Coccidioidomycosis in compromised hosts
- John N Galgiani, MD
John N Galgiani, MD
- Professor of Medicine
- University of Arizona
- Neil M Ampel, MD
Neil M Ampel, MD
- Professor of Medicine
- University of Arizona
Coccidioidomycosis is usually a self-limited infection, resulting in lifelong immunity. Approximately 150,000 coccidioidal infections occur each year resulting in an estimated 50,000 illnesses; of these only a few experience progressive pneumonia or spread of the infection to other parts of the body. (See "Primary coccidioidal infection" and "Management of pulmonary sequelae and complications of coccidioidomycosis" and "Manifestations and treatment of extrapulmonary coccidioidomycosis".)
For some of those infected, no apparent underlying medical condition appears to account for the development of complications. However, altered host immunity by identifiable predisposing diseases or drug therapies increasingly seems to be responsible for complications. Since the etiologies of immunosuppression are numerous and their effects vary in scope and depth, the exact effect of a specific immunosuppressive condition upon the course of a coccidioidal infection is not always predictable.
Some of the most well-known factors that have been associated with disseminated infection and emerging strategies for reducing their risk will be reviewed here. This has been an evolving field, and as more experience is obtained with coccidioidomycosis in immunocompromised patients, it is likely that recommendations will continue to change.
EFFECT ON DISEASE EXPRESSION
Increased disease severity — Immunosuppression affects the clinical severity of coccidioidomycosis primarily by increasing the risk of extrapulmonary dissemination. This observation was first suggested in case reports but later was established by measuring the incidence of dissemination within defined populations of susceptible hosts [1,2]. In renal transplant recipients, for example, three-quarters of diagnosed infections resulted in extrapulmonary lesions, perhaps 50- to 200-fold higher than in contemporaneous normal populations. In patients with rheumatologic diseases, the increased use of immunosuppressive regimens, including anti-TNF therapies, also carries the risk of more extensive coccidioidal infection [3,4].
The finding of a diffuse reticulonodular pneumonia, the result of hematogenous seeding of the lungs associated with fungemia , is also most common in immunosuppressed patients. As an example, in a series of 300 patients hospitalized for coccidioidal pneumonia, diffuse pneumonia was identified in 13, and of these 13, all but 3 had an underlying immunocompromising condition . (See "Management of pulmonary sequelae and complications of coccidioidomycosis", section on 'Diffuse reticulonodular pneumonia'.)
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- EFFECT ON DISEASE EXPRESSION
- Increased disease severity
- Sites of infection and histology
- Reactivation of infection
- MANAGEMENT OF IMMUNOSUPPRESSED PATIENTS
- Patients with HIV/AIDS
- - Risk factors
- - Clinical presentation
- - Diagnosis
- - Treatment
- Monitoring response to therapy
- Failure to respond
- Discontinuing treatment
- - When to initiate antiretroviral therapy
- - Prevention
- Solid organ transplantation
- Hematologic malignancies
- Hematopoietic cell transplantation
- Glucocorticoid and immunosuppressive therapies for autoimmune diseases
- Specific gene mutations
- CONDITIONS WITHOUT PROVEN RISK OF DISSEMINATION
- Diabetes mellitus
- Humoral deficiencies
- Chronic granulomatous disease
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS