A Case of Extra-Articular Coccidioidomycosis in the Knee of a Healthy Patient

Coccidioidomycosis is a fungal infection endemic to the Southwestern United States. Extrapulmonary Coccidioides immitis infections are uncommon and occur more frequently in immunocompromised individuals. There is often a delay in diagnosis and treatment due to the chronic, indolent nature of these infections. The clinical presentation is often nonspecific, and includes joint pain, erythema, or localized swelling. Therefore, these infections may only be identified after initial treatment failure and further workup is pursued. The majority of reported cases of coccidioidomycosis involving the knee have had intra-articular involvement or extension. This report describes a rare case of peri-articular Coccidioides immitis abscess of the knee that does not communicate with the joint in a healthy patient. This case illustrates the low threshold needed for additional testing, such as fluid or tissue sampling of joint-related fluid collections if the etiology is unclear. A high index of suspicion is prudent to avoid diagnostic delay, particularly for individuals who either reside in or travel to endemic areas.

Surveillance of rhinovirus diversity among a university community identifies multiple types from all three species including an unassigned rhinovirus A genotype

We determine the presence and diversity of rhinoviruses in nasopharyngeal swab samples from 248 individuals who presented with influenza-like illness (ILI) at a university clinic in the Southwest United States between October 1, 2020 and March 31, 2021. We identify at least 13 rhinovirus genotypes (A11, A22, A23, A25, A67, A101, B6, B79, C1, C17, C36, and C56, as well a new genotype [AZ88**]) and 16 variants that contributed to the burden of ILI in the community. We also describe the complete capsid protein gene of a member (AZ88**) of an unassigned rhinovirus A genotype.

Coccidioidomycosis in Northern Arizona: an Investigation of the Host, Pathogen, and Environment Using a Disease Triangle Approach

Coccidioides immitis and Coccidioides posadasii are the etiological agents of coccidioidomycosis (Valley fever [VF]). Disease manifestation ranges from mild pneumonia to chronic or extrapulmonary infection. If diagnosis is delayed, the risk of severe disease increases. In this report, we investigated the intersection of pathogen, host, and environment for VF cases in Northern Arizona (NAZ), where the risk of acquiring the disease is much lower than in Southern Arizona. We investigated reported cases and assessed pathogen origin by comparing genomes of NAZ clinical isolates to isolates from other regions. Lastly, we surveyed regional soils for presence of Coccidioides. We found that cases of VF increased in NAZ in 2019, and Coccidioides NAZ isolates are assigned to Arizona populations using phylogenetic inference. Importantly, we detected Coccidioides DNA in NAZ soil. Given recent climate modeling of the disease that predicts that cases will continue to increase throughout the region, and the evidence presented in this report, we propose that disease awareness outreach to clinicians throughout the western United States is crucial for improving patient outcomes, and further environmental sampling across the western U.S. is warranted.

IMPORTANCE Our work is the first description of the Valley fever disease triangle in Northern Arizona, which addresses the host, the pathogen, and the environmental source in the region. Our data suggest that the prevalence of diagnosed cases rose in 2019 in this region, and some severe cases necessitate hospitalization. We present the first evidence of Coccidioides spp. in Northern Arizona soils, suggesting that the pathogen is maintained in the local environment. Until disease prevention is an achievable option via vaccination, we predict that incidence of Valley fever will rise in the area. Therefore, enhanced awareness of and surveillance for coccidioidomycosis is vital to community health in Northern Arizona.

Salinity tolerance of a rare and endangered unionid mussel, Popenaias popeii (Texas Hornshell) and its implications for conservation and water management

Unionid mussels are considered sensitive to salinity and there is growing concern in arid and semi-arid regions that declining flows coupled with anthropogenic impacts are amplifying natural salinity levels. In this study, we tested the effects of varying salinity concentrations (3.0, 4.0, 5.0, 6.0, 7.0 and 10.0 ppt NaCl) on survival of adult Popenaias popeii, (Texas Hornshell). This species occurs in the Rio Grande basin of Texas and northern Mexico, an arid to semi-arid stream plagued by salinization, and was recently listed as Endangered under the U.S. Endangered Species Act. We performed 2, 4, and 10-day toxicity tests on individuals from two disjunct populations: Laredo, TX, and the Lower Canyons of the Rio Grande near Big Bend National Park. We found no significant differences in LC50 estimates between populations at 96-hrs or 10-days but significant differences in TUD50s at 5 ppt between populations, which indicates that tolerance does not vary but sensitivity may between these populations. Overlaying LC50 estimates at 10-days for both populations on plots of salinity (ppt) measured over time, we show parts of the Rio Grande periodically approach or exceed 4.0 ppt, indicating these reaches are becoming unsuitable for P. popeii and populations within them at risk.

A decade of flowering phenology of the keystone saguaro cactus (Carnegiea gigantea)

PREMISE OF THE STUDY

Phenology is the study of biological life cycle events, such as flowering and migration. Climate patterns can alter these life history events, having ecosystem-wide ramifications. For example, warmer springs are associated with earlier leaf-out for many species, impacting species interactions and growing-season carbon dynamics. While phenological research has been conducted extensively in temperate regions, relatively little is known about the phenological responses in arid and semi-arid regions.

METHODS

In this study we looked at the flowering phenology of a keystone species in the Sonoran Desert, the saguaro cactus (Carnegiea gigantea). The timing and abundance of flowering was observed on 151 individuals for 10 years at a site near Tucson, Arizona, USA. Using six phenological traits, we explored the relationship between saguaro size and flowering and the climatic drivers of flowering.

KEY RESULTS

Our analyses demonstrated how the calculation of phenological traits at the individual versus the population level can yield differing responses to climate variability, suggesting that not all studies examining the same trait (e.g., first day of bloom) are directly comparable. We found that larger cacti began flowering earlier, flowered for longer, and produced more flowers. Warmer temperatures were correlated with advanced onset and higher bloom yields, while increased precipitation appeared to delay onset and reduce bloom yields.

CONCLUSIONS

Given that climate models predict that the Southwestern USA will become increasingly warmer with more variable precipitation, saguaros may begin flowering earlier in the season and flower more intensely, which could impact pollen availability and population dynamics.

Environmental buttocks burns in children and adolescents with spina bifida in the Southwestern United States

PURPOSE

Spina Bifida (SB) is a congenital defect of the neural tube resulting in motor and sensory defects and frequently includes insensate skin on the buttocks and feet which are innervated by sacral nerves. For those living in hot climates such as the Southwestern United States, environmental surfaces reach temperatures throughout June-September that cause thermal burns. The objective of this novel case series was to evaluate the circumstances associated with environmental buttocks burns in children with SB who attend the District Medical Group Children's Rehabilitative Services Myelomeningocele (MM) Planning clinic in Phoenix, AZ.

METHODS

Nine children and adolescents with SB and a history of environmental buttocks burns were identified through participation in the National Spina Bifida Patient Registry at District Medical Group Children's Rehabilitative Services Myelomeningocele Planning Clinic. Parents and patients were interviewed about the burn circumstances, charts were reviewed, and information was gathered from the NSBPR including level of function and ambulation status.

RESULTS

Most of the patients were found to be of emerging independent ages (average age 10 years) and were not with their parents at the time of the burn. All had myelomeningocele (MM), almost all were community ambulators, and all had mid lumbar, low lumbar or sacral level function. There were no non-ambulators. In addition, the majority were wearing incontinence products.

CONCLUSIONS

Children and adolescents with MM who are community ambulators, of an emerging independent age, and live in hot climates are at risk of environmental buttocks burns. Enhanced education in environmental thermal burn prevention is important. This education should be particularly focused on the child as they spend more time in settings without their parents. In addition, this enhanced education should extend to those who support the child or teen such as teachers, coaches, family and friends.

A semi-arid river in distress: Contributing factors and recovery solutions for three imperiled freshwater mussels (Family Unionidae) endemic to the Rio Grande basin in North America

Freshwater resources in arid and semi-arid regions are in extreme demand, which creates conflicts between needs of humans and aquatic ecosystems. The Rio Grande basin in the southwestern United States and northern Mexico exemplifies this issue, as much of its aquatic biodiversity is in peril as a result of human activities. Unionid mussels have been disproportionately impacted, though the specific factors responsible for their decline remain largely unknown. This is problematic because the Rio Grande basin harbors one federally endangered unionid mussel (Popenaias popeii, Texas Hornshell) plus two other mussel species (Potamilus metnecktayi, Salina Mucket; and Truncilla cognata, Mexican Fawnsfoot), which are also being considered for listing under the U.S. Endangered Species Act. To date, surveys for these species have not corrected for variability in detection so current range estimates may be inaccurate. Using single occupancy-modeling to estimate detection and occupancy at 115 sites along ~800 river kilometers of the Rio Grande in Texas, we found that detection probabilities were relatively high, indicating that our survey design was efficient. In contrast, the estimated occupancy was low, indicating that our focal species were likely rare within the Rio Grande drainage. In general, the predicted occupancy of our focal species was low throughout their respective ranges, indicating possible range declines. A comparison of currently occupied ranges to presumptive ranges underscores this point. The best-approximating models indicated that occupancy was influenced by habitat, water quantity and quality, and proximity to large-scale human activities, such as dams and major urban centers. We also discuss a series of conservation options that may not only improve the long-term prognosis of our focal species but also other aquatic taxa.

Roads Less Traveled: Finding a Path to Using Complementary and Alternative Medicine

An increasing number of health seekers in the United States are looking outside conventional medicine to address their health needs. It is estimated that in the United States, 38% of adults use complementary and alternative medicine (CAM). Extant research characterizes CAM users as a unified homogeneous group, with little understanding of the differences among them in terms of attitudes toward body, wellness, disease, and pivotal aspects of their personal histories. In this article, we seek to better understand the nuances of who uses CAM and why, using the following questions: How do people communicate their life stories that explain their decision to use CAM? How do the life stories enable us to understand the similarities and differences among CAM users? Based on analysis of the narratives of 18 individuals, three clusters or types of CAM users emerged: natives, immigrants, and tourists. In an effort to push our analysis further, we theorized three dimensions that help to explain CAM users' objectives, motives, and resultant sense of empowerment. Together, these dimensions comprise The Pathfinder Model of CAM Usage. The Pathfinder Model can be useful to clarify self-understanding among CAM users themselves, as well as for conventional and alternative practitioners, as they establish a working relationship and communicate with their patients during medical encounters. Understanding the path of the health seeker can help influence the quality of the relationship and the communicative strategies providers use to educate and influence.

Development of a regression model to predict copper toxicity to Daphnia magna and site-specific copper criteria across multiple surface-water drainages in an arid landscape

The water effect ratio (WER) procedure developed by the US Environmental Protection Agency is commonly used to derive site-specific criteria for point-source metal discharges into perennial waters. However, experience is limited with this method in the ephemeral and intermittent systems typical of arid climates. The present study presents a regression model to develop WER-based site-specific criteria for a network of ephemeral and intermittent streams influenced by nonpoint sources of Cu in the southwestern United States. Acute (48-h) Cu toxicity tests were performed concurrently with Daphnia magna in site water samples and hardness-matched laboratory waters. Median effect concentrations (EC50s) for Cu in site water samples (n=17) varied by more than 12-fold, and the range of calculated WER values was similar. Statistically significant (α=0.05) univariate predictors of site-specific Cu toxicity included (in sequence of decreasing significance) dissolved organic carbon (DOC), hardness/alkalinity ratio, alkalinity, K, and total dissolved solids. A multiple-regression model developed from a combination of DOC and alkalinity explained 85% of the toxicity variability in site water samples, providing a strong predictive tool that can be used in the WER framework when site-specific criteria values are derived. The biotic ligand model (BLM) underpredicted toxicity in site waters by more than 2-fold. Adjustments to the default BLM parameters improved the model's performance but did not provide a better predictive tool compared with the regression model developed from DOC and alkalinity.

Diffusion of influenza viruses among migratory birds with a focus on the Southwest United States

The Southwest United States, including Arizona and New Mexico, has a diverse climate and is home to many different avian species. We sequenced the hemagglutinin (HA) gene of twenty influenza specimens for the years 2007-2009. This included four from Arizona, and sixteen from New Mexico. We analyzed the sequences and determined the following HA subtypes: H3, H4, H6, H8, and H11. For each subtype, we combined our virus sequences with those from a public database, and inferred phylogeographic models of influenza diffusion. Statistical phylogeography indicated that overall evolutionary diffusion of avian influenza viruses is geographically structured (p<0.05). In addition, we found that diffusion to the Southwest was often from nearby states including California. For H3, H4 and H6, the intra-flyway gene flow rates were significantly (p<0.001) higher than those of inter-flyway. Such rate difference was also observed in H8 and H11, yet, without statistical significance (p=0.132, p=0.190, respectively). Excluding any one flyway from the calculation generated similar results, suggesting that such barrier effect on gene flow rates is not exclusively produced by any single flyway. We also calculated the Bayes factor test for the significant non-zero rates between states and identified significant routes both within and across flyways. Such inter-flyway spread of influenza was probably the result of birds from four flyways co-mingling on breeding grounds in northern regions or marshaling on staging areas post breeding in Canada or Alaska, before moving south each fall. This study provides an initial analysis of evolutionary diffusion of avian influenza virus to and from the Southwest United States. However, more sequences from this region need to be generated to determine the role of host migration and other factors on influenza diffusion.