides immitis. In: Principles and Practice of Infectious Diseases. New York, NY: Churchill Livingstone; 2000:2746-57.

  17. Jones JL, Fleming PL, Ciesielski CA, et al. Coccidioidomycosis among persons with AIDS in the United States. J Infect Dis. Apr 1995;171(4):961-6. [Medline].

  18. Rosenstein NE, Emery KW, Werner SB. Risk factors for severe pulmonary and disseminated coccidioidomycosis: Kern County, California, 1995-1996. Clin Infect Dis. Mar 1 2001;32(5):708-15. [Medline].

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Further Reading

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Keywords

coccidioidomycosis, desert fever, Posadas-Wernicke disease, San Joaquin fever, San Joaquin Valley Fever, cocci fungal infection, Coccidioides immitis, CI, arthroconidia, extrapulmonary coccidioidomycosis disease, human immunodeficiency virus, HIV, acquired immunodeficiency syndrome, AIDS, certain lymphomas, posttransplant states, chronic steroid dependence, severe pulmonary infection, erythema nodosum, desert rheumatism, pneumonia, hemoptysis, pneumothorax, noncommunicating hydrocephalus, increased intracranial pressure, pericardial effusion, tamponade, osteomyelitis, septic arthritis, synovitis

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Contributor Information and Disclosures

Author

James de la Torre, MD, Staff Physician, Resident Emergency Medicine, Department of Emergency Medicine, University of Southern California/Los Angeles County Medical Center
Disclosure: Nothing to disclose.

Coauthor(s)

Allison J Richard, MD, Instructor of Clinical Emergency Medicine, Keck School of Medicine, University of Southern California; Consulting Staff, Department of Emergency Medicine, LAC-USC Medical Center
Allison J Richard, MD is a member of the following medical societies: International Society of Travel Medicine
Disclosure: Nothing to disclose.

Joseph Kim, MD, Chairman, Department of Emergency Medicine, Western Medical Center; Clinical Instructor, University of California at Irvine
Disclosure: Nothing to disclose.

Medical Editor

David FM Brown, MD, Assistant Professor, Department of Medicine, Division of Emergency Medicine, Harvard Medical School; Associate-Chief, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital
David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Barry J Sheridan, DO, Chief, Department of Emergency Medical Services, Brooke Army Medical Center
Barry J Sheridan, DO is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Program Director, Department of Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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