Nejm 1995;332:1077

Cause:Coccidioides immitis

Airborne spread (inhalation) of mycelial stage infective spores; endospore spread in body (description of storm-scattered epidemic in California—Nejm 1979;301:358). American southwest esp Arizona, Texas, and California., eg, San Joaquin valley (Stockton to Bakersfield); worst in wet season, esp in patients exposed to dirt in spring and late fall

Increased prevalence (reactivation?) in diabetics and patients on steroid rx, in AIDS and other immunocompromised pts

Sx:Hemoptysis; granulomatous reactions of face and neck; primary cocci picture (Nejm 1972;286:507) of pneumonitis, flu-like syndrome with generalized pruritus macular/papular rash; acute polyarthritis (Nejm 1972;287:1133)

Si:Erythema nodosum, pleural effusion

Mortality 1% in Caucasians, 20% in Asians and Mexicans with disseminated disease. Recurrent up to 10 yr after amphotericin rx (Nejm 1969;281:950)

Hypercalcemia (Nejm 1977;297:431); extrapulmonary lesions, onset 1+ yr after primary pulmonary infection, eg, bones, joints, skin, meninges

Lab:

Bact:Mycelial form (white, fluffy, distinctive) dangerous to lab personnel. Diphasic but no yeast forms in tissue. Urine culture frequently positive if concentrated by lab, even when disseminated disease not suspected

Serol:Comp-fix antibody titer >1/16 suggests disseminated active disease. Positive in 14/15 (Nejm 1970;283:326); decreases with successful rx

Skin test:20-50% false neg but still useful (Am Rev Respir Dis 1988;138:1081); indicates present or past disease

Xray:Nodular pneumonitis; primary pneumonias; coin lesions; thin-walled cavities, r/o rheumatoid nodules and pneumatoceles

Rx:

Beware steroids

Meningitis after acute rx must be rx'd w lifelong suppression (Ann IM 1996;124:305)

of acute disease (Nejm 1987;317:334):

• Amphotericin 0.5 mg/kg iv biw to total of 30 mg/kg if sick, if comp-fix is increased, or if hx of and on steroids; 20% relapse (4/20—Nejm 1970;283:325); intrathecal for meningitis, many complications
• Ketoconazole po is at least static in many moderate pulmonary/skin infections
• Fluconazole 400 mg qd po × years effectively suppresses meningitis (Ann IM 1993;119:28) and treats >50% of nonmeningeal infections (Ann IM 2000;133:676)
• Itraconazole 200 mg po bid, cures 63% of nonmeningeal infections (Ann IM 2000;133:676)