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Pathogen:
Coccidioides immitis, a fungus that resides in the soil and is endemic to
the southwestem U.S., Mexico, and Central and South America. Infection is caused
by inhalation of airborne, ineffective arthroconidia, one stage in the organism's
life cycle.
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Sites of Infection:
Most commonly the lungs. Advanced disease may involve the kidneys, spleen, lymph
nodes, brain, and thyroid gland.
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Symptoms:
Non-specific, including malaise, weight loss, fatigue and cough. Approximately
45% of people with coccidiodomycosis present with reticulonodular pulmonary
infection, 35% with focal pulmonary disease, 15% with extrapulmonary involvement,
and usually CD4 cell count <100.
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Diagnosis:
By examination of sputum or culture of bronchoscopically obtained specimen.
According to recent guidelines published by the Centers for Disease Control (CDC,
1995), routine skin testing with coccidioidin (spherulin) in
Coccidioidomycosis-endemic areas is not predictive of disease and should not be
performed.
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Treatment Results:
Intravenous amphotericin B (0.5-1 mg/kg/d) is the standard treatment for
coccidioidomycosis. Despite treatment, the mortality rate from coccidioidomycosis
remains high. Meningitis is the most serious complication of infection with
Coccidioides immitis and is nearly always fatal if untreated. The
only established therapy consists of frequent administration of amphotericin B
into the cerebral space.
Galgiani et al. treated 47 patients with coccidioidal meningitis with fluconazole (400 mg PO qd). Nine of these patients were HIV positive, none of them responded to treatment at this dose. 6/9 received fluconazole 800 mg qd; 4/6 responded.
Galgiani et al. treated 71 patients with chronic non-meningeal C. immitis infection with fluconazole (200-400 mg PO daily) and 38 patients with coccidioidal meningitis with fluconazole (400 mg PO daily). 61% of non-meningeal subjects improved clinically by the eighth month of treatment; 1/38 patients with meningeal disease failed to respond and 4 subjects died. No significant toxicities were observed.
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Prophylaxis:
REFERENCES:
Galgiani JN et a]. Fluconazole therapy for coccidioidal meningitis, Ann lnt Med
119(l): 28-35,1993.
OTHER REPORTS:
Centers for Disease Control. USPHS/IDSA Guidelines for the Prevention of
Opportunistic Infections in Persons Infected with Human Immunodeficiency Virus.
MMWR 44:1-24,1995.
Fish DG et al. Coccidioidomycosis during human immunodeficiency virus infection.
Medicine 69(6): 384-91,1990.
Galgiani JN et al. Coccidioidomycosis in human immunodeficiency virus-infected
patients. J Infect Dis 162(5): 1165-1169,1990.
Hostetler JS et al. Coccidioidal infections with amphotericin B collioidal
dispersion (Amphocil or ABCD). 32nd ICAAC, abstract 628: 215,1992.
A multi-center phase II/III placebo-controlled study of fluconazole (200 mg
daily) for the prevention of coccidioidomycosis has been discontinued due to poor
accrual.
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Menu
Galgiani JN et al. Fluconazole therapy for coccidioidomycosis. 30th ICAAC,
Abstract #574,1990.
Bronnimann DA et al. Coccidioidomycosis in the acquired immunodeficiency
syndrome. Ann Int Med 106(3): 372-9, 1987.
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