Coccidioidomycosis

Clinical and pathologic characteristics of disseminated cutaneous coccidioidomycosis

BACKGROUND

Cutaneous lesions are a common manifestation of disseminated coccidioidomycosis, which has increasing prevalence in endemic regions. The clinical and histologic features may be more variable than is currently recognized.

OBJECTIVE

To characterize the clinical and histologic findings from a large series of disseminated coccidioidomycosis cases in the southwestern United States.

METHODS

Histologic materials and clinical records for all biopsy-positive cases (1975-2006) from three medical centers in Arizona were reviewed.

RESULTS

Patterns of inflammation were generally granulomatous, but the degree of organization, associated inflammatory milieu, density of tissue fungemia, and size of fungal spherules were highly variable. The clinical presentation was also inconsistent.

LIMITATIONS

The study only included cases with diagnostic histology. Records of clinical information were somewhat incomplete.

CONCLUSION

Clinical and pathologic findings in disseminated cutaneous coccidioidomycosis are variable and often subtle. A diagnosis requires a high degree of suspicion, especially in patients who reside in or have traveled through endemic regions.

Coccidioidomycosis: a review and update

Coccidioidomycosis occurs in arid and semi-arid regions of the New World from the western United States to Argentina. Highly endemic areas are present in the southwest United States. Coccidioides species live in the soil and produce pulmonary infection via airborne arthroconidia. The skin may be involved by dissemination of the infection, or by reactive eruptions, such as a generalized exanthem or erythema nodosum. Interstitial granulomatous dermatitis and Sweet's syndrome have recently been recognized as additional reactive signs of the infection. Coccidioidomycosis is a "great imitator" with protean manifestations. Cutaneous findings may be helpful clues in the diagnosis of this increasingly important disease.

Primary cutaneous coccidiodomycosis: case report and review of the literature

BACKGROUND

Coccidiodomycosis is a systemic infection caused by Coccidioides immitis, a dimorphic fungus endemic in the south of the USA and the north of Mexico. The disease usually affects the lungs. Primary cutaneous infection is extremely rare. We present a report of a patient with primary cutaneous infection located on the nose. To our knowledge, such a presentation has never previously been reported in the literature.

OBSERVATIONS

The patient had a 3-cm-diameter elevated nodule with a verrucous aspect located on the tip of her nose. The histopathologic features of the lesion were consistent with coccidioidomycosis.

CONCLUSIONS

To our knowledge, this is the first report of primary cutaneous coccidioidomycosis located on the tip of nose.

Head and Neck Manifestations of Disseminated Coccidioidomycosis

OBJECTIVES/HYPOTHESIS

Coccidioidomycosis is a fungal disease endemic to semiarid regions in the southwestern United States, northern Mexico, and parts of South America. Although this is primarily a pulmonary disease, approximately 0.5% to 1.0% of infected individuals develop disseminated disease affecting skin, subcutaneous tissue, bone, joints, and meninges. The objectives of the study were to present three cases of head and neck manifestations of disseminated coccidioidomycosis and to review the literature of head and neck presentations, diagnosis, and treatment of this potentially life-threatening disease.

STUDY DESIGN

Case reports and literature review.

METHODS

A Medline search was performed with the keyword "coccidioidomycosis." Of 1719 articles in all, 47 were selected for their relevance to otolaryngology, diagnosis, or treatment.

RESULTS

Virtually all head and neck manifestations in patients with disseminated coccidioidomycosis involved the skin, with a predilection for the central face. Systemic symptoms such as fever and cough are often subtle, making the diagnosis difficult. Infections of multiple sites of the head and neck have been reported, including life-threatening airway lesions.

CONCLUSION

The incidence of patients with coccidioidomycosis has been steadily increasing since the late 1980s in endemic areas. Otolaryngologists are increasingly being called on to diagnose and manage the head and neck manifestations of the disease caused by Coccidioides immitis.

Identifying and treating mycotic skin infections

PURPOSE

To provide physicians and nurses with an overview of mycotic infections and related cutaneous manifestations.

TARGET AUDIENCE

This continuing-education activity is intended for physicians and nurses with an interest in learning how to recognize and treat mycotic skin infections.

OBJECTIVES

After reading the article and taking the test, the participant will be able to:1. Identify the cause and clinical presentation of mycotic skin infections.2. Identify diagnostic tests used in evaluating patients with mycotic skin infections.3. Identify appropriate treatment options in patients with mycotic skin infections.

Coccidioidomycosis: case report and update on diagnosis and management

Coccidioidomycosis is a disease known for its endemicity to the Southwest United States. However, given the current trends of more frequent tourist and business travel, an increasing number of coccidioidomycosis infections are being seen in patients in other areas of the United States. Because the majority of patients with disseminated disease experience cutaneous manifestations, dermatologists can be of primary importance in the diagnosis of this disease. We report a case of coccidioidomycosis manifesting as granulomatous cutaneous nodules on the face of an otherwise healthy white man. We attempt to provide an update on the diagnosis, management, and treatment of patients who present with cutaneous lesions caused by coccidioidomycosis infection.

Interstitial granulomatous dermatitis associated with pulmonary coccidioidomycosis

BACKGROUND

Coccidioides immitis is a soil-dwelling fungus found in arid regions of the Western Hemisphere. Interstitial granulomatous dermatitis is a histopathologic pattern that may be a reactive manifestation of diverse systemic diseases.

OBJECTIVE

Our purpose was to describe clinical and histopathologic findings in 5 patients who presented with interstitial granulomatous dermatitis associated with pulmonary coccidioidomycosis.

METHODS

Medical records and skin biopsy slides from 5 patients were retrospectively reviewed.

RESULTS

In each patient, edematous papules, nodules, and plaques developed abruptly during the onset of an acute febrile illness. Coccidioidomycosis was confirmed by serology. Skin biopsy specimens revealed interstitial granulomatous dermatitis with neutrophils, leukocytoclasis, and eosinophils. Fungal stains (5/5 cases) and fungal cultures (2/2 cases) revealed no organisms within the skin biopsy specimens.

CONCLUSION

Interstitial granulomatous dermatitis may be a presenting feature of pulmonary coccidioidomycosis and may possibly represent a reactive manifestation of the infection.

Dermatologic infections in the immunocompromised (non-HIV) host

The immunocompromised host's susceptibility to infections often present a difficult diagnostic challenge to the physician. A working knowledge of the host immune defenses and microbiologic complications that can occur when these functions are compromised provides a more focused framework for further evaluation and management. Infections in these patients are often morbid and life-threatening, creating an urgent need for prompt diagnosis. The skin may manifest the first clue(s) of a serious underlying infection. Appropriate workup and diagnosis of cutaneous lesions provide an expeditious, noninvasive, and potentially life-saving approach to the immunocompromised host with a dermatologic infection.

Coccidioidomycosis in non-endemic areas: a case series

Coccidioidomycosis is a systemic infection caused by the soil fungus Coccidioides immitis, which is endemic to the south-western United States. Manifestations range from flu-like illness to pneumonia and septic shock. Diagnosis may be delayed or missed in non-endemic areas because of the low index of suspicion. We describe a series of 23 patients with coccidioidomycosis at one institution in a non-endemic area. Diagnosis was often delayed. In two patients, the route of exposure could not be determined, but 20 patients had a history of residence or travel to endemic areas, and the remaining patient had an occupational history of exposure to fomites from an endemic region. Five patients were immunosuppressed. Most patients responded well to medical therapy, surgery, or both. Although coccidioidomycosis is rare in non-endemic areas, physicians must keep it in mind when evaluating patients who have traveled to endemic areas or who are immunosuppressed.

Outbreak of coccidioidomycosis in Washington state residents returning from Mexico

In July 1996 the Washington State Department of Health (Seattle) was notified of a cluster of a flulike, rash-associated illness in a 126-member church group, many of whom were adolescents. The group had recently returned from Tecate, Mexico, where members had assisted with construction projects at an orphanage. After 1 member was diagnosed with coccidioidomycosis, we initiated a study to identify further cases. We identified 21 serologically confirmed cases of coccidioidomycosis (minimum attack rate, 17%). Twenty cases (95%) occurred in adolescents, and 13 patients (62%) had rash. Sixteen symptomatic patients saw 19 health care providers; 1 health care provider correctly diagnosed coccidioidomycosis. Coccidioides immitis was isolated from soil samples from Tecate by use of the intraperitoneal mouse inoculation method. Trip organizers were unaware of the potential for C. immitis infection. Travelers visiting regions where C. immitis is endemic should be made aware of the risk of acquiring coccidioidomycosis, and health care providers should be familiar with coccidioidomycosis and its diagnosis.

Lymphocutaneous syndrome. A review of non-sporothrix causes

The lymphocutaneous syndrome can be caused by a number of diverse microorganisms requiring very different antimicrobial therapy for resolution. The epidemiology and geographic occurrence of the infection often can provide important first clues to the microbiologic etiology. Accurate diagnosis can be accomplished usually by punch or wedge biopsy of a primary lesion or proximal subcutaneous nodule submitted for histopathologic examination and culture. The microbiology laboratory staff should be alerted to the diagnostic possibilities so that appropriate cultural and incubation techniques, procedures, and precautions can be initiated. Provision of a correct microbiologic diagnosis and institution of appropriate antimicrobial therapy will result in a complete cure in almost all instances. Adjunctive surgical debridement may be required for certain organisms such as Nocardia or Mycobacterium chelonae.

Fungal infections in HIV-infected patients

Opportunistic fungal infections are commonly encountered in the acquired immunodeficiency syndrome (AIDS) patient population. Fungal infections in the patient infected with the human immunodeficiency virus (HIV) are a major cause of morbidity and mortality. The yeasts Candida and Cryptococcus neoformans, the dimorphic fungi Histoplasma capsulatum and Sporothrix schenckii, and the dermatophyte fungi are the most common pathogenic fungi in patients infected with HIV. The characteristics of these and other relevant mycotic pathogens, and their clinical presentation are discussed. Mycoses in the patient infected with HIV are often atypical, and can be masked by other infections. Cutaneous manifestations may provide valuable diagnostic clues. The clinician must maintain a high index of suspicion to establish an early diagnosis and rapidly institute therapy. Treatment may suppress rather than cure the mycosis, because host immunity in conjunction with antifungal agents is necessary to eliminate infection.