Systemic coccidioidomycosis in a llama cria native to Missouri.

A 3-mo-old male llama was examined because of a 4-wk history of lethargy and ill thrift. Clinical examination revealed subcutaneous masses in the left prescapular and right inguinal regions, mild ataxia, a slight head tilt to the right, and right ear droop. The cria died before clinical workup was complete. At autopsy, there was generalized lymphadenomegaly, a hepatic nodule, a midbrain mass causing rostral compression of the cerebellum, and internal hydrocephalus. Microscopic findings included pyogranulomatous lymphadenitis, meningoencephalitis, hepatitis, and bronchopneumonia. Intralesional fungal spherules, most consistent with Coccidioides spp., were identified in the lymph nodes, lung, and brain. Fungal culture, single-nucleotide variation genotyping real-time PCR, and DNA sequencing confirmed Coccidioides posadasii. The dam of the cria was native to Arizona and had been moved to Missouri ~2.5 y previously. Agar gel immunodiffusion assay of the herd revealed that only the dam was positive for Coccidioides spp.; 6 herdmates were negative. Computed tomography of the dam revealed multiple nodules within the lungs and liver, which were presumed to be an active coccidioidomycosis infection. This case of systemic coccidioidomycosis in a llama native to Missouri was presumably acquired by vertical transmission from the dam.

Autochthonous Transmission of Coccidioides in Animals, Washington, USA.

We report 5 cases of coccidioidomycosis in animals that were acquired within Washington, USA, and provide further evidence for the environmental endemicity of Coccidioides immitis within the state. Veterinarians should consider coccidioidomycosis in animals with compatible clinical signs that reside in, or have traveled to, south central Washington.

Coccidioidomycosis: first cases reported in Pernambuco, Brazil.

Coccidioidomycosis is a fungal infection caused by Coccidioides immitis or Coccidioides posadasii. These fungi are known to thrive in desert climate. Fungi produce infectious arthroconidia in soil, they are aerosolized in the air and when inhaled by humans, usually cause infections such as pneumonia. The first cases of coccidioidomycosis in Brazil were reported in 1978. Since then, there have been other reports mainly from desert regions of Northeastern Brazil. The present report describes three cases of coccidioidomycosis on male farmers from Serra Talhada county, Pernambuco State, who developed pneumonia and were subsequently diagnosed with pulmonary coccidioidomycosis. These three farmers were successfully treated with oral fluconazole. They reported having hunted armadillos in a rural and arid area of Pernambuco State. Armadillos are known to be carriers of Coccidioides. This is the first report of infection caused by Coccidioides in Pernambuco State, Brazil.

Imported endemic mycoses in Spain: Evolution of hospitalized cases, clinical characteristics and correlation with migratory movements, 1997-2014.

Endemic mycoses are systemic fungal infections. Histoplasmosis is endemic in all temperate areas of the world; coccidioidomycosis and paracoccidioidomycosis are only present in the American continent. These pathogens are not present in Spain, but in the last years there has been an increase of reported cases due to migration and temporary movements. We obtained from the Spanish hospitals records clinical and demographic data of all hospitalized cases between 1997 and 2014. There were 286 cases of histoplasmosis, 94 of Coccidioidomycosis and 25 of paracoccidioidomycosis. Overall, histoplasmosis was strongly related to HIV infection, as well as with greater morbidity and mortality. For the other mycoses, we did not find any immunosuppressive condition in most of the cases. Although we were not able to obtain data about clinical presentation of all the cases, the most frequently found was pulmonary involvement. We also found a temporal correlation between the Spanish population born in endemic countries and the number of hospitalized cases along this period. This study reflects the importance of imported diseases in non-endemic countries due to migratory movements.

Donor-Related Coccidioidomycosis Transmitted Through Left-Liver Transplant to a Child Recipient in a Nonendemic Area.

This first observation of donor-transmitted coccidioidomycosis in a pediatric liver-transplant recipient underlines a rare condition in transplanted patients in a nonendemic area. This transmission was observed after a liver split, the patient being contaminated by the left liver while the right-liver recipient was not.

The habitat of Coccidioides spp. and the role of animals as reservoirs and disseminators in nature.

BACKGROUND: Coccidioidomycosis, a potentially fatal fungal infection, is considered an emergent mycotic disease because of the increased incidence of fungal infections registered over recent years. Infection occurs through the inhalation of arthroconidia from two main species of Coccidioides: Coccidioides immitis and C. posadasii, which are both endemic to arid and semi-arid regions of North America. Coccidioides species not only infect humans but can also infect other mammals (land, aquatic, wild or domestic), reptiles and birds. OBJECTIVE: To obtain information regarding the habitat of Coccidioides spp. and the animals infected by this fungus and to identify the role that infected animals play as reservoirs and disseminators of this fungus in nature. MATERIALS: A literature review was conducted to identify the habitat of Coccidioides spp. and the infected non-human animal species targeted by this fungus. RESULTS AND CONCLUSIONS: This review allows us to suggest that Coccidioides spp. may be classified as halotolerant organisms; nevertheless, to perpetuate their life cycle, these organisms depend on different animal species (reservoirs) that serve as a link with the environment, by acting as disseminators of the fungi in nature.

Coccidioidomycosis Transmission Through Organ Transplantation: A Report of the OPTN Ad Hoc Disease Transmission Advisory Committee.

Donor-derived coccidioidomycosis has caused unexpected morbidity and mortality in transplant recipients. All proven or probable reports of donor-derived coccidioidomycosis to the Disease Transmission Advisory Committee between 2005 and August 2012 were reviewed. Six reports of proven or probable coccidioidomycosis were discovered. In four of six, the infection was first detected at autopsy in the recipient. In two cases it was first identified in the donor. Twenty-one recipients received organs from these six donors. Transmission occurred in 43% at a median of 30 days posttransplant with a mortality rate of 28.5%. Eleven recipients received preemptive antifungals, seven did not receive treatment, and treatment information was not reported for three recipients. Five of seven who did not receive prophylaxis/treatment died and all 11 who received early therapy survived. Six deaths occurred 14 to 55 days after transplant, with a median of 21 days. For exposed recipients, donor-derived coccidioidomycosis is a significant cause of morbidity and mortality. Evidence of infection in one recipient should prompt immediate evaluation for treatment of all other recipients from the same donor as preemptive treatment was effective. Further studies are needed to decide whether all donors from endemic areas should have routine serologic screening.

Distance from construction site and risk for coccidioidomycosis, Arizona, USA.

Coccidioides spp. fungi, which are present in soil in the southwestern United States, can become airborne when the soil is disrupted, and humans who inhale the spores can become infected. In 2012, our institution in Maricopa County, Arizona, USA, began a building project requiring extensive excavation of soil. One year after construction began, we compared the acquisition of coccidioidomycosis in employees working adjacent to the construction site (campus A) with that of employees working 13 miles away (campus B). Initial testing indicated prior occult coccidioidal infection in 20 (11.4%) of 176 campus A employees and in 19 (13.6%) of 140 campus B employees (p = 0.55). At the 1-year follow-up, 3 (2.5%) of 120 employees from campus A and 8 (8.9%) of 90 from campus B had flow cytometric evidence of new coccidioidal infection (p = 0.04). The rate of coccidioidal acquisition differed significantly between campuses, but was not higher on the campus with construction.

Systemic fungal infections in patients with human inmunodeficiency virus.

Histoplasmosis is a systemic infection caused by the dimorphic fungus Histoplasma capsulatum. In immunocompromised patients, primary pulmonary infection can spread to the skin and meninges. Clinical manifestations appear in patients with a CD4(+) lymphocyte count of less than 150 cells/µL. Coccidioidomycosis is a systemic mycosis caused by Coccidioides immitis and Coccidioides posadasii. It can present as diffuse pulmonary disease or as a disseminated form primarily affecting the central nervous system, the bones, and the skin. Cryptococcosis is caused by Cryptococcus neoformans (var. neoformans and var. grubii) and Cryptococcus gattii, which are members of the Cryptococcus species complex and have 5 serotypes: A, B, C, D, and AD. It is a common opportunistic infection in patients with human immunodeficiency virus (HIV)/AIDS, even those receiving antiretroviral therapy. Histopathologic examination and culture of samples from any suspicious lesions are essential for the correct diagnosis of systemic fungal infections in patients with HIV/AIDS.

Coccidioidomycosis.

Coccidioidomycosis is a common, environmentally acquired, pulmonary fungal infection in arid and semi-arid regions of the West, especially Arizona and California. The infection is frequently associated with striking cutaneous manifestations. Reactive, immunologically mediated eruptions include erythema nodosum, a generalized exanthem, Sweet syndrome, and reactive granulomatous dermatitis. Less commonly, the skin can harbor the actual organisms as a result of dissemination from the lungs. Dermatologists may play a key role in the recognition of coccidioidomycosis

Biowarfare and bioterrorism.

Bioterrorism is not only a reality of the times in which we live but bioweapons have been used for centuries. Critical care physicians play a major role in the recognition of and response to a bioterrorism attack. Critical care clinicians must be familiar with the diagnosis and management of the most likely bioterrorism agents, and also be adequately prepared to manage a mass casualty situation. This article reviews the epidemiology, diagnosis, and treatment of the most likely agents of biowarfare and bioterrorism.

Donor-derived organ transplant transmission of coccidioidomycosis.

Coccidioidomycosis in solid organ transplant recipients most often occurs as a result of primary infection or reactivation of latent infection. Herein, we report a series of cases of transplant-related transmission of coccidioidomycosis from a single donor from a non-endemic region whose organs were transplanted to 5 different recipients. In all, 3 of the 5 recipients developed evidence of Coccidioides infection, 2 of whom had disseminated disease. The degree of T-cell immunosuppression and timing of antifungal therapy initiation likely contributed to development of disease and disease severity in these recipients. This case series highlights the importance of having a high index of suspicion for Coccidioides infection in solid organ transplant recipients, even if the donor does not have known exposure, given the difficulties of obtaining a detailed and accurate travel history from next-of-kin.

Donor-derived Coccidioides immitis fungemia in solid organ transplant recipients.

We report disseminated coccidioidomycosis in 3 transplant recipients from a donor in an endemic area found to have unrecognized meningeal coccidioidomycosis. All 3 transplant recipients presented within 3 weeks of receipt of their organ. Only 1 organ recipient survived the acute presentation of coccidioidomycosis. Serologic testing for Coccidioides immitis infection should be considered for organ donors residing in endemic areas.

Subclinical dissemination of coccidioidomycosis in a liver transplant recipient.

Coccidioidomycosis is common in the southwestern United States, northern Mexico, and areas of South America. Coccidioides immitis and Coccidioides posadasii form arthroconidia that, if inhaled, can cause respiratory infection. Rarely, the organism disseminates throughout the body, causing disease in bones, lymph nodes, skin, joints, and brain in most severe cases. Certain populations are at higher risk for dissemination, including persons with compromised cellular immunity. This group includes patients with human immunodeficiency virus, patients undergoing immunosuppression for rheumatologic disorders, and patients receiving antirejection therapy after organ transplant. For patients undergoing a solid organ transplant in endemic areas, screening for past or present coccidioidal disease is completed pretransplantation. Those with known disease are given triazole therapy to prevent reactivation of disease posttransplantation. Usually, transplantation is postponed if the disease is active. We present a patient with known, active coccidioidomycosis who underwent successful liver transplant and later had subclinical posttransplantation peritoneal dissemination.

Landscape-epidemiological study design to investigate an environmentally based disease.

Cost-effective approaches for identifying and enrolling subjects in community-based epidemiological studies face many challenges. Additional challenges arise when a neighborhood scale of analysis is required to distinguish between individual- and group-level risk factors with strong environmental determinants. A stratified, two-stage, cross-sectional, address-based telephone survey of Greater Tucson, Arizona, was conducted in 2002-2003. Subjects were recruited from direct marketing data at neighborhood resolution using a geographic information system (GIS). Three geomorphic strata were divided into two demographic units. Households were randomly selected within census block groups, selected using the probability proportional to size technique. Purchased direct marketing lists represented 45.2% of Census 2000 households in the surveyed block groups. Survey design effect (1.6) on coccidioidomycosis prevalence (88 per 100,000 per year) was substantially reduced in four of the six strata (0.3-0.9). Race-ethnicity was more robust than age and gender to compensate for significant selection bias using poststratification. Clustered, address-based telephone surveys provide a cost-effective, valid method for recruiting populations from address-based lists using a GIS to design surveys and population survey statistical methods for analysis. Landscape ecology provides effective methods for identifying scales of analysis and units for stratification that will improve sampling efficiency when environmental variables of interest are strong predictors.

A risk factor study of coccidioidomycosis by controlling differential misclassifications of exposure and susceptibility using a landscape ecology approach.

State-reported coccidioidomycosis cases in Arizona have dramatically increased since 1997, raising concerns about a possible epidemic, its cause, and associated risk factors, including spatio-temporal differences in susceptibility and exposure. This stratified, two-stage, cross-sectional study evaluates inherent, socio-economic, and environmental risk factors of coccidioidomycosis from information collected during an address-based telephone survey of 5460 households containing 14,105 individuals in greater Tucson, Arizona. Three geomorphic and two demographic strata controlled for differences in group-level exposures and susceptibility, and assured recruitment of a minority population. Logistic regression of self-reported cases indicates that location of residence by geomorphic and demographic strata was a risk factor that confounded the associations of coccidioidomycosis with age, race-ethnicity, and educational attainment. The risk due to age is more evenly distributed across the population than bivariate results when individual- and group-level exposure and susceptibility factors are controlled. Similarly the association for being Hispanic decreased from strong bivariate 0.28 odds ratio to a weak multivariate 0.75. Location of residence confounded the risk due to race-ethnicity and was an effect modifier of risk due to age. Differential misclassification of exposure to Coccidioides spores and susceptibility to coccidioidomycosis was reduced through landscape stratification by demographics and geomorphic types. Landscape epidemiological studies of diseases with strong environmental and demographic determinants can reduce residual confounding and account for spatial and temporal differences between neighborhoods and at broader scales.