Professional Documents
Culture Documents
Welsh 2012
Welsh 2012
Coccidioidomycosis
Oliverio Welsh, MD a,⁎, Lucio Vera-Cabrera, PhD a , Adrian Rendon, MD b ,
Gloria Gonzalez, PhD c , Alexandro Bonifaz, BS, MS d
a
Department of Dermatology, “Dr. Jose E. Gonzalez” University Hospital, Universidad Autónoma de Nuevo León,
Ave Madero y Ave Gonzalitos s/n, Colonia Mitras Centro, Monterrey, Nuevo Leon, 64460, México
b
Department of Pulmonology, Hospital Universitario “Dr. Jose E. Gonzalez,” Ave. Madero y Gonzalitos s/n,
Colonia Mitras Centro, Monterrey, N.L. 64460, México
c
Microbiology Department of the School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, N.L. 64460, México
d
Mycology Laboratory, Hospital General, México D.F. 04510, México
0738-081X/$ – see front matter © 2012 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.clindermatol.2012.01.003
574 O. Welsh et al.
Microbiology
Taxonomy
Fig. 6 Sabouraud colony of Coccidioides immitis and C posadasii. containing endospores, can be identified by hematoxylin
and eosin. Special stains (periodic acid-Schiff, Grocott;
Figure 9) can enhance, in doubtful cases, the sensibility
and lung tissue, and in extrapulmonary sites, specimens from for fungus identification on direct slide examination.
skin and bone biopsy, pus from abscesses, joint fluid, Spherules do not take up Gram stain but may be
cerebrospinal fluid, and others. Universal precautions must visualized with potassium hydroxide, Lugol, calcofluor
be observed when handling them. Processing should be white, or Papanicolaou preparations.
performed promptly. The laboratory must be alerted about
the possibility of isolating C immitis. Slides for direct Laboratory
examination must be processed, stained, and reviewed right
away, and covered with a permanent mount. Handling this fungus is dangerous, and laboratory
When left unsealed for a few hours, formation of personnel require level II biosafety practices and a class II
hyphae from the spherule is observed (Figure 8). On biologic safety cabinet that has a vertical airflow and high-
direct examination, thick-walled mature spherules of efficiency particulate air–filtered supply and exhaust air for
different sizes, measuring up to 80 μm in diameter, working with the fungus. These protect the worker, the
processed material, and the environment.17 Because of the
capacity of the fungus to infect exposed individuals, a careful
protocol must be strictly enforced.
Fig. 7 Microculture showing arthroconidia. Fig. 8 Direct examination of spherules growing hyphae.
578 O. Welsh et al.
Fig. 10 Scanning electron microscopy of hyphae (left) and spherules (right) of Coccidioides immitis (courtesy of Dr Hillel Levine).
Coccidioidomycosis 579
Other methods, such as proteomic techniques, are used tube precipitin antibodies. This test detects antibodies
for the study of fungus proteins, which are essential to between the first and third week of onset. IgG antibodies
evaluate their antigenic activity and development. The against the fungus can be detected with the complement
information obtained can be useful for designing new fixation (CF) test between weeks 2 and 28. Their levels can
therapeutic targets that could inhibit fungus reproduction remain detectable for several months and are usually related
and facilitate its destruction.21 to infection activity and response to treatment.
Serologic studies have been recognized as being less
sensitive in self-limited clinical cases and in immunocom-
promised patients. Therefore, a negative serologic result
Immune detection of coccidiomycosis cannot rule out the diagnosis, especially in the early period
of infection.
Cellular and antibody analysis Three laboratory techniques are available for detecting
serologic response: enzyme immunoassays, immunodiffu-
Exposure to this fungus can be detected for clinical and sion, and CF. The first detects IgM and IgG antibodies.
epidemiologic purposes with the coccidioidin or spherulin Immunodiffusion is useful in sera that have anticomple-
skin tests. In the former, antigens are prepared from mentary activity. Traditionally, the CID reaction and CF
arthroconidia proteins; in the latter, the antigen is obtained have been used as the most common immunologic tests
from proteins of the parasitic stage of the fungus. A positive for epidemiologic diagnosis and therapeutic prognosis.
cutaneous intradermal (CID) reaction indicates the individual The CF and immunodiffusion titers generally decrease as
has been exposed to a subclinical infection or active disease. the disease improves.
In cases of immunosuppression, an anergic response is
observed. This usually occurs in individuals who receive
systemic corticoids or chemotherapy, or in individuals after
organ transplant or with AIDS. The CID reaction is
Pathophysiology
considered positive when the erythema and induration
exceed 0.5 cm. In Mexico, the antigen available in Infection is transmitted by inhalation of arthroconidia.
laboratories is coccidioidin. Coccidioidin and spherulin are Transmission by direct inoculation is rare, and person-to-
no longer available in the United States.22 person transfer is almost nonexistent; when it happens, it is
Coccidioidin was prepared using tuberculin as a usually through fomites in which the fungus has transformed
model. The antigen was obtained from mycelia grown into the arthroconidia saprophytic stage.
in a liquid media for 8 weeks. Thimerosal was added to As a dimorphic fungus, C immitis changes in tissue to
maintain the filtrate free of bacterial contamination. The endosporulating spherules that are easily recognized with
antigen, which contains some proteins and is rich in hematoxylin and eosin, periodic acid-Schiff, and Gomori-
polysaccharides, was heat-stable. The ability of coccidioidin Grocott stains. These spherules grow and mature with time.
to induce late-type hypersensitivity is lost when the protein Their wall eventually breaks, and many small spherules are
content is destroyed. released that reinitiate this cycle in vivo.
Coccidioidin was used in airmen working in the San
Joaquin Valley during the 1940s. Those with a positive skin
test or those whose tests converted to positive were asked to Pathology
answer a questionnaire. The data from the 1,351 participants
showed that 60% did not recall having any symptoms.23 In The lungs are the most affected area, but infection can
coccidioidomycosis only 40% of infected individuals spread and involve other organs. Among these are lymph
develop some flulike symptoms. From this group, 5% also nodes, the skin, the spleen, the liver and kidneys, bone,
have erythema nodosum or erythema multiforme, and less joints, the meninges, and the central nervous system. Tissue
than 1% develop extrathoracic dissemination.24 reacts with different histologic patterns that are characterized
A positive CID reaction reveals activation of cellular by a coccidioidal granuloma. The presence of necrosis with
immunity against C immitis/posadasii antigens. This immu- abundant polymorphonuclear leukocytes and eosinophils is a
nity is long-lasting but can disappear in cases of reinfection common feature in abscesses, but they can also be present in
due to severe immune cellular depression, as reported in other clinical forms. Lymphocytes, epithelioid cells, multi-
patients receiving chemotherapy,25 anti–tumor necrosis nucleated giant cells, areas of necrotic tissue, and fibrosis are
factor-α treatment,26 and untreated patients with AIDS.27 also seen.
A common finding is the presence of double-walled
Serologic tests spherules with endospores varying in size from 10 to
80 μm. The spherules are sometimes abundant and at
Serologic studies in coccidioidomycosis detection tradi- other times scanty. They can be detected with hematox-
tionally include, in the early stage, immunoglobulin (Ig) M ylin and eosin (Figure 11), and special stains, such as
580 O. Welsh et al.
Fig. 11 Granulomas show large spherules and a giant cell containing small spherules (hematoxylin and eosin stain; original magnification ×400).
periodic acid-Schiff, Gridley, and particularly, Grocott- able to induce production of interferon-γ and interleukin
Gomori and methenamine-silver (Figure 12). The latter two (IL)-2 by peripheral blood mononuclear cells (PBMCs) in
are used in doubtful cases or when the spherules are scarce. coccidioidal immune individuals but not in nonimmune
These reveal the spherules in black in a green background. individuals. T27K is highly glycosylated, and among its
When the spherules are young and small, the differential contents, has elevated amounts of mannose, glucose, and
diagnosis with other fungal organisms, such as C neofor- galactose, and also discrete antigens such as Ag2/PRA and
mans and Blastomyces dermatitides must be made, and when aspartyl protease. The recombinant proteins of these
the spherules are very large with rhinosporidiosis. Real-time antigens have been used as vaccines in experimentally
PCR can be used for identification of the fungus and is induced coccidioides infections in mice, achieving protec-
sensitive and useful for genetic and epidemiologic studies.28 tion from infection.
Coccidioides immitis and C posadasii have several Besides activation of the proinflammatory cytokines of
antigens that can induce a cellular immune response. A the host in fungal infections, other adaptive host defense
preparation made by the lysate of spherules stimulated mechanisms are triggered through a set of ligands called
peritoneal mast cells formation in immune but not in pattern recognition receptors that are located in dendritic
nonimmune donors.29 cells. These pattern recognition receptors molecules are
Another study detected that T27K, a coccidioidal C-lectin–type receptors with the characteristic of identifying
antigen made by mechanical disruption of spherules, was carbohydrate structures and are calcium-dependent.30
Mannose-binding lectin is a soluble molecule that
increases the risk of diverse infections when present in low
levels. Low levels of mannose-binding lectin were seen in
patients with active and disseminated coccidioidomycosis.31
Other molecules involved in innate defense mecha-
nisms are the Toll-like receptors (TLRs). Up to now, 13
of these have been identified. The TLRs recognize a
broad series of ligands; for example, the first described
ligand for TLR4 is a lipopolysaccharide. An experimental
analysis of the response of PBMCs to the coccidioidal
antigen T27K after blockage of the activity of TLR2 and
TLR4 in immune individuals resulted in a significant
reduction of tumor necrosis factor-α concentration. These
results appear to support the thesis that TLR2 and TLR4
are involved in an in vitro cellular immune response in
human coccidioidomycosis.
The role of dendritic cells in patients with coccidioido-
mycosis has not been completely elucidated. Dendritic cells
Fig. 12 Spherule with a broken outer wall releasing endospores from patients with disseminated coccidioidomycosis main-
(Grocott stain, original magnification ×400). tain the ability to react to coccidioidal antigens (T27K) and
Coccidioidomycosis 581
Fig. 13 Thin-walled cavity with a regular shape in the left upper Fig. 15 Very irregularly shaped cavity with a thin wall located in
lobe. This image is characteristic of coccidioidomycosis. Several the right upper lobe. Several small nodules and interstitial infiltrates
small nodules are observed surrounding the cavity. are observed around the cavity.
582 O. Welsh et al.
Fig. 16 Nodulelike consolidation in the right upper lobe Fig. 18 Loculated right pneumothorax. There is severe pleural
above the hilum. An interstitial infiltrate is observed in the thickening and lung entrapment.
neighboring segments.
lesions reveal coccidial granulomas containing typical
These often disappear with time. The differential diagnosis spherules of the fungus (see Pathology section).
should include other systemic mycosis, tuberculosis, and The spectrum of skin manifestations can be present as
lung cancer.34 lesions of erythema nodosum and erythema multiforme,
and rarely, Sweet syndrome. Erythema nodosum generally
Cutaneous coccidioidomycosis appears in the first month after infection. Biopsy
specimens show a septal granulomatous panniculitis;
When the disease spreads out of the lungs, the skin is one coccidioidin and spherulin CID are positive in these
of the most affected organs. The first patient Posadas saw
presented because of a cutaneous lesion on his cheek that
spread in the following years to different organs, causing his
death. The clinical spectrum of the cutaneous lesions varies
from papules, nodules, gummas, acneiform pustular lesions,
ulcerated and verrucous plaques, scarlike lesions, abscesses,
which should be debrided (Figures 19-24), and fistulae. The
differential diagnosis includes histoplasmosis, blastomyco-
sis, tuberculosis, chromoblastomycosis, sporotrichosis, my-
cetoma, nocardiosis, other bacterial and viral infections, and
cancer. When lymph nodes are involved, the possibility of
lymphoma should be ruled out. Biopsy specimens of the
Fig. 21 Ulcerated scarlike lesion of coccidioidomycosis. Fig. 23 Abscess caused by coccidioidomycosis infection.
584 O. Welsh et al.
Opthalmic involvement is very infrequent. The only pregnancy and can only be used if the potential benefit
patient we have seen in Monterrey was a 40-year-old woman justifies the potential risk to the fetus.47
with a history of an erythematous plaque in the left
supraciliary region, with the diagnosis of coccidioidomyco- Differential diagnosis
sis made by biopsy. When we examined the patient, the skin
lesion had disappeared, but the eye examination detected a We have included the differential diagnosis of this
whitish retinal streak in her left eye. The patient was treated infection under each clinical form. We want to emphasize
with itraconazole (400 mg) for 16 months, showing that in our state (Nuevo León), which is part of the
improvement of the retinal lesion. After treatment was northeastern endemic zone of Mexico for coccidioidomyco-
discontinued, the disease returned, and amphotericin B had sis, each time we think of coccidioidomycosis, our first
to be administered (unreported case).43 differential diagnosis is tuberculosis and vice versa. Other
fungal (histoplasmosis, South American blastomycosis),
Genitourinary involvement viral, and bacterial infections, such as tularemia, actinomy-
cetoma, pyogenic bacterial infections, viral warts, and
Genitourinary coccidioidomycosis can affect patients cancer, are often considered in the differential diagnosis.
with severe disseminated disease. The localization and
severity of the infection will determine the symptoms.
Coccidiodouria culture isolation, and identification of the Vaccines
fungus by biopsy specimen establish the diagnosis.44
Vaccines for coccidioidomycosis are needed for patients
Coccidioidomycosis in children who could be at risk for acquiring the disease by living in
endemic zones, particularly transplant recipients, pregnant
The infection is more frequent in infants than in adults. It women, and individuals receiving chemotherapy or immu-
predominates among dark-skinned individuals. Most primary nosuppressive doses of corticosteroids. Coccidioides is a
coccidioidomycosis in children is controlled by the host highly immunogenic organism that induces a good immu-
immune response and resolves without treatment.45 Only 1 in nologic response in most individuals. That 60% of infected
every 500 infections will progress to a disseminated form, and individuals did not notice any symptoms of infection and all
there are no differences in sex before puberty. In these cases, had a positive CID reaction (also present in most individuals
survival is less frequent at age younger than 5 years. There are with clinical disease) is indicative of a good native and
three clinical presentations in children: primary coccidioido- specific cellular immune response. Coccidioidal antigens
mycosis, primary coccidioidal granuloma, and disseminated with a proven antigenic response in vitro have been
disease. All three can lead to a chronic or systemic illness. successfully used in protecting against lethal inoculation of
Although several authors have stated that infection is milder the fungus in experimental animals. Up to now, a successful
in children than in adults, children with disseminated disease vaccine for use in humans remains elusive.48-50
and bone and meningeal involvement have a high mortality
rate. The diagnosis of coccidioidomycosis may be difficult to
achieve in young children.46
Prevention
Pregnancy Public health measures that can be used to lower the
incidence of coccidioidomycosis are detection of endemic
Coccidioidomycosis in pregnancy has a wide range of zones with a higher incidence and increased awareness
clinical manifestations that can vary from mild symptoms among health professionals. Modification of the habitat
resembling influenza (90%) to disseminated disease (10%). where the fungus grows can be achieved by advising
Pregnant patients with disseminated disease can present construction companies to reduce dust by wetting the soil
central nervous system manifestations and skin involve- before digging and by paving roads. Planting trees and lawns
ment. When erythema nodosum appears, the prognosis is around residences and industrial plants can reduce the rate of
relatively benign. Most patients present with clinical infection by about half.51,52
manifestations that include pulmonary signs and symp-
toms, as previously described. The mortality rate increases
when the diagnosis is delayed (third trimester). Because
azoles are contraindicated in pregnancy, amphotericin B is Treatment and brief description of current
the drug of choice, especially in the early stages of antifungal therapy
pregnancy. This antifungal has been used in pregnant
patients for 50 years without significant adverse effects to The first effective treatment for coccidioidomycosis was
the mother or fetus. Caspofungin is a category C drug in amphotericin B, reported in 1959.53 This drug is a polyene
586 O. Welsh et al.
isolated from Streptomyces nodosus, a strain obtained from individuals with immunosuppression (AIDS, chemotherapy,
the soil on the riversides of the Orinoco River in high-dose steroids, anti–tumor necrosis factor-α), treatment
Venezuela.54 The amphotericin molecule has a hydrophilic is always indicated.
and a hydrophobic region; therefore, it has very little Azoles have been the milestones for oral treatment of
solubility in aqueous solutions and for this reason addition coccidioidomycosis. Clinical trials started at the end of the
of another agent (deoxycholate containing sodium phos- 1970s and the beginning of the 1980s. These fungistatic drugs
phate as buffers) is required for clinical administration. The exert their therapeutic action by binding to fungal cytochrome
addition of amphotericin B to a solution containing salt P-450 isozymes (lanosterol 14-alpha-demethylase), causing
will cause precipitation of the drug. Prepared amphotericin inhibition of ergosterol synthesis that alters membrane-bound
B is compatible with dextrose solutions for intravenous enzyme function and fungal membrane permeability and
(IV) and intrathecal administration and with sterile water causes blunted cell growth and cell death.
for local application. Its mechanism of action is due to The first studies with miconazole showed an in vitro
binding of the hydrophobic moiety to the spherule's cell inhibitory concentration of C immitis. A limiting factor was
membrane ergosterol moiety, producing cell membrane that the drug had to be given IV for a long time, and clinical
damage leading to fungal cell death. Amphotericin B also relapse was often seen.61
binds to the cholesterol of mammalian cell membranes, The first azole used for oral treatment of coccidioidomy-
which causes some of its toxic potential.55 The differential cosis was ketoconazole. We performed one of the first trials
rate binding of ergosterol (much higher) and of cholesterol with this antifungal. The drug was given orally, once daily
allows its therapeutic use in patients. This antifungal agent after meals, avoiding milk and antacids. The dose fluctuated
promotes inflammatory cytokine release by TLR and between 200 and 400 mg daily. In 7 of 11 patients included,
CD14-dependent mechanisms.56 we observed clinical improvement. The general symptoms
Amphotericin B deoxycholate can be given in an IV disappeared, and there was clinical amelioration of lesions
dose range of 0.3 to 1.5 mg/kg (average of approximately during treatment. The best results were found in patients
1 mg/kg). It is often associated with fever, chills, headache, with a chronic pulmonary lesion. Another study stated
nausea, vomiting, hypotension, and bronchospasm. These that ketoconazole seemed to suppress but not eradicate
symptoms can be reduced with the administration of C immitis. 62-64 Itraconazole and fluconazole have
diphenhydramine, acetaminophen, and meperidine. Potas- become the main drugs for treatment of uncomplicated
sium and magnesium levels should be evaluated periodi- primary and disseminated coccidioidomycosis.65
cally to detect low levels of these electrolytes. The main Fluconazole is a bis-triazole antifungal drug with
adverse effect of amphotericin B is renal toxicity; therefore, metabolic stability and relatively high water solubility,
renal function should be closely monitored. A basal and which contribute to its therapeutic activity. Its relatively
follow-up electrocardiogram is indicated for detection of high polarity results in low protein binding and uniform
cardiac abnormalities. tissue distribution. Its penetration to cerebrospinal fluid is
Other compounds containing amphotericin B are ampho- approximately 80% of serum levels, which offers a good
tericin B colloidal dispersion, amphotericin B lipid complex, therapeutic option in fungal meningitis. Accessibility of oral
and amphotericin B liposomal. These lipid formulations have and IV formulations permits, depending on the patient's
less renal toxicity than amphotericin B deoxycholate, condition, the administration of either formulation. Absolute
without changes in their therapeutic efficacy.57-59 Doses bioavailability facilitates administration of fluconazole and
fluctuate between 2 and 5 mg/kg (or more) daily, results in predictable tissue levels. Fluconazole has been one
administered IV.60 In developing countries, a limiting factor of the most commonly administered antifungals for treatment
for indicating these amphotericin B compounds is their price of coccidioidomycosis. In a study of 75 patients who
and availability. received 200 to 400 mg of fluconazole daily, a satisfactory
Daily doses are indicated for severe forms of coccidioi- response was observed in 12 of 14 patients (86%) with
domycosis; in mild forms, the regimen can be three times per skeletal involvement, in 22 of 40 patients (55%) with chronic
week. The duration of treatment with amphotericin B pulmonary disease, and in 16 of 21 patients (76%) with soft
deoxycholate or lipid medications of amphotericin B is tissue involvement. Treatment was modified in five patients
similar, lasting about 1 to 4 months. (7%) because of adverse effects. Forty-one patients who
Current treatment of coccidioidomycosis with amphoter- responded were monitored off drug, and 15 (37%)
icin B is indicated for severely affected individuals, pregnant experienced reactivation of the infection.66
women, in patients in whom azoles cannot be administrated, Itraconazole is a common triazole used for treatment of
in osteoarticular involvement, mainly in patients with rapid coccidioidomycosis. It is more effective and has fewer side
progression, and particularly, in patients in whom treatment effects than ketoconazole. Itraconazole seems to have a
with azoles is unable to solve the infection. better effect in skin, subcutaneous tissue, and skeletal
Many patients with coccidioidomycosis develop mild lesions. Its bioavailability after oral solution administration
symptoms that resolve spontaneously in 2 to 4 months. during fasting conditions is 60% greater compared with
When infection persists, progresses, or disseminates in capsules taken after meals. Hydroxyitraconazole is an active
Coccidioidomycosis 587
antifungal metabolite of this drug that accumulates at twice respiratory illness, which can spontaneously resolve, to
the rate of the parent drug, increasing the absolute progressive pulmonary involvement with dissemination to
bioavailability of itraconazole to at least 80%.67 other organs, including the central nervous system, which
There is a long list of drugs that interact with azoles, could require life-long treatment,69 as well as in some
which can affect the concentration of the administered chronically immunosuppressed patients, such as those with
antifungal or of the drugs. This list increases with time; AIDS or after organ transplantation. Treatment strategies can
therefore, it is essential for clinicians to consult up-to-date vary depending on the background and clinical picture of
sources. A representative list of these drugs includes each patient. Immunocompetent individuals with early
rifampin, statins, warfarin, digoxin, H+ blockers, and infections and minimal pulmonary lesions often resolve
cyclosporine A. The most commonly described adverse without antifungal treatment. Patients should be monitored to
effects include gastrointestinal disturbances, dizziness, and detect recurrence, progression to chronic stages, and
headache. Liver toxicity has been rarely described. Blood development of extrapulmonary disease.
pressure should be monitored periodically.65 The antifungal drugs currently indicated for chronic and
Itraconazole (400 mg daily) is frequently administered for extrapulmonary disease include amphotericin B deoxycolate,
coccidioidomycosis; however, higher doses have been used lipid formulations of amphotericin B, fluconazole, and
without complications. Total duration of therapy with itraconazole. Recommendations for treatment are reviewed
fluconazole or itraconazole is variable and will depend on in depth in the Infectious Diseases Society of America
the location, extension, severity of the disease, and the guidelines14 and more recently in the American Thoracic
patient's comorbidities that induce immunosuppression. In Society statement70 (see treatment algorithm, Figure 25).
limited and uncomplicated cases, 4 to 6 weeks of treatment, Posaconazole and voriconazole are the latest commer-
after active infection has resolved, can achieve cure of the cially available triazoles for treatment of coccidiodomyosis.
disease. Therapy for extrapulmonary disease may be Posaconazole (Noxafil, Schering Corporation, Kenilworth,
extended, depending on clinical and paraclinical results. NJ) was approved by the Food and Drug Administration for
Treatment lasts 6 months to 1 year after the disease has use as prophylaxis against invasive Aspergillus and Candida
become inactive. In some patients, this may be lengthened infections in immunocompromised patients. This triazole is
to years.14 structurally similar to itraconazole and has a wide spectrum
For the purpose of defining whether fluconazole or of activity against human fungal infection and emerging
itraconazole is superior for treatment of nonmeningeal fungi that require systemic treatment.71
progressive coccidioidal infections, a multicenter, random- Unlike newer azoles, posaconazole is not extensively
ized, double-blind, placebo-controlled trial was conducted in metabolized by cytochrome P450 enzymes and is primarily
centers in California, Arizona, and Texas. Included were 198 excreted as a parent compound in the feces. Posaconazole is
patients with chronic pulmonary, soft tissue, or skeletal a cytochrome P3A4 inhibitor but does not inhibit the activity
coccidioidal infections. The antifungal doses given were of other cytochrome P enzymes. Posaconazole therefore
fluconazole (400 mg once daily) or itraconazole (200 mg have may have potentially fewer drug interactions compared
twice daily). A predefined scoring system was used at 4, 8, with other azoles.72,73
and 12 months to assess changes in severity of infection. In a report of posaconazole treatment (800 mg daily in
The findings were compared with baseline data, and 50% divided doses given for 1 to 2 years) in six patients with
of patients (47 of 94) in the fluconazole group and 63% chronic coccidioidomycosis unresponsive to previous
(61 of 97) in the itraconazole group responded to 8 months treatments, success was reported in five of six patients.
of treatment (P=.08). Patients with skeletal infections Two patients continued treatment after the trial was
responded twice as frequently to itraconazole as to ended.74 Efficacy of posaconazole was 85% in patients
fluconazole. By 12 months, 57% of patients had responded with chronic pulmonary or nonmeningeal disseminated
to fluconazole and 72% had responded to itraconazole coccidioidomycosis.75 Another multicenter clinical trial
(P=.05). An increased likelihood of response was associated evaluated the therapeutic effect of posaconazole treatment
with soft tissue involvement. Serum drug concentrations for for chronic refractory coccidioidomycosis in 15 patients, 7
both azoles were not helpful in predicting therapeutic with pulmonary disease, and 8 with a disseminated form.
outcome. Neither group showed a difference in relapse rate The response to treatment was prompt in most patients (1 to
after stopping antifungals (28% after fluconazole treatment 3 months), with a final overall response of 73%. The
and 18% after itraconazole treatment). Both drugs were well authors suggest that this antifungal can be used for treating
tolerated. The authors concluded that neither fluconazole patients with coccidioidomycosis when standard therapy is
nor itraconazole showed statistically superior efficacy in not successful.76
nonmeningeal coccidioidomycosis, although there was a The dose of posaconazole prescribed for coccidioido-
slight trend toward greater efficacy with itraconazole at the mycosis has been 400 mg twice daily in the form of an
doses studied.68 oral suspension (40 mg/mL). Administration with meals
The infection caused by Coccidioides spp has an ample ensures maximal absorption levels of the antifungal.77
variety of clinical presentations, ranging from a mild Coadministration of an antacid with posaconazole had no
588 O. Welsh et al.
††
•
•
•
•
•
Fig. 25 Treatment algorithm for coccidioidomycosis. DM, diabetes mellitus; TNF, tumor necrosis factor.
significant effects on its bioavailability under fasting or fungi that are resistant to fluconazole. It is formulated for
nonfasting conditions.78 oral (oral suspension and 50- and 200-mg tablets) and IV
The most commonly reported adverse events with this administration. The dose varies from 3 to 4 mg/kg IV or
triazole were fever, diarrhea, nausea, vomiting, and head- 200 to 300 mg orally daily. Drug interactions are the same
ache. Other less frequent manifestations included hypokale- as with other triazoles. When administered 1 hour before or
mia, rash, thrombocytopenia, and abdominal pain. Elevated 1 hour after a meal, the bioavailability of the oral
liver enzyme levels, hyperbilirubinemia, and hepatocellular formulation exceeds 90%. Gastric acid is not needed for
damage have been reported. These enzyme elevations were absorption; fatty foods decrease bioavailability to less than
generally mild and resolved upon discontinuation of therapy. 80%. In adults, after oral administration of 200 mg twice
Liver function tests should be monitored at baseline and daily, steady-state plasma concentrations of 2 to 3 mg/mL
throughout posaconazole therapy. Treatment should be are obtained. Adverse effects such as gastrointestinal
discontinued if serious hepatic abnormalities occur. Posaco- disturbances, rash and photosensitivity, transient visual
nazole administration is contraindicated if the patient is disturbances (nonsight threatening), as well as hepatitis,
taking terfenadine, astemizole, pimozide, cisapride, quini- have been reported.79,80
dine, or ergot alkaloids due to potential QT prolongation. In coccidioidomycosis (coccidioidal meningitis), there
When other drugs are concomitantly administered, the have been isolated reports of successful treatment with
clinician must consult the latest list of drug interactions of voriconazole. Up to now, there is no further informa-
this triazole. tion about clinical trials evaluating its efficacy for this
Voriconazole (Vfend), a second-generation triazole, is fungal infection.81-83
fungistatic against yeasts and fungicidal against susceptible Caspofungin belongs to a recently developed class of
filamentous molds. It is a synthetic derivant of fluconazole antifungal agents, the echinocandins, which targets the fungal
that exerts improved antifungal action that include some cell wall itself via interruption of b-1,3 glucan synthesis.84
Coccidioidomycosis 589
There is a report of a patient with meningeal coccidioi- 6. Bonifaz A, Vázquez-González D, Perusquía-Ortiz AM. Endemic
domycosis who was treated with caspofungin, 70 mg IV and systemic mycoses: coccidioidomycosis, histoplasmosis, paracocci-
dioidomycosis and blastomycosis. J Dtsch Dermatol Ges 2011;9:
50 mg daily thereafter for 22 days, without changes in the 705-14.
clinical course. Afterward, fluconazole and amphotericin B 7. Posadas A. Un Nuevo Caso de Micosis Fungoidea con Psorospermias.
were restarted, with no therapeutic response, and ending in a An d Circ Med Argent 1892;15:585-97.
fatal outcome.85 Another patient, who had received a renal 8. Wernicke R. Ueber einen Protozoenbefund bei Mycosis fungoides.
Centralbl f Bakt 1892;12:859-61.
allograft from a cadaver, developed flulike symptoms and
9. Deresinski SC. History of coccidioidomycosis: dust to dust. In: Stevens
multiple nodules that were detected by chest x-ray imaging. DA, editor. Coccidioidomycosis: a text. New York: Plenum Medical
Bronchoscopy and analysis of a nodular lesion specimen Book Co.; 1980. p. 1-20.
substantiated the diagnosis of coccidioidomycosis. He was 10. Negroni R. Evolución de los conocimientos sobre aspectos clínico-
initially treated with fluconazole for 3 days, but after epidemiológicos de la Coccidioidomycosis en las Américas. Rev
detection of an increase in creatinine levels (3.2 mg/dL), Argent Microbiol 2008;40:246-56.
11. Ophuls W, Moffitt HC. A new pathogenic mould (formerly described as
the treatment was changed to amphotericin B liposomal a protozoon: Coccidioides immitis pyogenes). Philadelphia Med J
given for 7 days, which caused a further increase in 1900;5:1471-2.
creatinine levels (4.2 mg/dL). Thereafter, treatment was 12. Ophüls W. Further observations on a pathogenic mould formerly
changed to caspofungin (50 mg/d IV) for 4 weeks. General described as a protozoon (coccidioides immitis, coccidioides pyogenes).
symptoms and renal and liver function tests improved. J Exp Med 1905;6:443-85.
13. Centers for Disease Control and Prevention (CDC). Increase in
Maintenance with fluconazole (200 mg daily) was then given Coccidioidomycosis—California, 2000-2007. MMWR Morb Mortal
for 6 months.86 Wkly Rep 2009;58:105-9.
Combination therapy with caspofungin (initially 70 mg 14. Galgiani JN, Ampel NM, Blair JE, et al. Coccidioidomycosis. Clin
and then 50 mg daily IV) and oral fluconazole (400 mg daily) Infect Dis 2005;41:1217-23.
was reported to be successful in the treatment of a patient 15. Fisher MC, Koening GL, White TJ, et al. Molecular and phenotipic
description of Coccidioides posadasii sp. Nov., previously recognized
with pulmonary and cutaneous coccidioidomycosis.87 Fur- as the non-California population of Coccidioides immitis. Mycologia
ther evaluation of the therapeutic efficacy of caspofungin is 2002;94:73-84.
needed for defining the usefulness of this drug in the 16. Castañón-Olivares LR, Laniado-Laborín R, Concepcion T, et al.
treatment of coccidioidomycosis. Clinical comparison of two Mexican coccidioidins. Mycopathologia
2010;169:427-30.
17. U.S. Department of Health and Human Services. Biosafety in
microbiological and biomedical laboratories. 5th ed. Washington,
Conclusions DC: U.S. Government Printing Office; 2007.
18. de Aguiar Cordeiro R, Nogueira Brilhante RS, Gadelha Rocha MF,
et al. Rapid diagnosis of coccidioidomycosis by nested PCR assay of
Coccidioidomycosis remains a challenging disease in its sputum. Clin Microbiol Infect 2007;13:449-51.
diagnosis and treatment. We have to keep in mind the 19. Bialek R, Kern J, Herrmann T, et al. PCR assays for identification of
possibility of this diagnosis in patients with the signs and Coccidioides posadasii based on the nucleotide sequence of the antigen
2/proline-rich antigen. J Clin Microbiol 2004;42:778-83.
symptoms described in this contribution. Despite treatment 20. Kohne DE, Steigerwalt AG, Brenner DJ. Nucleic acid probe specific
guidelines, therapy should be customized according to the for members of the genus Legionella. In: Thornsberry C, Ballows A,
severity and dissemination of the infection as well as the Freeley W, et al, editors. Legionella. Proc 2nd International
patient's comorbidities, immune status, and response to Symposium. Washington, DC: American Society for Microbiology;
initial treatment. 1984. p. 107-8.
21. Rohrbough JG, Galgiani JN, Wysocki VH. The application of
proteomic techniques to fungal protein identification and quantification.
Ann N Y Acad Sci 2007;1111:133-46.
22. Ampel NM, Hector RF, Lindan CP, et al. An archived lot of
coccidioidin induces specific coccidioidal delayed-type hypersensitiv-
References ity and correlates with in vitro assays of coccidioidal cellular immune
response. Mycopathologia 2006;161:67-72.
1. Fisher FS, Bultman MW, Johnson SM, et al. Coccidioides niches and 23. Smith CE, Beard R. Varieties of coccidioidal infection in relation to the
habitat parameters in the southwestern United States. Ann N Y Acad Sci epidemiology and control of the diseases. Am J Public Health 1946;36:
2007;1111:47-72. 1394-402.
2. Gonzalez-Ochoa A. La coccidioidomicosis en Mexico. Rev Invest 24. Kirkland TN, Fierer J. Coccidioidomycosis: a reemerging infectious
Salud Publ (Mex) 1966;26:245-62. disease. Emerg Infect Dis 1996;2:192-9.
3. Poncio Mendes R, Negroni R, Bonifaz A, et al. New aspects of some 25. Ampel NM, Ryan KJ Carry PJ, et al. Fungemia due to Coccidioides
endemic mycoses. Med Mycol 2000;38(Suppl 1):237-41. immitis. An analysis of 16 episodes in patients and a review of the
4. Laniado-Laborin R. Expanding understanding of epidemiology of literature. Medicine (Balt) 1986;65:312-21.
coccidioidomycosis in the western hemisphere. Ann N Y Acad Sci 26. Bergstrom L, Yocum DE, Ampel NM, et al. Increased risk of
2007;1111:19-34. coccidioidomycosis in patients treated with tumor necrosis factor
5. Wanke B, Lazera M, Monterio PC, et al. Investigation of an outbreak of alpha antagonists. Arthritis Rheum 2004;50:1959-66.
endemic coccidioidomycosis in Brazil's nortern state of Piaui with a 27. Hernandez JL, Echevarria S, Garcia-Valtuille A, et al. Atypical
review of the occurrence and distribution of Coccidioides immitis in coccidioidomycosis in an AIDS patient succesfully treated with
three other Brazilian states. Mycopathologia 1999;148:57-67. fluconazole. Eur J Clin Microbiol Infect Dis 1997;16:592-4.
590 O. Welsh et al.
28. Binnicker MJ, Buckwalter SP, Eisberner JJ, et al. Detection of 54. Groll AH, Walsh TJ. Polyene antifungal agents. In: Sarosi GA, Davies
Coccidioides species in clinical specimens by real-time PCR. J Clin SF, editors. Fungal diseases of the lung. 3rd ed. Philadelphia: Lippincott
Microbiol 2007;45:173-8. Williams & Wilkins; 2000. p. 271-7.
29. Galgiani JN, Dugger KO, Ampel NM, et al. Extraction of serologic and 55. Brajtburg J, Bolard J. Carrier effects on biological activity of
delayed hypersensitivity antigens from spherules of Coccidioides amphotericin B. Clin Microbiol Rev 1996;9:512-31.
immitis. Diagn Microbiol Infect Dis 1988;11:65-80. 56. Sau K, Mambula SS, Latz E, et al. The antifungal drug amphotericin B
30. Geijtenbeek TB, van Vliet SJ, Engering A, et al. Self- and nonself- promotes inflammatory cytokine release by a Toll-like receptor- and
recognition by C-type lectins on dendritic cells. Annu Rev Immunol CD14-dependent mechanism. J Biol Chem 2003;278:37561-8.
2004;22:33-54. 57. Clemons KV, Ranney DF, Stevens DA. A novel heparin-coated
31. Ampel NM. The complex immunology of human coccidioidomycosis. hydrophilic preparation of amphotericin B hydrosomes. Curr Opin
Ann N Y Acad Sci 2007;1111:245-58. Investig Drugs 2001;2:480-7.
32. Janeway Jr CA, Medzhitov R. Innate immune recognition. Annu Rev 58. Antony S, Dominguez DC, Sotelo E. Use of liposomal amphotericin B
Immunol 2002;20:197-216. in the treatment of disseminated coccidioidomycosis. J Natl Med Assoc
33. Parish JM, Blair JE. Coccidioidomycosis. Mayo Clin Proc 2008;83: 2003;95:982-5.
343-8 [quiz 348-9]. 59. González GM, Tijerina R, Najvar LK, et al. Efficacies of amphotericin
34. Chiller TM, Galgiani JN, Stevens DA. Coccidioidomycosis. Infect Dis B (AMB) lipid complex, AMB colloidal dispersion, liposomal AMB,
Clin North Am 2003;17:41-57. and conventional AMB in treatment of murine coccidioidomycosis.
35. Arsura EL, Kilgore WB, Ratnayake SN. Erythema nodosum in pregnant Antimicrob Agents Chemother 2004;48:2140-3.
patients with coccidioidomycosis. Clin Infect Dis 1998;27:1201-3. 60. Ostrosky-Zeichner L, Marr KA, Rex JH, et al. Amphotericin B: time for
36. Werner SB. Coccidioidomycosis misdiagnosed as contact dermatitis. a new “gold standard.”. Clin Infect Dis 2003;37:415-25.
Calif Med 1972;117:59-61. 61. Stevens D. Miconazole in the treatment of systemic fungal infections.
37. DiCaudo DJ, Yiannias JA, Laman SD, et al. The exanthem of acute Am Rev Respir Dis 1977;116:801-6.
pulmonary coccidioidomycosis: clinical and histopathologic features of 62. Welsh O, González JG, Diaz M, et al. Therapeutic evaluation of
3 cases and review of the literature. Arch Dermatol 2006;142:744-6. ketoconazole in patients with coccidioidomycosis. Rev Infect Dis 1980;2:
38. Dresinski SC. Coccioioidomycosis of bones and joints. In: Stevens D, 651-5.
editor. Coccidioidomycosis: a text. New York: Plenum Publishing 63. Graybill JR, Lundberg D, Donovan W, et al. Treatment of
Corp; 1980. p. 195-209. coccidioidomycosis with ketoconazole: clinical and laboratory studies
39. Igcr M. Coccidioidal osteomyelitis. In: Ajello L, editor. Coccidioido- of 18 patients. Rev Infect Dis 1980;2:661-73.
mycosis: current clinical and diagnostic status. Miami: Symposia 64. Catanzaro A, Einstein H, Levine B, et al. Ketoconazole for treatment of
Specialists; 1977. p. 177-90. disseminated coccidioidomycosis. Ann Intern Med 1982;96:436-40.
40. Dalinka MK, Dinnenberg S, Greendyk WH, et al. Roentgenographic 65. Prentice AG, Glasmacher A. Making sense of itraconazole pharmaco-
features of osseous coccidioidomycosis and differential diagnosis. kinetics. J Antimicrob Chemother 2005;56(Suppl 1):i17-22.
J Bone Joint Surg Am 1971;53:1157-64. 66. Catanzaro A, Galgiani JN, Levine BE, et al. Fluconazole in the treatment of
41. Johnson RH, Einstein HE. Coccidioidal meningitis. Clin Infect Dis chronic pulmonary and nonmeningeal disseminated coccidioidomycosis.
2006;42:103-7. NIAID Mycoses Study Group. Am J Med 1995;98:249-56.
42. Williams PL. Vasculitic complications associated with coccidioidal 67. Meinhof W. Kinetics and spectrum of activity of oral antifungals: the
meningitis. Semin Respir Infect 2001;16:270-9. therapeutic implications. J Am Acad Dermatol 1993;29:S37-41.
43. Gagliani JN. Opthalmic coccidioidomycosis. In: Stevens D, editor. 68. Galgiani JN, Catanzaro A, Cloud GA, et al. Comparison of oral
Coccidioidomycosis: a text. New York: Plenum Publishing Corp; 1980. fluconazole and itraconazole for progressive, nonmeningeal coccidioi-
p. 231-6. domycosis. A randomized, double-blind trial. Mycoses Study Group.
44. Petersen EA. Genitourinary coccidioidomycosis. In: Stevens D, editor. Ann Intern Med 2000;133:676-86.
Coccidioidomycosis: a text. New York: Plenum Publishing Corp; 1980. 69. Dewsnup DH, Galgiani JN, Graybill JR, et al. Is it ever safe to stop
p. 225-8. azole therapy for Coccidioides immitis meningitis? Ann Intern Med
45. Homans JD, Spencer L. Itraconazole treatment of nonmeningeal 1996;124:305-10.
coccidioidomycosis in children: two case reports and review of the 70. Limper AH, Knox KS, Sarosi GA, et al. American Thoracic Society
literature. Pediatr Infect Dis J 2010;29:65-7. Fungal Working Group. An official American Thoracic Society
46. Lavetter A. Coccidioidomycosis in Pediatrics. In: Stevens D, editor. statement: treatment of fungal infections in adult pulmonary and
Coccidioidomycosis: a text. New York: Plenum Publishing Corp; 1980. critical care patients. Am J Respir Crit Care Med 2011;183:96-128.
p. 245-7. 71. Greer ND. Posaconazole (Noxafil): a new triazole antifungal agent.
47. Spinello IM, Johnson RH, Baqi S. Coccidioidomycosis and pregnancy: Proc (Bayl Univ Med Cent) 2007;20:188-96.
a review. Ann N Y Acad Sci 2007;1111:358-64. 72. Herbrecht R. Posaconazole: a potent, extended-spectrum triazole anti-
48. Levine HB, Miller RL, Smith CE. Influence of vaccination on fungal for the treatment of serious fungal infections. Int J Clin Pract
respiratory coccidiodial disease in cynomolgus monkeys. J Immunol 2004;58:612-24.
1962;89:242-51. 73. Rachwalski EJ, Wieczorkiewicz JT, Scheetz MH. Posaconazole: an oral
49. Pappagianis D. Evaluation of the protective efficacy of the killed Coc- triazole with an extended spectrum of activity. Ann Pharmacother
cidioides immitis spherule vaccine in humans. The Valley Fever Vaccine 2008;42:1429-38.
Study Group. Am Rev Respir Dis 1993;148:656-60. 74. Anstead GM, Corcoran G, Lewis J, et al. Refractory coccidioidomy-
50. Johnson SM, Lerche NW, Pappagianis D, et al. Safety, antigenicity, and cosis treated with posaconazole. Clin Infect Dis 2005;40:1770-6.
efficacy of a recombinant coccidioidomycosis vaccine in cynomolgus 75. Catanzaro A, Cloud GA, Stevens DA, et al. Safety, tolerance, and
macaques (Macaca fascicularis). Ann N Y Acad Sci 2007;1111:290-300. efficacy of posaconazole therapy in patients with nonmeningeal
51. Schmelzer LL, Tabershaw IR. Exposure factors in occupational coccidi- disseminated or chronic pulmonary coccidioidomycosis. Clin Infect
oidomycosis. Am J Public Health Nations Health 1968;58:107-13. Dis 2007;45:562-8.
52. Park BJ, Sigel K, Vaz V, et al. An epidemic of coccidioidomycosis in 76. Stevens DA, Rendon A, Gaona-Flores V, et al. Posaconazole therapy
Arizona associated with climatic changes, 1998-2001. J Infect Dis for chronic refractory coccidioidomycosis. Chest 2007;132:952-8.
2005;191:1981-7. 77. Courtney R, Wexler D, Radwanski E, et al. Effect of food on the relative
53. Winn WA. The use of amphotericin B in the treatment of coccidioidal bioavailability of two oral formulations of posaconazole in healthy
disease. Am J Med 1959;27:617-35. adults. Br J Clin Pharmacol 2004;57:218-22.
Coccidioidomycosis 591
78. Courtney R, Radwanski E, Lim J, et al. Pharmacokinetics of 83. Cortez KJ, Walsh TJ, Bennett JE. Successful treatment of coccidioidal
posaconazole coadministered with antacid in fasting or nonfasting meningitis with voriconazole. Clin Infect Dis 2003;36:1619-22.
healthy men. Antimicrob Agents Chemother 2004;48:804-8. 84. Letscher-Bru V, Herbrecht R. Caspofungin: the first representative of a
79. Lazarus HM, Blumer JL, Yanovicjh S, et al. Safety and pharmacoki- new antifungal class. J Antimicrob Chemother 2003;51:513-21.
netics of oral voriconazole in patients at risk of fungal infection: a dose 85. Hsue G, Napier JT, Prince RA, et al. Treatment of meningeal
escalation study. J Clin Pharmacol 2002;42:395-402. coccidioidomycosis with caspofungin. J Antimicrob Chemother
80. Saravolatz LD, Johnson LB, Kauffman CA. Voriconazole: a new 2004;54:292-4.
triazole antifungal agent. Clin Infect Dis 2003;36:630-7. 86. Antony S. Use of the echinocandins (caspofungin) in the treatment of
81. Proia LA, Tenorio AR. Successful use of voriconazole for treatment of disseminated coccidioidomycosis in a renal transplant recipient. Clin
coccidioides meningitis. Antimicrob Agents Chemother 2004;48:2341. Infect Dis 2004;39:879-80.
82. Prabhu RM, Bonnell M, Currier BL, et al. Successful treatment of 87. Park D, Sohn J, Cheong H, et al. Combination therapy of disseminated
disseminated nonmeningeal coccidioidomycosis with voriconazole. coccidioidomycosis with caspofungin and fluconazole. BMC Infect Dis
Clin Infect Dis 2004;39:e74-7. 2006;6:26.