Disclosure Coccidioidomycosis Nothing to disclose Greg Melcher, - - PDF document

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Coccidioidomycosis

Greg Melcher, M.D. Professor of Clinical Medicine Division of HIV, ID and Global Medicine Zuckerman San Francisco General Hospital University of California, San Francisco

Disclosure

• Nothing to disclose

Learning Objectives

• Understand the changing epidemiology of

coccidioidomycosis

• Recognize the varied pulmonary presentations of cocci
• Be familiar with common presentations of

disseminated coccidioidomycosis

• Be familiar with treatment and clinical monitoring for

coccidioidomycosis

Coccidioidomycosis “Cocci”

• Coccidioides immitis and Coccidioides posadasii

– Dimorphic fungus

spherule endospores mycelia arthroconidia

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The Ecology of Cocci Changing Epidemiology of Cocci

Texas

5 10 15 20 25 30 35 40 45 1998 2011 5.3/100K 42.6/100K

Missouri

0.05 0.1 0.15 0.2 0.25 0.3 2004 2013 0.05/100K 0.28/100K

Transmission of Cocci

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Pulmonary Cocci Primary Pulmonary Cocci

• 60% of infections are

asymptomatic or mild respiratory illness

– 25% of community‐acquired pneumonia in endemic areas

• Segmental or lobar

consolidation, +/‐ regional adenopathy

• Eosinophilic pleural

effusion

Primary Pulmonary Cocci

Clinical Manifestations

• Cough, fever, dyspnea, scant sputum

production

• Onset 1‐3 weeks after exposure to

arthroconidia

• Possible erythema nodosum – good prognosis
• Pleural effusion only approximately 10%

Primary Pulmonary Cocci

• Diagnosis

– Most often serology

• immunodiffusion tube precipitin (IgM)
• Immunodiffusion complement fixation antibody (IgG)
• EIA tests are sensitive, but not specific

– Sputum culture – Nucleic acid testing under investigation

• Treatment optional

– Fluconazole 200‐400 mg/day – Itraconazole 100‐200 mg BID

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Diffuse Cocci Pneumonia

• High inoculum
• Immunosuppression
• Pregnancy
• Treatment may be

prolonged

Other Forms of Pulmonary Cocci

Solitary Pulmonary Nodule

• No treatment required

Chronic Progressive Cavitary

• Treatment indicated ‐ prolonged

Disseminated Coccidioidomycosis

Disseminated Coccidioidomycosis Risk Factors

• Filipino or African

ethnicity

• Immunosuppression

– Prednisone – TNF‐ inhibitors – Chemotherapy – Organ transplantation

• HIV/AIDS
• Diabetes mellitus
• Pregnancy
• Cardiopulmonary

disease

• CF titer > 1:16

Stockamp N, Thompson GR. Infect Dis Clin N Am, 2015. http://dx.doi.org/10.1016

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Diagnosis of Disseminated Cocci

• Serology supportive if CF titer > 1:16
• Definitive diagnosis

– Any positive CF titer from CSF – Culture – Histopathology (spherules in tissue)

www.mycology.adelaide.edu.au

Cutaneous Cocci

• Most common form of

dissemination

• Non‐healing, wart‐like

ulceration

• Diagnosis confirmed by

skin biopsy

– Histopathology with spherules – Culture often positive

Soft Tissue Cocci

• Fluctuant, usually

painless fluid collections

• Favor bony prominences

such as hips, spinal column, sternum and ribs

• Diagnosis confirmed by

aspiration for direct smear and culture

Bone and Joint Cocci

• Painful joint or long bone
• Similar to other causes of

septic arthritis

• Diagnosis by

arthrocentesis, synovial biopsy, or bone x‐ray in setting of active cocci

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Treatment of Non‐Meningeal Disseminated Cocci

• Triazoles are the mainstay of therapy

– Fluconazole 400‐800 mg daily

– Itraconazole 200 mg BID preferred for bone and joint disease

• Monitor serum CF titer; once low or undetectable can

consider lowering dose

• Most clinicians consider disseminated cocci to require life‐

long therapy at lowest possible dose

• Can monitor serum CF titer as marker of disease activity

Stockamp N, Thompson GR. Infect Dis Clin N Am, 2015. http://dx.doi.org/10.1016

Cocci Meningitis

• LP indicated for persons with symptoms suggestive of

meningitis

– Blurred vision, headache, photophobia, meningismus, altered mental status, focal neurologic finding (CN III‐VIII)

• CSF mononuclear cell pleocytosis, elevated protein and

low glucose

• Diagnosis confirmed by CF titer or culture (rare)
• Imaging studies supportive; can mimic tuberculous

meningitis

Treatment of Cocci Meningitis

• Fluconazole 800‐1200 mg daily
• Liposomal amphotericin B 5‐10 mg/kg/day

– Intrathecal deoxycholate amphotericin B

• Voriconazole
• Posaconazole
• Isavuconazole
• Lifelong treatment is recommended

Complications of Cocci Meningitis

• Hydrocephalus

– VP shunt

• CNS vasculitis
• Cerebral ischemia/infarction
• Vasospasm
• Hemorrhage

Nguyen, C. et al. Clin Microbiol Rev 2013;26:505‐525.

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Monitoring Response to Cocci Therapy

• Clinical signs and symptoms
• Serial serum and/or CSF cocci CF titer

– Four‐fold change required to be significant