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Coccidioidomycosis is an endemic fungal infection in the southwestern USA and northern Mexico. It is caused by Coccidioides immitis and C. posadasii. This infection occurs due to the inhalation of airborne arthroconidia, causing a mild pulmonary infection, but most cases are asymptomatic. Disseminated coccidioidomycosis (DC) is a rare entity occurring in less than 1% of all cases, usually in immunocompromised patients, and it carries high risks of morbidity and mortality. The skin is one of the most frequently affected organs and in some cases cutaneous lesions may be the first or only sign of infection. A wide spectrum of clinical lesions may develop, including cold abscess. In immunocompromised hosts, DC represents a diagnostic and therapeutic challenge. Treatment is based on antifungal drugs, such as amphotericin B and azoles, administered for long periods of time and under close follow up to monitor the treatment response and to detect relapse. In the following case report, we present a 35-year-old male patient with systemic lupus erythematosus under immunosuppressive therapy who presented with cold subcutaneous abscesses as the first sign of DC.

Summary A 52-year-old woman with pulmonary sarcoidosis on immunosuppressive therapy developed pulmonary infiltrates and cutaneous granulomatous abscesses after a trip to the USA in April 2005. A hyphomycete was identified, further characterized by a gene probe as Coccidioides spp. and then definitively identified as Coccidioides posadasii by polymerase chain reaction and sequencing. Antibodies towards Coccidioides spp. were detected. The infection was successfully treated with posaconazole (Noxafil®), 2 x 400 mg/d.

The human immune response during coccidioidomycosis is intimately involved with the development of delayed-type hypersensitivity and cellular immunity. Sixty percent of those infected have no symptoms and benign outcome is generally associated with a specific cellular immune response to coccidioidal antigens. We have recently teased out the human pulmonary granulomatous response during coccidioidomycosis and noted that there are perigranulomatous clusters of lymphocytes consisting predominantly of B lymphocytes and CD4(+) T lymphocytes. In other work, we have found that the mannose receptor as well as the toll-like receptors TLR2 and TLR4 may have a role in recognizing glycosylated coccidioidal antigens. In addition, the IL-12 receptor axis appears to be operative during antigen recognition and IL-12p40 may be the active moiety. Finally, peripheral blood mononuclear cells from persons with disseminated coccidioidomycosis are able to respond to coccidioidal antigen when it is presented by a mature monocyte-derived IL-4-generated dendritic cell (DC). These observations could be useful in the development of a human vaccine against coccidiodomycosis.

Purpose This case study is designed to help the nurse practitioner recognize atypical symptoms of coccidioidal meningitis, particularly in high-risk groups that require further diagnostic treatment. Data sources Selected research, clinical articles, and case studies. Conclusions Coccidioidal meningitis is a potentially lethal infection unless recognized and treated. Unlike other infectious meningitides that present with more acute meningeal symptoms, disseminated coccidioidomycosis can present insidiously. When it presents as cognitive dysfunction, it may be mistaken for early dementia and if undiagnosed can result in death. While it is an infectious disease that is endemic to a small number of southwestern states, these areas see a high volume of tourists who can unwittingly become infected. Knowledge of this infectious disease and the many ways it can imitate other diseases is critical to its early recognition and treatment. Implications for practice Failure to recognize this reemerging, endemic fungal infection in high-risk groups can result in death.

Objectives/Hypothesis Coccidioidomycosis is a fungal disease endemic to semiarid regions in the southwestern United States, northern Mexico, and parts of South America. Although this is primarily a pulmonary disease, approximately 0.5% to 1.0% of infected individuals develop disseminated disease affecting skin, subcutaneous tissue, bone, joints, and meninges. The objectives of the study were to present three cases of head and neck manifestations of disseminated coccidioidomycosis and to review the literature of head and neck presentations, diagnosis, and treatment of this potentially life-threatening disease. Study Design Case reports and literature review. Methods A Medline search was performed with the keyword “coccidioidomycosis.” Of 1719 articles in all, 47 were selected for their relevance to otolaryngology, diagnosis, or treatment. Results Virtually all head and neck manifestations in patients with disseminated coccidioidomycosis involved the skin, with a predilection for the central face. Systemic symptoms such as fever and cough are often subtle, making the diagnosis difficult. Infections of multiple sites of the head and neck have been reported, including life-threatening airway lesions. Conclusion The incidence of patients with coccidioidomycosis has been steadily increasing since the late 1980s in endemic areas. Otolaryngologists are increasingly being called on to diagnose and manage the head and neck manifestations of the disease caused by Coccidioides immitis.

A 60-year-old male kidney transplant recipient presented with pneumonia 4 months after transplantation. Coccidioidomycosis was suspected and empirically treated with fluconazole. He was maintained on suppressive fluconazole without problems. Three weeks after discontinuing secondary prophylaxis, the patient experienced coccidioidal arthritis and an infection of the soft tissue of the hand that required debridement. Transplant recipients may have quiescent disseminated coccidioidomycosis that is reactivated by immunosuppression after withdrawal of suppressive antifungal therapy.

This case emphasizes that aggressive neurosurgical management may benefit patients with disseminated coccidioidomycosis and skull abscesses. Disseminated infection due to Coccidioides immitis, the causative agent of coccidioidomycosis, is difficult to treat and often requires prolonged antifungal therapy in addition to surgical debridement. We present a case of a young woman with disseminated coccidioidomycosis who had multiple skull lesions, two of which penetrated the skull and invaded the subgaleal and epidural spaces. Despite prolonged aggressive medical management, these lesions failed to resolve until they were surgically drained.

A 25-year-old black man had a 7-month history of draining chest wall abscesses. Potassium hydroxide examination of abscess drainage revealed numerous spherules with doubly refractile walls. Although uncommon, a diagnosis of nonendemic coccidioidomycosis should be considered in cases of atypical cutaneous infections in highly mobile persons.

Coccidioidomycosis is a fungal infection endemic to the arid Southwestern United States. It is contracted initially as a pulmonary disease when coccidioides immitus spores found in soil are inhaled. Disseminated disease occurs primarily in the immunocompromised population. We present herein a case of disseminated coccidioidomycosis presenting as a temporal fossa lesion extending intracranially. Our patient showed a robust response to antifungal therapy that obviated the need for surgical intervention. Coccidioidomycosis of the Temporal Fossa with

The diagnosis of disseminated coccidioidomycosis was made in two pregnant women by the biopsy of facial granulomas. The unusual presentation and the problems associated with the management of this disease in pregnancy stimulated a literature review and a report of these two cases. The history of the discovery and elucidation of this disease is reviewed. Documentation of interhuman transmission of coccidioidomycosis by fomites is presented. Previous reports of disseminated coccidioidomycosis being found in the endolarynx, epiglottis and region of the head and neck are cited. The high incidence of fetal wastage, the high maternal mortality associated with dissemination and the role of Amphotericin B in the therapy of the disseminated disease are discussed.

Leprosy has the reputation of a simulator of other diseases in clinical medicine. Conversely, leprosy has nondiagnostic but characteristic clinical features that may be imitated on occasion by other diseases. Recently, a patient with an appearance compatible with the clinical diagnosis of lepromatous leprosy was found to have a peculiar manifestation of disseminated coccidioidomycosis.