Download Coccidioidomycosis San Joaquin Valley Fever

 31-year-old, African-American
US Army
Soldier
• Presents with fever, chills, night sweats, non-
productive cough of 4 weeks
• Past medical history unremarkable
• Recently detected a painless right breast mass
• Stationed at Fort Irwin, CA
Stafford et. al., Infect Med 24 (Suppl 8): 23-25, 2007.
 Physical
exam:
• Unremarkable
• Firm, nontender, 3-cm subcutaneous mass over
right breast
• Multiple small nontender lymph nodes were
palpable in the axillae and groin
 Lab
results:
• WBC = 11.9/µl, 30% eosinophils
• Elevated alkaline phosphatase
Stafford et. al., Infect Med 24 (Suppl 8): 23-25, 2007.
 Blood
cultures = negative
 Cryptococcus antigen = negative
 Histoplasma urine antigen = negative
 HIV antibody = negative
 Tuberculin test = negative
 CT
scan of chest revealed diffuse, 1-2 mm
micronodules in all lobes and right chest
wall mass.
Stafford et. al., Infect Med 24 (Suppl 8): 23-25, 2007.
 Fine
needle aspirate of the mass revealed
spherules filled with endospores
Stafford et. al., Infect Med 24 (Suppl 8): 23-25, 2007.
 Culture
grew Coccidioides immitis
 Serology
 CSF
panel for C. immitis was positive
= normal
 Bone
scan revealed multiple region of
increased osteoblastic activity
Stafford et. al., Infect Med 24 (Suppl 8): 23-25, 2007.
 Epidemiology:
• Endemic in arid, temperate, desert climate
• especially Southwest United States
• Travel history - Central-Southern CA; south NV, AZ,NM,TX
• Fungus grows in soil and matures to form arthroconidia
• Infection is initiated by inhalation of infectious arthroconidia
• Filipinos, African/Native Americans & Hispanics - greatest risk of
dissemination
 Virulence
factors and pathogenesis:
• Highly infectious
• Not highly virulent, ~99.5% of infected individuals resolve
• Defects in CMI predispose to systemic disease
-Hyphae differentiate into
arthroconidia, which break loose
and may be suspended in the air
-Soil disruptions and wind
facilitate spread and the
probability of inhalation into
lungs
-In the human host environment,
in vivo differentiation produces
cleavage planes and eventually
huge spherules containing
endospores
-Spherules rupture releasing
endospores, which can then
repeat the in vivo cycle
 Clinical
Manifestations:
• Not contagious
• Route of infection: inhalation
• Incubation: 10-21 days
• Respiratory infection - 60% asymptomatic, all convert to skin
test +
• < 1% dissemination – soon after primary infection or years
later
• Often produces:
• Meningitis
• Lesions in viscera or cutaneous granulomatous lesions which may form
draining ulcers
• Incidence in HIV-infected persons has increased
Coccidioidomycosis Manifestations
 Coccidioides
immitis:
• Thermally dimorphic fungus
• In tissue: Huge (20-60 μm) thick-walled, round
“spherules” filled with small (2-5 μm) endospores
• Spherules rupture
• In 25°C culture:
 SDA and SDA-CC positive, 2-4 weeks; SABHI positive, 1-2
weeks
 Hyaline septate hyphae forming barrel-shaped arthroconidia
• At 37°C: Thermal conversion requires animals, but is
not done
•
Coccidioidin skin test:
• Not available in US
•
Serologic tests:
• Combination of latex agglutination and immunodiffusion tests
detects >90% early in symptomatic illness
• Complement fixation (CF) tests for Dx
• Serial CF titers are useful for prognosis
• Rising titer = poor prognosis
Coccidioidomycosis
Lung tissue with a large
thick-walled spherule
containing multiple
endospores. The smaller
spherule to its left has
ruptured releasing
endospores.
Coccidioidomycosis
Coccidioidomycosis
Coccidioidomycosis
- May take ~ 2 weeks
Coccidioidomycosis
Arthroconidia
Disjuncture
Definitive identification
of Coccidioides immitis
ExoAg
--or-NA
confirmation
 Treatment:
• Most do not require anti-fungals
• Azoles – pneumonia & nonmeningeal dissemination
• Amphotericin B – meningeal infection and previous
treatment failures

For our patient:
• In spite of Amphotericin B treatment, neck pain increased
and progressive enlargement of the mass was noted
• Surgical debridement
• Long-term antifungal therapy

Clues to the diagnosis of disseminated
coccidioidomycosis included an infectious
prodrome, peripheral eosinophilia, hilar
lymphadenopathy, characteristic pattern of organ
involvement (lungs, bones, soft tissues),
residence in an endemic area, and AfricanAmerican ethnicity.
Stafford et. al., Infect Med 24 (Suppl 8): 23-25, 2007.
 Paracoccidioidomycosis
• Paracoccidioides brasiliensis
• Endemic to Latin American countries
• Pulmonary infection – asymptomatic, self-
limiting
• Dissemination to mucous membranes and
skin
Histopathology:
-Yeast with multiple buds
-”Mariner’s Wheel”
 Penicilliosis
Marneffei
• Penicillium marneffei
• HIV-infected individuals in Thailand and
Southern China
• Only species of Penicillium that is dimorphic
 Intracellular yeast, with single septum
• Infection mimics tuberculosis or histoplasmosis
• Patient presentation:
 Fever, cough, pulmonary infiltrates, organomegaly,
anemia, leukopenia, thrombocytopenia