Management of pulmonary sequelae and complications of coccidioidomycosis
- John N Galgiani, MD
John N Galgiani, MD
- Professor of Medicine
- University of Arizona
- Dawn Jaroszewski, MD, MBA, FACS
Dawn Jaroszewski, MD, MBA, FACS
- Associate Professor of Surgery
- Division of Cardiothoracic Surgery
- Mayo Clinic Arizona
Approximately two-thirds of people experience few or no symptoms following respiratory exposure to arthroconidia of Coccidioides spp. Those who become ill typically develop symptoms, such as cough, pleurisy, fever, and weight loss, one to three weeks after exposure; these symptoms generally resolve over the ensuing several months [1,2]. Marked fatigue, one of the common manifestations of the primary infection, may be especially prolonged and slow to resolve.
Whether or not the primary exposure is recognized, most infections are self-limited without additional events or complications. However, occasional patients have persistent pulmonary consequences of coccidioidomycosis that require medical and/or surgical management. These include residual pulmonary nodules, coccidioidal cavities, and diffuse reticulonodular pneumonia.
The clinical manifestations and management of these sequelae will be reviewed here. Primary and disseminated coccidioidomycosis are discussed separately. (See "Primary coccidioidal infection" and "Manifestations and treatment of extrapulmonary coccidioidomycosis" and "Coccidioidal meningitis".)
RESIDUAL PULMONARY NODULES
In approximately 4 percent of patients with primary coccidioidal pneumonia, infiltrates do not completely resolve and radiographic findings may persist for months to years following the disappearance of symptoms. These pulmonary nodules range up to several centimeters in diameter, are often solitary, and are frequently located in the periphery of the lung, close to or abutting the pleura.
Confirming the diagnosis — A residual nodule usually poses no problems and requires no treatment if it is known to be the consequence of an initial coccidioidal infection. However, in many cases, coccidioidal nodules are discovered incidentally and can be difficult to distinguish from malignancy.
- Kerrick SS, Lundergan LL, Galgiani JN. Coccidioidomycosis at a university health service. Am Rev Respir Dis 1985; 131:100.
- Galgiani JN, Ampel NM, Blair JE, et al. 2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Treatment of Coccidioidomycosis. Clin Infect Dis 2016; 63:e112.
- Reyes N, Onadeko OO, Luraschi-Monjagatta Mdel C, et al. Positron emission tomography in the evaluation of pulmonary nodules among patients living in a coccidioidal endemic region. Lung 2014; 192:589.
- Read CT. Coin lesion, pulmonary: in the Southwest. (Solitary pulmonary nodules). Ariz Med 1972; 29:775.
- Chitkara YK. Evaluation of cultures of percutaneous core needle biopsy specimens in the diagnosis of pulmonary nodules. Am J Clin Pathol 1997; 107:224.
- Ashfaq A, Vikram HR, Blair JE, Jaroszewski DE. Video-assisted thoracoscopic surgery for patients with pulmonary coccidioidomycosis. J Thorac Cardiovasc Surg 2014; 148:1217.
- SMITH CE, BEARD RR, SAITO MT. Pathogenesis of coccidioidomycosis with special reference to pulmonary cavitation. Ann Intern Med 1948; 29:623.
- Cunningham RT, Einstein H. Coccidioidal pulmonary cavities with rupture. J Thorac Cardiovasc Surg 1982; 84:172.
- Santelli AC, Blair JE, Roust LR. Coccidioidomycosis in patients with diabetes mellitus. Am J Med 2006; 119:964.
- Galgiani JN, Catanzaro A, Cloud GA, et al. Comparison of oral fluconazole and itraconazole for progressive, nonmeningeal coccidioidomycosis. A randomized, double-blind trial. Mycoses Study Group. Ann Intern Med 2000; 133:676.
- Catanzaro A, Cloud GA, Stevens DA, et al. Safety, tolerance, and efficacy of posaconazole therapy in patients with nonmeningeal disseminated or chronic pulmonary coccidioidomycosis. Clin Infect Dis 2007; 45:562.
- Stevens DA, Rendon A, Gaona-Flores V, et al. Posaconazole therapy for chronic refractory coccidioidomycosis. Chest 2007; 132:952.
- Kim MM, Vikram HR, Kusne S, et al. Treatment of refractory coccidioidomycosis with voriconazole or posaconazole. Clin Infect Dis 2011; 53:1060.
- Ampel NM, Ryan KJ, Carry PJ, et al. Fungemia due to Coccidioides immitis. An analysis of 16 episodes in 15 patients and a review of the literature. Medicine (Baltimore) 1986; 65:312.
- Werner SB, Pappagianis D, Heindl I, Mickel A. An epidemic of coccidioidomycosis among archeology students in northern California. N Engl J Med 1972; 286:507.
- DiTomasso JP, Ampel NM, Sobonya RE, Bloom JW. Bronchoscopic diagnosis of pulmonary coccidioidomycosis. Comparison of cytology, culture, and transbronchial biopsy. Diagn Microbiol Infect Dis 1994; 18:83.
- Fish DG, Ampel NM, Galgiani JN, et al. Coccidioidomycosis during human immunodeficiency virus infection. A review of 77 patients. Medicine (Baltimore) 1990; 69:384.
- Sampaio EP, Hsu AP, Pechacek J, et al. Signal transducer and activator of transcription 1 (STAT1) gain-of-function mutations and disseminated coccidioidomycosis and histoplasmosis. J Allergy Clin Immunol 2013; 131:1624.