Risk factors for severe pulmonary and disseminated coccidioidomycosis: Kern County, California, 1995-1996

Climate change and public health in California: A structured review of exposures, vulnerable populations, and adaptation measures

California faces several serious direct and indirect climate exposures that can adversely affect public health, some of which are already occurring. The public health burden now and in the future will depend on atmospheric greenhouse gas concentrations, underlying population vulnerabilities, and adaptation efforts. Here, we present a structured review of recent literature to examine the leading climate risks to public health in California, including extreme heat, extreme precipitation, wildfires, air pollution, and infectious diseases. Comparisons among different climate-health pathways are difficult due to inconsistencies in study design regarding spatial and temporal scales and health outcomes examined. We find, however, that the current public health burden likely affects thousands of Californians each year, depending on the exposure pathway and health outcome. Further, while more evidence exists for direct and indirect proximal health effects that are the focus of this review, distal pathways (e.g., impacts of drought on nutrition) are more uncertain but could add to this burden. We find that climate adaptation measures can provide significant health benefits, particularly in disadvantaged communities. We conclude with priority recommendations for future analyses and solution-driven policy actions.

Clinical Characteristics and Mortality Risks Among Patients With Culture-Proven Coccidioidomycosis Who Are Critically Ill: A Multicenter Study in an Endemic Region

Background

Coccidioidomycosis is an endemic mycosis in the southwestern United States. While most infections are mild, severe cases can be devastating. We aimed to describe the clinical characteristics and mortality risks of patients in the intensive care unit (ICU) with culture-proven coccidioidomycosis.

Methods

We performed a retrospective chart review of patients in the ICU with positive Coccidioides spp culture in a large health care system in Arizona between 1 October 2017 and 1 July 2022. All data were entered into REDCap.

Results

An overall 145 patients were identified and included. The median age was 51 years, with the majority male (69%) and non-Hispanic White (39%). Most patients (n = 104, 72%) had pulmonary coccidioidomycosis, and 41 had extrapulmonary disease (17 meningitis, 13 fungemia, 10 musculoskeletal disease, and 4 pericardial or aortic involvement). Seventy patients (48%) died during hospitalization, and most (91%) received antifungal therapy during hospitalization. In the multivariate logistic regression model, age ≥60 years (odds ratio [OR], 7.0; 95% CI, 2.6-18.8), cirrhosis (OR, 13.1; 95% CI, 1.6-108.8), and mechanical ventilation or vasopressor support (OR, 15.4; 95% CI, 3.9-59.6) were independently associated with increased all-cause mortality, but pre-ICU antifungal use had a statistically insignificant mortality risk association (OR, 0.5; 95% CI, .2-1.2).

Conclusions

In our study of patients in the ICU with coccidioidomycosis and multiple comorbidities, the mortality rate was high. Older age, cirrhosis, and mechanical ventilation or vasopressor support were significantly associated with high mortality. Future studies are recommended to evaluate those risk factors and the efficacy of rapid diagnosis and early therapy in patients at high risk.

Coccidioidomycosis in Immunocompromised at a Non-Endemic Referral Center in Mexico

The incidence and distribution of coccidioidomycosis are increasing. Information scarcity is evident in Mexico, particularly in non-endemic zones and specific populations. We compared the treatment and outcomes for patients with isolated pulmonary infections and those with disseminated coccidioidomycosis, including mortality rates within six weeks of diagnosis. Of 31 CM cases, 71% were male and 55% were disseminated. For 42% of patients, there was no evidence of having lived in or visited an endemic region. All patients had at least one comorbidity, and 58% had pharmacologic immunosuppressants. The general mortality rate was 30%; without differences between disseminated and localized disease. In our research, we describe a CM with a high frequency of disseminated disease without specific risk factors and non-significant mortality. Exposure to endemic regions was not found in a considerable number of subjects. We consider diverse reasons for why this may be, such as climate change or migration.

Risk of Coccidioidomycosis Infection Among Individuals Using Biologic Response Modifiers, Corticosteroids, and Oral Small Molecules

OBJECTIVE

The study objective was to examine associations between the use of biologic response modifiers (BRMs), corticosteroids, and oral small molecules (OSMs) and subsequent coccidioidomycosis infection risk among US Medicare beneficiaries with rheumatic or autoimmune diseases.

METHODS

This retrospective cohort study used US 2011 to 2016 Medicare claims data. We identified geographic areas with endemic coccidioidomycosis (≥25 cases per 10,000 beneficiaries). Among beneficiaries having any rheumatic/autoimmune diseases, we identified those initiating BRMs, corticosteroids, and OSMs. Based on refill days supplied, we created time-varying exposure variables for BRMs, corticosteroids, and OSMs with a 90-day lag period after drug cessation. We examined BRMs, corticosteroids, and OSMs and subsequent coccidioidomycosis infection risk using multivariable Cox proportional hazard regression.

RESULTS

Among 135,237 beneficiaries (mean age: 67.8 years; White race: 83.1%; Black race: 3.6%), 5,065 had rheumatic or autoimmune diseases, of which 107 individuals were diagnosed with coccidioidomycosis during the study period (6.1 per 1,000 person-years). Increased risk of coccidioidomycosis was observed among beneficiaries prescribed any BRMs (17.7 per 1,000 person-years; adjusted hazard ratio [aHR] 3.94; 95% confidence interval [CI] 1.18-13.16), followed by individuals treated with only corticosteroids (12.2 per 1,000 person-years; aHR 2.29; 95% CI 1.05-5.03) compared to those treated with only OSMs (4.2 per 1,000 person-years). The rate of those treated with only OSMs was the same as that of beneficiaries without these medications.

CONCLUSION

Incidence of coccidioidomycosis was low among 2011 to 2016 Medicare beneficiaries with rheumatic or autoimmune diseases. BRM and corticosteroid users may have higher risks of coccidioidomycosis compared to nonusers, warranting consideration of screening for patients on BRMs and corticosteroids in coccidioidomycosis endemic areas.

Coccidioidomycosis in Oklahoma: A retrospective case series

BACKGROUND

Coccidioidomycosis is a systemic fungal disease endemic to arid regions of the Western Hemisphere. In the south-western US, Coccidioides spp. may account for up to 20%-25% of all cases of community acquired pneumonia. Clinical manifestations vary widely, from asymptomatic infection to life-threatening disease, especially in immunocompromised hosts.

OBJECTIVES

The primary objective of the study was to characterise cases of coccidioidomycosis in an area of the United States not considered traditionally endemic for the disease.

METHODS

We performed a single-centre retrospective study of all cases of coccidioidomycosis from 1 January 2000 to 31 December 2020, in the University of Oklahoma Health Sciences Medical Center.

RESULTS

A total of 26 patients were included for analysis. The central nervous system (CNS) and the lungs were the sites most frequently involved. Twenty (77%) had travelled to a coccidioidomycosis endemic region. Most were male (81%) with a median age of 42 years (range: 3-78 years). The majority (46%) were Caucasians, 19% were African American, 19% Hispanic, and 12% Native American. The most common comorbidities were diabetes mellitus and acquired immunodeficiency syndrome, identified in 27% and 23% of patients, respectively. Patients on immunosuppressive therapy accounted for 12% of all cases.

CONCLUSION

Our study is one of the largest single-centre case series of coccidioidomycosis from a non-endemic area. Diabetes mellitus was the most frequent comorbidity. Compared to other case series of coccidioidomycosis, our patient population had higher rates of immunosuppression and had both a higher rate of disseminated disease and overall mortality.

The Known and Unknown "Knowns" of Human Susceptibility to Coccidioidomycosis

Coccidioidomycosis occurs after inhalation of airborne spores of the endemic, dimorphic fungus, Coccidioides. While the majority of individuals resolve the infection without coming to medical attention, the fungus is a major cause of community-acquired pneumonia in the endemic region, and chronic pulmonary and extrapulmonary disease poses significant personal and economic burdens. This review explores the literature surrounding human susceptibility to coccidioidomycosis, including chronic pulmonary and extrapulmonary dissemination. Over the past century of study, themes have emerged surrounding factors impacting human susceptibility to severe disease or dissemination, including immune suppression, genetic susceptibility, sex, pregnancy, and genetic ancestry. Early studies were observational, frequently with small numbers of cases; several of these early studies are highly cited in review papers, becoming part of the coccidioidomycosis "canon". Specific genetic variants, sex, and immune suppression by TNF inhibitors have been validated in later cohort studies, confirming the original hypotheses. By contrast, some risk factors, such as ABO blood group, Filipino ancestry, or lack of erythema nodosum among black individuals, are repeated in the literature despite the lack of supporting studies or biologic plausibility. Using examination of historical reports coupled with recent cohort and epidemiology studies, evidence for commonly reported risk factors is discussed.

The dog as a sentinel and animal model for coccidioidomycosis

Coccidioidomycosis is a potentially fatal fungal disease of humans and animals that follows inhalation of Coccidioides spp. arthroconidia in the environment. The disease in dogs resembles that in people, and because dogs may be at increased risk of exposure due to their proximity to the ground and digging behavior, they are valuable models for the disease in humans. Dogs have been sentinels for identification of new regions of endemicity in Washington and Texas. Canine serosurveillance has also been used to predict variables associated with environmental presence of Coccidioides spp. Expansion of the endemic region of coccidioidomycosis with climate change-along with predicted population increases and increased development in the southwest United States-may result in 45.4 million additional people at risk of infection by 2090. Here we provide an overview of the value of dogs as sentinels for the disease and encourage the routine reporting of coccidioidomycosis cases in dogs to public health agencies. We also highlight the value of dogs as naturally occurring models for studying novel treatment options and preventatives, such as a novel live avirulent coccidioidomycosis vaccine.

Social determinants of health as drivers of fungal disease

Disparities in social determinants of health (SDOH) play a significant role in causing health inequities globally. The physical environment, including housing and workplace environment, can increase the prevalence and spread of fungal infections. A number of professions are associated with increased fungal infection risk and are associated with low pay, which may be linked to crowded and sub-optimal living conditions, exposure to fungal organisms, lack of access to quality health care, and risk for fungal infection. Those involved and displaced from areas of armed conflict have an increased risk of invasive fungal infections. Lastly, a number of fungal plant pathogens already threaten food security, which will become more problematic with global climate change. Taken together, disparities in SDOH are associated with increased risk for contracting fungal infections. More emphasis needs to be placed on systematic approaches to better understand the impact and reducing the health inequities associated with these disparities.

Coccidioidomycosis Osteoarticular Dissemination

Valley fever or coccidioidomycosis is a pulmonary infection caused by species of Coccidioides fungi that are endemic to California and Arizona. Skeletal coccidioidomycosis accounts for about half of disseminated infections, with the vertebral spine being the preferred site of dissemination. Most cases of skeletal coccidioidomycosis progress to bone destruction or spread to adjacent structures such as joints, tendons, and other soft tissues, causing significant pain and restricting mobility. Manifestations of such cases are usually nonspecific, making diagnosis very challenging, especially in non-endemic areas. The lack of basic knowledge and research data on the mechanisms defining susceptibility to extrapulmonary infection, especially when it involves bones and joints, prompted us to survey available clinical and animal data to establish specific research questions that remain to be investigated. In this review, we explore published literature reviews, case reports, and case series on the dissemination of coccidioidomycosis to bones and/or joints. We highlight key differential features with other conditions and opportunities for mechanistic and basic research studies that can help develop novel diagnostic, prognostic, and treatment strategies.

Epidemiology of Coccidioidomycosis in the Veterans Health Administration, 2013-2022

We describe the epidemiology of coccidioidomycosis among a national cohort of Veterans. Using electronic health record data from adults tested for coccidioidomycosis between 1 January 2013 and 31 December 2022, we analyzed differences in baseline demographics (age, sex, race/ethnicity, birth country, comorbidities, residence, and Charlson Comorbidity Index score) between 4204 coccidioidomycosis-test-positive and 63,322 test-negative Veterans. Log-binomial regression models with adjusted risk ratios (aRRs) were used to evaluate risk factors associated with coccidioidomycosis including dissemination, hospitalization, and mortality. Case counts and incidence rates were highest in select counties in Arizona and California where Coccidioides is endemic. Coccidioidomycosis-positive Veterans were younger, more likely to be male, and Philippine-born. The risk factors most highly associated with being coccidioidomycosis-positive included Native Hawaiian/Pacific Islander (aRR 1.068 [95%CI: 1.039-1.098]), Asian (aRR 1.060 [95%CI: 1.037-1.083]), Black (aRR 1.029 [95%CI: 1.022-1.036]), American Indian/Alaska Native (aRR 1.026 [95%CI: 1.004-1.048]) race, and Hispanic/Latino ethnicity (aRR 1.021 [95%CI: 1.013-1.028]). Black race (aRR: 1.058 [95%CI: 1.037-1.081]) and Hispanic/Latino ethnicity (aRR 1.018 [95%CI: 1.0003-1.036]) were also associated with disseminated coccidioidomycosis, strengthening the evidence for the association of coccidioidomycosis, including severe infections, with specific racial and ethnic groups. There were no statistically significant differences in hospitalization within 45 days of testing or 30-day all-cause mortality. Improving our understanding of coccidioidomycosis risk factors is important for targeted prevention strategies and to reduce delays in diagnosis and ineffective treatment.

Challenges in the Long-term Management of Patients With Coccidioidal Meningitis: A Retrospective Analysis of Treatment and Outcomes

Background

Coccidioidal meningitis (CM) is the most severe form of disseminated coccidioidomycosis. Despite years of clinical experience, it remains a difficult condition to treat, often requiring surgical procedures, such as placement of a ventriculoperitoneal shunt, in addition to lifelong antifungal therapy.

Methods

We performed a retrospective analysis of patients with CM seen in a large referral center in Central Valley, California, from 2010 to 2020. Data pertinent to CM were collected and analyzed.

Results

Among 133 patients with CM identified in the 10-year period, nonadherence to antifungal therapy was noted in 43% of patients. Of the 80 patients who underwent ventriculoperitoneal shunt placement for management of intracranial pressure, shunt failure requiring revision surgery occurred in 42 (52.5%). Rehospitalizations due to CM-related reasons occurred in 78 of 133 patients (59%). Twenty-three percent of patients (n = 29) died due to complications from CM, on an average 22 months after the diagnosis of CM. Encephalopathy at presentation was associated with a significantly higher risk of death.

Conclusions

Patients with CM in central California are predominantly rural agricultural workers with elevated levels of poverty and low health literacy and many barriers to care, leading to high rates of medication nonadherence and loss to follow-up outpatient care. Management challenges are frequent, such as failure of antifungal therapy, high rates of rehospitalization, and the need for repeated shunt revision surgeries. In addition to the development of curative new antifungal agents, understanding the barriers to patient adherence to care and antifungal therapy and identifying means to overcome such barriers are of paramount importance.

Review of Clinical and Laboratory Diagnostics for Coccidioidomycosis

Coccidioidomycosis is a fungal disease associated with soil exposure that frequently goes undiagnosed due at least in part to its nonspecific presentation and the lack of clinical suspicion by health care providers. Currently available diagnostics for coccidioidomycosis offer qualitative results that can suffer from low specificity, while semiquantitative assays are labor-intensive and complex and can require multiple days to complete. Furthermore, significant confusion exists regarding the optimal diagnostic algorithms and appropriate usage of available diagnostic tests. This review aims to inform clinical laboratorians and treating clinicians about the current diagnostic landscape, appropriate diagnostic strategies, and future diagnostic directions for coccidioidomycosis, which is expected to become more prevalent due to increased migration into areas of endemicity and climate changes.

Pediatric Laryngeal Coccidioidomycosis: A Case Series in an Endemic Region

BACKGROUND

Laryngeal coccidioidomycosis is a rare but life-threatening manifestation of coccidioidomycosis. Data in children are sparse and limited to case reports. We conducted this study to review the characteristics of laryngeal coccidioidomycosis in children.

METHODS

We performed a retrospective review of patients ≤21 years of age with laryngeal coccidioidomycosis who were treated from January 2010 to December 2017. We collected demographic data, clinical and laboratory studies and patient outcomes.

RESULTS

Five cases of pediatric laryngeal coccidioidomycosis were reviewed. All children were Hispanic and 3 were female. The median age was 1.8 years and the median duration of symptoms before diagnosis was 24 days. The most common symptoms included fever (100%), stridor (60%), cough (100%) and vocal changes (40%). Airway obstruction requiring tracheostomy and/or intubation for airway management was present in 80%. The most frequent location of lesions was the subglottic area. Coccidioidomycosis complement fixation titers were frequently low and culture/histopathology of laryngeal tissue was necessary to make a definitive diagnosis. All patients required surgical debridement and were treated with antifungal agents. None of the patients had recurrence during the follow-up period.

CONCLUSIONS

This study suggests that laryngeal coccidioidomycosis in children presents with refractory stridor or dysphonia and severe airway obstruction. Favorable outcomes can be achieved with a comprehensive diagnostic work-up and aggressive surgical and medical management. With the rise in cases of coccidioidomycosis, physicians should have a heightened awareness regarding the possibility of laryngeal coccidioidomycosis when encountering children who have visited or reside in endemic areas with stridor or dysphonia.

Coccidioides-Induced Pyopneumothorax in an Immunocompetent Patient

Coccidioidomycosis is a rare infection caused by the dimorphic fungi Coccidiodes immitus or Coccidioides posadasii. This fungal infection is very common in the American Southwest as well as northern Mexico. Though the fungus is ubiquitous, symptomatic coccidioidomycosis usually occurs in the elderly or immunocompromised. This case report discusses a unique instance of an immunocompetent 29-year-old male without any notable past medical history who was found to have a coccidioidal cavitary lung lesion with concomitant pyopneumothorax.

Outcomes with severe pulmonary coccidioidomycosis and respiratory failure in the United States

Background:

Coccidioidomycosis is a fungal infection with presentations ranging from asymptomatic illness to severe pneumonia and respiratory failure. The outcomes of patients with severe pulmonary coccidioidomycosis requiring mechanical ventilation (MV) are not well understood.

Methods:

We performed a retrospective cohort analysis utilizing the Nationwide Inpatient Sample (NIS) from 2006 to 2017. Patients >18 years of age with a diagnosis of pulmonary coccidioidomycosis were included in the cohort.

Results:

A total of 11,045 patients were hospitalized with a diagnosis of pulmonary coccidioidomycosis during the study period. Of these, 826 (7.5%) patients required MV during their hospitalization with a mortality rate of 33.5% compared to 1.3% ( p < 0.01) for patients not requiring MV. Results of the multivariable logistic regression model show that risk factors for MV included the history of neurological disorders and paralysis (OR 3.38, 95% CI 2.70 to 4.20, p < 0.01; OR 3.13, 95% CI 1.91 to 5.15, p < 0.01, respectively) and HIV (OR 1.63, 95% 1.10 to 2.43, p < 0.01). Risk factors for mortality among patients requiring MV included older age (OR 1.24 per 10-year increase, 95% CI 1.08 to 1.42, p < 0.01), coagulopathy (OR 1.61, 95% CI 1.09 to 2.38, p = 0.01) and HIV (OR 2.83; 95% CI 1.32 to 6.10; p < 0.01).

Conclusions:

Approximately 7.5% of patients admitted with coccidioidomycosis in the United States require MV, and MV is associated with high mortality (33.5%).

Race and ethnicity: Risk factors for fungal infections?

Racial and ethnic identities, largely understood as social rather than biologic constructs, may impact risk for acquiring infectious diseases, including fungal infections. Risk factors may include genetic and immunologic differences such as aberrations in host immune response, host polymorphisms, and epigenomic factors stemming from environmental exposures and underlying social determinants of health. In addition, certain racial and ethnic groups may be predisposed to diseases that increase risk for fungal infections, as well as disparities in healthcare access and health insurance. In this review, we analyzed racial and ethnic identities as risk factors for acquiring fungal infections, as well as race and ethnicity as they relate to risk for severe disease from fungal infections. Risk factors for invasive mold infections such as aspergillosis largely appear related to environmental differences and underlying social determinants of health, although immunologic aberrations and genetic polymorphisms may contribute in some circumstances. Although black and African American individuals appear to be at high risk for superficial and invasive Candida infections and cryptococcosis, the reasons for this are unclear and may be related to underling social determinants of health, disparities in access to healthcare, and other socioeconomic disparities. Risk factors for all the endemic fungi are likely largely related to underlying social determinants of health, socioeconomic, and health disparities, although immunologic mechanisms likely play a role as well, particularly in disseminated coccidioidomycosis.

Osteoarticular Mycoses

Osteoarticular mycoses are chronic debilitating infections that require extended courses of antifungal therapy and may warrant expert surgical intervention. As there has been no comprehensive review of these diseases, the International Consortium for Osteoarticular Mycoses prepared a definitive treatise for this important class of infections. Among the etiologies of osteoarticular mycoses are Candida spp., Aspergillus spp., Mucorales, dematiaceous fungi, non-Aspergillus hyaline molds, and endemic mycoses, including those caused by Histoplasma capsulatum, Blastomyces dermatitidis, and Coccidioides species. This review analyzes the history, epidemiology, pathogenesis, clinical manifestations, diagnostic approaches, inflammatory biomarkers, diagnostic imaging modalities, treatments, and outcomes of osteomyelitis and septic arthritis caused by these organisms. Candida osteomyelitis and Candida arthritis are associated with greater events of hematogenous dissemination than those of most other osteoarticular mycoses. Traumatic inoculation is more commonly associated with osteoarticular mycoses caused by Aspergillus and non-Aspergillus molds. Synovial fluid cultures are highly sensitive in the detection of Candida and Aspergillus arthritis. Relapsed infection, particularly in Candida arthritis, may develop in relation to an inadequate duration of therapy. Overall mortality reflects survival from disseminated infection and underlying host factors.

Fun with fungi: a comprehensive review of common fungal organisms encountered in cytology

The ability to detect and diagnose infection is essential in the practice of cytopathology. The identification of suppurative or granulomatous inflammation should prompt careful evaluation for infection. Many of the most commonly encountered fungal organisms demonstrate characteristic microscopic appearances that allow accurate identification even with routine cytology stains, particularly when considered in the context of clinical factors such as geographic location, social history, patient immune status, and symptoms. Given the vital role cytopathologists play in the accurate diagnosis or presumptive identification of infections, this review explores the epidemiology, clinical manifestations, and morphologic features of common fungal pathogens in addition to their differential diagnoses and ancillary testing methods.

Immunogenetics associated with severe coccidioidomycosis

Disseminated coccidioidomycosis (DCM) is caused by Coccidioides, pathogenic fungi endemic to the southwestern United States and Mexico. Illness occurs in approximately 30% of those infected, less than 1% of whom develop disseminated disease. To address why some individuals allow dissemination, we enrolled patients with DCM and performed whole-exome sequencing. In an exploratory set of 67 patients with DCM, 2 had haploinsufficient STAT3 mutations, and defects in β-glucan sensing and response were seen in 34 of 67 cases. Damaging CLEC7A and PLCG2 variants were associated with impaired production of β-glucan-stimulated TNF-α from PBMCs compared with healthy controls. Using ancestry-matched controls, damaging CLEC7A and PLCG2 variants were overrepresented in DCM, including CLEC7A Y238* and PLCG2 R268W. A validation cohort of 111 patients with DCM confirmed the PLCG2 R268W, CLEC7A I223S, and CLEC7A Y238* variants. Stimulation with a DECTIN-1 agonist induced DUOX1/DUOXA1-derived hydrogen peroxide [H2O2] in transfected cells. Heterozygous DUOX1 or DUOXA1 variants that impaired H2O2 production were overrepresented in discovery and validation cohorts. Patients with DCM have impaired β-glucan sensing or response affecting TNF-α and H2O2 production. Impaired Coccidioides recognition and decreased cellular response are associated with disseminated coccidioidomycosis.

Spinal Arachnoiditis in Patients with Coccidioidomycosis Meningitis-Analysis of Clinical and Imaging Features

Background: Coccidioidomycosis meningitis (CM) is the most aggressive form of coccidioidomycosis, requiring lifelong antifungal treatment and often cerebrospinal fluid (CSF) diversion. Long-standing CM can be associated with spinal complications such as arachnoiditis. However, studies describing the frequency, clinical, and imaging characteristics of arachnoiditis in patients with CM are limited. Methods: We identified 133 patients with CM based on CSF culture, PCR, or serology between January 2010 and December 2020. Of these, 37 patients underwent spinal imaging. Data on demographics, risk factors, symptoms, antifungal therapy, surgical management, follow-up visits, adherence, serological trends, and imaging findings were reviewed. Results: Abnormal findings were observed in 30 of the 37 patients with CM who underwent spinal imaging. The imaging abnormalities noted in our study included leptomeningeal enhancement (53%), arachnoiditis (53%), syringomyelia (23%), cord signal abnormalities (10%), and osteomyelitis (7%). Of the 30 patients, 90% had symptoms, such as weakness, numbness, or urinary retention. The incidence of arachnoiditis in the present study was 12%. Higher initial CSF protein levels and intra cranial pressure were associated with a higher risk of developing arachnoiditis/syringomyelia. Management of CM was challenging, as evidenced by shunt failure (46%), medication non-compliance (57%), and lack of adequate follow-up (60%). Persistent disabilities were noted in 62% of the patients. Conclusions: Patients with CM develop spinal complications such as arachnoiditis, or syringomyelia. Many cases may go undetected due to lack of symptoms in early stages. CM management challenges such as shunt failure, lack of follow-up care, and medication noncompliance, were frequent.

Surveillance for Coccidioidomycosis, Histoplasmosis, and Blastomycosis - United States, 2019

PROBLEM/CONDITION

Coccidioidomycosis, histoplasmosis, and blastomycosis are underdiagnosed fungal diseases that often mimic bacterial or viral pneumonia and can cause disseminated disease and death. These diseases are caused by inhalation of fungal spores that have distinct geographic niches in the environment (e.g., soil or dust), and distribution is highly susceptible to climate changes such as expanding arid regions for coccidioidomycosis, the northward expansion of histoplasmosis, and areas like New York reporting cases of blastomycosis previously thought to be nonendemic. The national incidence of coccidioidomycosis, histoplasmosis, and blastomycosis is poorly characterized.

REPORTING PERIOD

2019.

DESCRIPTION OF SYSTEM

The National Notifiable Diseases Surveillance System (NNDSS) tracks cases of coccidioidomycosis, a nationally notifiable condition reported to CDC by 26 states and the District of Columbia. Neither histoplasmosis nor blastomycosis is a nationally notifiable condition; however, histoplasmosis is voluntarily reported in 13 states and blastomycosis in five states. Health departments classify cases based on the definitions established by the Council of State and Territorial Epidemiologists.

RESULTS

In 2019, a total of 20,061 confirmed coccidioidomycosis, 1,124 confirmed and probable histoplasmosis, and 240 confirmed and probable blastomycosis cases were reported to CDC. Arizona and California reported 97% of coccidioidomycosis cases, and Minnesota and Wisconsin reported 75% of blastomycosis cases. Illinois reported the greatest percentage (26%) of histoplasmosis cases. All three diseases were more common among males, and the proportion for blastomycosis (70%) was substantially higher than for histoplasmosis (56%) or coccidioidomycosis (52%). Coccidioidomycosis incidence was approximately four times higher for non-Hispanic American Indian or Alaska Native (AI/AN) persons (17.3 per 100,000 population) and almost three times higher for Hispanic or Latino persons (11.2) compared with non-Hispanic White (White) persons (4.1). Histoplasmosis incidence was similar across racial and ethnic categories (range: 0.9-1.3). Blastomycosis incidence was approximately six times as high among AI/AN persons (4.5) and approximately twice as high among non-Hispanic Asian and Native Hawaiian or other Pacific Islander persons (1.6) compared with White persons (0.7). More than one half of histoplasmosis (54%) and blastomycosis (65%) patients were hospitalized, and 5% of histoplasmosis and 9% of blastomycosis patients died. States in which coccidioidomycosis is not known to be endemic had more cases in spring (March, April, and May) than during other seasons, whereas the number of cases peaked slightly in autumn (September, October, and November) for histoplasmosis and in winter (December, January, and February) for blastomycosis.

INTERPRETATION

Coccidioidomycosis, histoplasmosis, and blastomycosis are diseases occurring in geographical niches within the United States. These diseases cause substantial illness, with approximately 20,000 coccidioidomycosis cases reported in 2019. Although substantially fewer histoplasmosis and blastomycosis cases were reported, surveillance was much more limited and underdiagnosis was likely, as evidenced by high hospitalization and death rates. This suggests that persons with milder symptoms might not seek medical evaluation and the symptoms self-resolve or the illnesses are misdiagnosed as other, more common respiratory diseases.

PUBLIC HEALTH ACTION

Improved surveillance is necessary to better characterize coccidioidomycosis severity and to improve detection of histoplasmosis and blastomycosis. These findings might guide improvements in testing practices that enable timely diagnosis and treatment of fungal diseases. Clinicians and health care professionals should consider coccidioidomycosis, histoplasmosis, and blastomycosis in patients with community-acquired pneumonia or other acute infections of the lower respiratory tract who live in or have traveled to areas where the causative fungi are known to be present in the environment. Culturally appropriate tailored educational messages might help improve diagnosis and treatment. Public health response to these three diseases is hindered because information gathered from states' routine surveillance does not include data on populations at risk and sources of exposure. Broader surveillance that includes expansion to other states, and more detail about potential exposures and relevant host factors can describe epidemiologic trends, populations at risk, and disease prevention strategies.

Coccidioidomycosis Knowledge and Behaviors of California Hispanic Farm Workers

(1) Describe knowledge, attitudes, beliefs, and behaviors related to coccidioidomycosis (Valley fever, VF) reported by farm workers in a highly endemic area to design and evaluate prevention messages and (2) identify health information sources preferred by farm workers to disseminate VF prevention messages. There were 119 primarily Mexican-born residents of two migrant farm labor housing centers in Kern County, who completed an interviewer-administered survey on VF knowledge, attitudes, beliefs, and behaviors in 2017. The 73% of participants aware of VF demonstrated a knowledge score of 53%. Over 90% erroneously believed VF was associated with pesticide exposure; approximately two-thirds believed that wearing a bandana mask was protective. Over half of respondents believed that VF was contagious, could be contracted from contaminated food or water, and caused gastrointestinal symptoms. Of those aware of VF, 75% expressed concern about becoming infected because of where they lived and working outdoors. Working outdoors in dusty conditions was the most commonly reported risk-associated work practice. Among 67 participants reporting use of respiratory protection, 94% indicated they wear a bandana; most male participants did not wear face coverings in dusty conditions. The most frequent protective work practice was wetting soil. Preferred sources of health information included television; family, friend, or co-worker; healthcare provider; and radio. Farm workers reported multiple risk factors for VF. Results identified several areas of poor knowledge, risk behavior, and preferred channels of prevention messages. Important protective behaviors are not under the control of farm workers; engagement with employers is essential.

Sex Differences in the Susceptibility to Coccidioidomycosis

To assess sex-specific differences in coccidioidomycosis, a retrospective analysis of human patients, nonhuman primates, and veterinary patients (including the neutered status of the animal) was performed. We found higher rates of infection and severity in males. This observed increased infection risk suggests deeper biological underpinnings than solely occupational/exposure risks.

Contribution of Biologic Response Modifiers to the Risk of Coccidioidomycosis Severity

Background

The risk of coccidioidomycosis (CM) as a life-threatening respiratory illness or disseminated CM (DCM) increases as much as 150-fold in immunosuppressed patients. The safety of biologic response modifiers (BRMs) as treatment for patients with autoimmune disease (AI) in CM-endemic regions is not well defined. We sought to determine that risk in the Tucson and Phoenix areas.

Methods

We conducted a retrospective study reviewing demographics, Arizona residency length, clinical presentations, specific AI diagnoses, CM test results, and BRM treatments in electronic medical records (EMR) of patients &gt;18 years old with International Classification of Diseases (ICD-10) codes for CM and AI from 10/01/2017 to 12/31/2019.

Results

We reviewed 944 charts with overlapping ICD-10 codes for CM and AI, of which 138 were confirmed to have both diagnoses. Male gender was associated with more CM (p=0.003), and African ancestry was three times more likely than European to develop DCM (p&lt;0.001). Comparing CM+/AI+ (138) with CM+/AI- (449) patients, there were no significant differences in CM clinical presentations. Patients receiving BRMs had 2.4 times more DCM compared to Pulmonary CM (PCM).

Conclusions

AI does not increase the risk of any specific CM clinical presentation, and BRM treatment of most AI patients does not lead to severe CM. However, BRMs significantly increase the risk of DCM, and prospective studies are needed to identify the immunogenetic subset that permits BRM-associated DCM.

Disseminated Coccidioidomycosis Presenting as Fever of Unknown Origin and Erythema Nodosum in a 3-Year-Old Child

Disseminated coccidioidomycosis is a disease caused by Coccidioides species, fungi endemic to the southwestern United States. We present here an uncommon case of a young child with erythema nodosum and fever of unknown origin, found to have the infection. While more common in adults, coccidioidomycosis should be considered in all patients with erythema nodosum.

Coccidioidomycosis

Coccidioidomycosis, caused by the dimorphic pathogenic fungi Coccidioides immitis and Coccidioides posadassi, is endemic to the southwestern United states and Central and South America. The incidence of coccidioidomycosis continues to increase. Coccidioidomycosis is typically a self-limiting influenza-like respiratory illness; however, it can lead to disseminated disease outside of the lungs. Not all nondisseminated cases require therapy, but antifungal therapy is typically beneficial requiring treatment ranging from months to lifelong. Clinical factors related to treatment decisions include severity of symptoms, radiography, coccidioidomycosis serologic results, and concurrent medical problems including immunosuppression. This review summarizes the epidemiology, clinical manifestations, and treatment options.

Smoking as a Risk Factor of Invasive Fungal Disease: Systematic Review and Meta-Analysis

To investigate the association between smoking and invasive fungal disease (IFD), we searched MEDLINE and Web of Science for studies published until September 2018. Two authors independently performed study selection and data extraction. Relative risks (RRs) were pooled using random-effects meta-analysis. We included 25 studies (18 171 participants; 2527 IFD cases). The meta-analysis showed an increased risk of IFD in smokers (RR 1.41 [95% confidence interval 1.09-1.81]; P = .008). The risk of IFD was higher in retrospective than in prospective studies (RR 1.93 [1.28-2.92] vs. 1.02 [0.78-1.34]; P = .04), in studies with multivariate adjustment compared to studies with univariate analysis (RR 2.15 [1.27-3.64] vs. 1.15 [0.88-1.51]; P = .06), and in studies published after 2002 (RR 2.08 [1.37-3.15] vs. 0.95 [0.75-1.22]; P = .008); other subgroup characteristics did not significantly influence the association in metaregression. Smoking cessation strategies should be implemented, especially in patients who are already at risk for IFD.

Economic Valuation of Coccidioidomycosis (Valley Fever) Projections in the United States in Response to Climate Change

Coccidioidomycosis, or valley fever, is an infectious fungal disease currently endemic to the southwestern United States. Symptoms of valley fever range in severity from flu-like illness to severe morbidity and mortality. Warming temperatures and changes in precipitation patterns may cause the area of endemicity to expand northward throughout the western United States, putting more people at risk for contracting valley fever. This may increase the health and economic burdens from this disease. We developed an approach to describe the relationship between climate conditions and valley fever incidence using historical data and generated projections of future incidence in response to both climate change and population trends using the Climate Change Impacts and Risk Analysis (CIRA) framework developed by the U.S. Environmental Protection Agency. We also developed a method to estimate economic impacts of valley fever that is based on case counts. For our 2000-15 baseline time period, we estimated annual medical costs, lost income, and economic welfare losses for valley fever in the United States were $400,000 per case, and the annual average total cost was $3.9 billion per year. For a high greenhouse gas emission scenario and accounting for population growth, we found that total annual costs for valley fever may increase up to 164% by year 2050 and up to 380% by 2090. By the end of the twenty-first century, valley fever may cost $620,000 per case and the annual average total cost may reach $18.5 billion per year. This work contributes to the broader effort to monetize climate change-attributable damages in the United States.

Sociodemographic factors associated with patients hospitalised for coccidioidomycosis in California and Arizona, State Inpatient Database 2005-2011

Coccidioidomycosis is endemic in the Southwestern United States. Disseminated infection can be life-threatening and is responsible for hospitalisation and significant healthcare resource utilisation. There are limited data evaluating factors associated with hospitalisation for coccidioidomycosis. We conducted a cross-sectional study to assess incidence and factors associated with coccidioidomycosis-associated hospitalisation in California and Arizona. We analysed hospital discharge data obtained from the State Inpatient Dataset for California and Arizona between 2005 and 2011 and performed multivariable logistic regression examining factors associated with coccidioidomycosis-associated hospitalisation. During our time frame, we found 23 758 coccidioidomycosis-associated hospitalisations. Coccidioidomycosis incidence was over sixfold higher in Arizona compared to California (198.9 vs. 29.6/100 000 person-years). In our multivariable model, coccidioidomycosis-associated hospitalisation was associated with age group 40-49 years (referent group: age 18-29 years, adjusted odds ratio (aOR) = 1.50 (95% confidence interval (CI) 1.43-1.59)), African American race (referent group: Caucasian, aOR = 1.98 (95% CI 1.89-2.06)), residing in a large rural town (referent group: urban area, aOR = 2.28 (95% CI 2.19-2.39)), uncomplicated diabetes (aOR = 1.47 (95% CI 1.41-1.52)) chronic obstructive pulmonary disease (aOR = 1.59 (95% CI 1.54-1.65)) and higher number of comorbidities (aOR = 1.02 (95% CI 1.02-1.03) for each point in the Elixhauser score). Identifying persons at highest risk for hospitalisation with coccidioidomycosis may be helpful for future prevention efforts.

Valley Fever (Coccidioidomycosis) Awareness - California, 2016-2017

Valley fever (coccidioidomycosis) is endemic in the southwestern United States and caused by inhalation of Coccidioides spp. fungal spores from soil or dust; 97% of U.S. Valley fever cases are reported from Arizona and California (1). In California, Valley fever incidence increased 213% from 2014 to 2018 (2). In 2016, the California Department of Public Health (CDPH) added three questions to the adult California Behavioral Risk Factor Surveillance System (BRFSS) survey to better understand whether Californians had heard of Valley fever, knew the environmental risk where they live, and knew who is at risk for severe disease. A total of 2,893 BRFSS respondents aged ≥18 years answered at least one Valley fever question. Using the weighted California population, 42.4% of respondents reported general awareness of Valley fever; awareness was lowest among adults aged 18-44 years (32.9%) and Hispanic persons (26.4%). In addition, despite higher percentages reporting awareness of Valley fever, only 25.0% of persons living in a high-incidence region and 3.0% of persons living in a moderate-incidence region were aware that they lived in areas where Coccidioides spp. exist. Among persons with one or more risk factors for severe disease, 50.8% reported having heard about Valley fever, but only 3.5% knew they were at increased risk for severe disease. The findings from this survey helped to inform a statewide Valley fever awareness campaign implemented during 2019-2020 and to guide outreach to persons living in high- and moderate-incidence regions in California and potentially other southwestern states or who are at risk for severe disease.

Smoking increases the risk of infectious diseases: A narrative review

Smoking is relevant to infectious diseases resulting in increased prevalence and mortality. In this article, we aim to provide an overview of the effects of smoking in various infections and to explain the potential mechanisms. We searched PubMed and other relevant databases for scientific studies that explored the relationship between smoking and infection. The mechanisms of susceptibility to infection in smokers may include alteration of the structural, functional and immunologic host defences. Smoking is one of the main risk factors for infections in the respiratory tract, digestive tract, reproductive tract, and other systems in humans, increasing the prevalence of HIV, tuberculosis, SARS-CoV, and the current SARS-CoV-2. Smoking cessation can reduce the risk of infection. Smoking increases the incidence of infections and aggravates the progress and prognosis of infectious diseases in a dose-dependent manner. Smoking cessation promotion and education are the most practical and economical preventive measures to reduce aggravation of disease infection owing to tobacco use.

Coccidioidal meningitis in non-AIDS patients. A case series at a Mexican neurological referral center

BACKGROUND

Coccidioidal meningitis is a life-threatening condition and a diagnostic challenge in cases of chronic meningitis. It is associated to severe complications, like basal arachnoiditis, hydrocephalus, and secondary vasculitis.

OBJECTIVE

To present a 20-year retrospective clinical series of coccidioidal meningitis cases at a Mexican neurological referral center.

RESULTS

The clinical records of 11 patients, predominantly males, were retrieved. Weight loss and night sweats were observed in 64 % of cases. Neurological signs included intracranial hypertension in 91 % of cases, altered alertness and meningeal syndrome in 72 %, and neuropsychiatric symptoms in 64 %. Mean CSF glucose levels were 30 ± 25 mg/dL, and pleocytosis ranged from 0 to 2218 cells/mm³. The diagnosis was confirmed by coccidioidal antigen latex agglutination in 91 % of cases. Radiological findings were hepatomegaly in 55 % of cases and pneumonia in 45 %. Neuroimaging findings included leptomeningitis in 73 % of cases, pachymeningitis in 45 %, and vascular involvement in 91 %. Less common findings included spinal cord lesion and mycotic aneurism, found in 18 % of cases. A molecular coccidioidal DNA test confirmed the predominance of Coccidioides immitis, detected in 64 % of cases. With respect to the clinical outcome, 46 % of patients died. The survivors suffered from sequels like chronic headache, cognitive alterations, and depression.

CONCLUSIONS

Coccidioidal meningitis is an entity with high mortality rates. More than one half of patients suffered disseminated disease. Although meningeal signs are not frequent in chronic meningitis, more than two-thirds of our patients showed mild nuchal rigidity. In addition, cerebral and cerebellar volume loss, associated with cognitive impairment and depression, was often observed in surviving patients during the clinical-radiological follow-up.

Innate Immune Receptors and Defense Against Primary Pathogenic Fungi

The innate immune system is critical for natural resistance to all pathogenic microorganisms, including fungi. The innate response plays a vital role in resistance to infections before the antigen-specific immune response and also influences antigen-specific adaptive immunity. There are many different receptors for the innate immune response to fungi, and some receptors have been found to play a significant role in the response to human infections with opportunistic fungi. Most human infections are caused by opportunistic fungi, but a small number of organisms are capable of causing infections in normal hosts. The primary pathogenic fungi that cause invasive infections include Blastomyces spp., Cryptococcus gattii, Coccidioides spp., Histoplasma spp., and Paracoccidioides spp. In this review of innate immune receptors that play a role in infections caused by these organisms, we find that innate immunity differs between organisms.

Coccidioidomycosis in solid organ transplant recipients

PURPOSE OF REVIEW

The purpose of the review is an update of diagnosis and treatment of coccidioidomycosis infection in solid organ transplant (SOT) patients. Endemic fungal infections continue to be a cause of serious morbidity and mortality in transplant recipients.

RECENT FINDINGS

In transplant patients there are recommendations regarding screening in areas that are endemic for coccidioidomycosis. This screening involves serologic testing and chest imaging. In endemic areas pretransplant seropositivity varies from 1.4 to 5.6%. In immunocompromised patients with elevated complement fixation titers, evaluation of cerebrospinal fluid is recommended even in the absence of symptoms. Although coccidioidomycosis can be a self-limited disease in immunocompotent patients, all SOT patients should be treated regardless of severity. This may include intravenous amphotericin B in severe cases and fluconazole therapy in milder episodes. In those SOT recipients with evidence of prior coccidioidomycosis, lifelong secondary prophylaxis with fluconazole given risk of recurrent disease.

SUMMARY

Coccidioidomycosis continues to be a cause of serious morbidity and mortality in transplant recipients but with proper screening and treatment can be successfully managed.

Infectious Lung Disease

Infectious diseases are one of the main causes of morbidity and mortality worldwide. With new pathogens continuously emerging, known infectious diseases reemerging, increasing microbial resistance to antimicrobial agents, global environmental change, ease of world travel, and an increasing immunosuppressed population, recognition of infectious diseases plays an ever-important role in surgical pathology. This becomes particularly significant in cases where infectious disease is not suspected clinically and the initial diagnostic workup fails to include samples for culture. As such, it is not uncommon that a lung biopsy becomes the only material available in the diagnostic process of an infectious disease. Once the infectious nature of the pathological process is established, careful search for the causative agent is advised. This can often be achieved by examination of the hematoxylin and eosin-stained sections alone as many organisms or their cytopathic effects are visible on routine staining. However, ancillary studies such as histochemical stains, immunohistochemistry, in situ hybridization, or molecular techniques may be needed to identify the organism in tissue sections or for further characterization, such as speciation.

The mysterious desert dwellers: Coccidioides immitis and Coccidioides posadasii, causative fungal agents of coccidioidomycosis

The genus Coccidioides consists of two species: C. immitis and C. posadasii. Prior to 2000, all disease was thought to be caused by a single species, C. immitis. The organism grows in arid to semiarid alkaline soils throughout western North America and into Central and South America. Regions in the United States, with highest prevalence of disease, include California, Arizona, and Texas. The Mexican states of Baja California, Coahuila, Sonora, and Neuvo Leon currently have the highest skin test positive results. Central America contains isolated endemic areas in Guatemala and Honduras. South America has isolated regions of high endemicity including areas of Colombia, Venezuela, Argentina, Paraguay, and Brazil. Although approximately 15,000 cases per year are reported in the United States, actual disease burden is estimated to be in the hundreds of thousands, as only California and Arizona have dedicated public health outreach, and report and track disease reliably. In this review, we survey genomics, epidemiology, ecology, and summarize aspects of disease, diagnosis, prevention, and treatment.

Viral, bacterial, and fungal infections of the oral mucosa: Types, incidence, predisposing factors, diagnostic algorithms, and management

For millions of years, microbiota residing within us, including those in the oral cavity, coexisted in a harmonious symbiotic fashion that provided a quintessential foundation for human health. It is now clear that disruption of such a healthy relationship leading to microbial dysbiosis causes a wide array of infections, ranging from localized, mild, superficial infections to deep, disseminated life-threatening diseases. With recent advances in research, diagnostics, and improved surveillance we are witnessing an array of emerging and re-emerging oral infections and orofacial manifestations of systemic infections. Orofacial infections may cause significant discomfort to the patients and unnecessary economic burden. Thus, the early recognition of such infections is paramount for holistic patient management, and oral clinicians have a critical role in recognizing, diagnosing, managing, and preventing either new or old orofacial infections. This paper aims to provide an update on current understanding of well-established and emerging viral, bacterial, and fungal infections manifesting in the human oral cavity.

Investigation of Genetic Susceptibility to Blastomycosis Reveals Interleukin-6 as a Potential Susceptibility Locus

Genetic differences are hypothesized to underlie ethnic disparities in incidence rates of the endemic systemic mycoses, including blastomycosis. Individuals of Hmong ancestry display elevated risk for this serious fungal infection. Here, we interrogated the genomes of Wisconsin (WI) Hmong blastomycosis patients using homozygosity mapping to uncover regions of the genome that are likely shared among the greater Hmong population and filtered for variants with high potential to affect disease susceptibility. This approach uncovered 113 candidate susceptibility variants, and among the most promising are those in genes involved in the interleukin-17 (IL-17) response. In particular, we identified 25 linked variants near the gene encoding IL-6 (IL6). We validated differences in cytokine production between Hmong and European volunteers and formally demonstrated a critical role for IL-6 in the development of adaptive immunity to Blastomyces dermatitidis Our findings suggest that the dysregulation of IL-17 responses underlies a recently reported and poorly understood ethnic health disparity.IMPORTANCE Blastomycosis is a potentially life-threatening infection caused by the fungus Blastomyces dermatitidis As with related fungal diseases, blastomycosis is noted to affect some populations more than others. These patterns of illness are often not related to predisposing conditions or exposure risks; thus, genetic differences are thought to underlie these health disparities. People of Hmong ancestry in Wisconsin are at elevated risk of blastomycosis compared to the general population. We studied the genetic codes of Hmong blastomycosis patients and identified candidate sites in their genomes that may explain their susceptibility to this infection. We further studied one particular region of the genome that is involved with the immune processes that fight B. dermatitidis Our work revealed population differences in the response to fungi. A better understanding of the genetic underpinnings of susceptibility to infectious diseases has broader implications for community health, especially in the paradigm of personalized medicine.

Coccidioidomycosis Among American Indians and Alaska Natives, 2001-2014

Background

American Indians and Alaska Natives (AI/ANs) may be uniquely vulnerable to coccidioidomycosis given the large population residing in the Southwestern United States. We describe coccidioidomycosis-associated hospitalizations and outpatient visits during 2001-2014 in the Indian Health Service (IHS) system and compare hospitalizations with data from the Agency for Healthcare Research and Quality's National (Nationwide) Inpatient Sample (NIS).

Methods

We identified hospitalizations in the IHS and the NIS and outpatient visits in the IHS using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes 114.0-114.9. We calculated average annual hospitalization and outpatient visit rates per 1 000 000 population and used Poisson regression to calculate rate ratios (RRs) and 95% confidence intervals (CIs). We used multivariable logistic regression to assess factors associated with IHS hospitalization.

Results

AI/ANs had the highest average annual hospitalization rate (58.0; 95% CI, 49.5-66.6) of any racial/ethnic group in the NIS, compared with 13.4 (95% CI, 12.7-14.2) for non-Hispanic whites. IHS data showed a hospitalization rate of 37.0; the median length of stay (interquartile range) was 6 (3-10) days. The average annual outpatient visit rate in IHS was 764.2, and it increased from 529.9 in 2001 to 845.9 in 2014. Male sex, age ≥65 years, diabetes, and extrapulmonary or progressive coccidioidomycosis were independently associated with increased risk for hospitalization. Twenty-four percent of patients had ICD-9-CM codes for community-acquired pneumonia in the 3 months before coccidioidomycosis diagnosis.

Conclusions

AI/ANs experience high coccidioidomycosis-associated hospitalization rates, high morbidity, and possible missed opportunities for earlier diagnosis. Yearly trends in IHS data were similar to the general increase in hospitalizations and reported cases nationwide in the same period.

Testing for Coccidioidomycosis among Community-Acquired Pneumonia Patients, Southern California, USA1

We conducted a cohort study to identify characteristics associated with testing for, and testing positive for, coccidioidomycosis among patients with community-acquired pneumonia in southern California, USA. Limited and delayed testing probably leads to underdiagnosis among non-Hispanic black, Filipino, or Hispanic patients and among high-risk groups, including persons in whom antimicrobial drug therapy has failed.

Pediatric Coccidioidomycosis: Case Series From a California Pediatric Infectious Diseases Clinic

BACKGROUND

Coccidioidomycosis is not as well described in the pediatric population as it is in the adult population. We describe clinical findings, diagnosis and management of coccidioidomycosis in 108 pediatric patients seen in an outpatient clinic in the California Central Valley, an area endemic for coccidioidomycosis.

METHODS

We reviewed medical records of a convenience sample of pediatric patients (≤17 years of age) diagnosed with coccidioidomycosis who visited an infectious diseases clinic in Madera, CA, during January 1 to October 1, 2012. We described demographic characteristics, symptoms, diagnostic testing, extent of infection (acute/pulmonary or disseminated), treatment and management.

RESULTS

Of 108 patients, 90 (83%) had acute/pulmonary coccidioidomycosis and 18 (17%) had disseminated disease. The median age at diagnosis was 9 years (range, 5 months to 17 years). Only 3 (3%) patients were immunocompromised. Before coccidioidomycosis diagnosis, 72 (82%) patients received antibiotics, and 31 (29%) had at least 1 negative coccidioidomycosis serology at the time of or before diagnosis. Coccidioidomycosis was diagnosed significantly later after symptom onset among patients with disseminated (median, 57 days) than with acute/pulmonary (median, 16 days) disease (p < 0.01). A total of 104 (96%) patients received antifungal therapy, 51 (47%) visited an emergency room and 59 (55%) were hospitalized with a median stay of 44 days (range, 1-272 days).

CONCLUSIONS

Substantial acute/pulmonary and disseminated coccidioidomycosis was seen among pediatric patients at this infectious disease clinic in California. In endemic areas, increased coccidioidomycosis awareness and vigilance among families and providers is necessary to facilitate early diagnosis and appropriate management.

Chronic Cavitary Infections Other than Tuberculosis: Clinical Aspects

Lung cavitation may be due to infectious or noninfectious pathologic processes. The latter category includes nonmalignant conditions, such as granulomatosis with polyangiitis, and malignant conditions, such as squamous cell carcinoma of the lung. Infectious etiologies that produce lung cavitation usually cause chronic illness, although some, particularly pyogenic bacteria, may produce acute cavitary disease. Tuberculosis is the most common cause of chronic pulmonary infection with cavitation. The goal of this review was to highlight a selection of the better-known infectious agents, other than tuberculosis, that can cause chronic lung disease with cavitation. Emphasis is placed on the following organisms: nontuberculous mycobacteria, Histoplasma, Blastomyces, Coccidioides, Paracoccidioides, Aspergillus, Burkholderia pseudomallei, Paragonimus westermani, and Rhodococcus equi. These organisms generally produce clinical features and radiologic findings that overlap or mimic those of tuberculosis. In a companion article, we have further emphasized aspects of the same conditions that are more pertinent to radiologists.

Myeloid Differentiation Factor 88 and Interleukin-1R1 Signaling Contribute to Resistance to Coccidioides immitis

Rodents are a natural host for the dimorphic pathogenic fungi Coccidioides immitis and Coccidioides posadasii, and mice are a good model for human infection. Humans and rodents both express Dectin-1 and Toll-like receptor 2 (TLR2) on myeloid cells, and those receptors collaborate to maximize the cytokine/chemokine responses to spherules (the tissue form of the fungi) and to formalin-killed spherules (FKS). We showed that Dectin-1 is necessary for resistance to pulmonary coccidioidomycosis, but the importance of TLR2 in vivo is uncertain. Myeloid differentiation factor 88 (MyD88) is the adapter protein for TLR2 and -4, interleukin-1R1 (IL-1R1), and IL-18R1. MyD88/TRIF^-/- and MyD88^-/- mice were equally susceptible to C. immitis infection, in contrast to C57BL/6 (B6) controls. Of the four surface receptors, only IL-1R1 was required for resistance to C. immitis, partially explaining the susceptibility of MyD88^-/- mice. We also found that FKS stimulated production of IL-1Ra by bone marrow-derived dendritic cells (BMDCs), independent of MyD88 and Dectin-1. There also was a very high concentration of IL-1Ra in the lungs of infected B6 mice, supporting the potential importance of this regulatory IL-1 family protein in the largely ineffective response of B6 mice to coccidioidomycosis. These results suggest that IL-1R1 signaling is important for defense against C. immitis infection.

Effect of Geography on the Analysis of Coccidioidomycosis-Associated Deaths, United States

Because coccidioidomycosis death rates vary by region, we reanalyzed coccidioidomycosis-associated mortality in the United States by race/ethnicity, then limited analysis to Arizona and California. Coccidioidomycosis-associated deaths were shown to increase among African-Americans but decrease among Native Americans and Hispanics. Separately, in a Native American cohort, diabetes co-varied with coccidioidomycosis-associated death.