Diagnosis and Treatment of Pulmonary Coccidioidomycosis and Paracoccidioidomycosis

Abstract

Coccidioidomycosis (CM) and paracoccidioidomycosis (PCM) are systemic mycoses that are highly endemic in Latin America and have recently been included on the World Health Organization (WHO) Fungal Priority Pathogens List. Coccidioides immitis and Coccidioides posadasii are recognized as etiological agents of CM, with peculiarities in their geographic distribution. The genus Paracoccidioides now includes Paracoccidioides lutzii and the Paracoccidioides brasiliensis complex, which encompasses four phylogenetic species. In both diseases, pulmonary signs and symptoms are the main reasons for patients to seek medical assistance, and they are frequently misdiagnosed as tuberculosis. In this paper, we present a critical view of the strategies for diagnosis and clinical management of CM and PCM. Over the past few decades, there has been an increase in the number of reports of endemic fungal infections in areas previously thought to be “non-endemic” due to climate change and increased travel, among other factors. Learning to recognize their main epidemiological aspects and clinical manifestations is crucial so that clinicians can include them in the differential diagnosis of lung disease and avoid late diagnosis.

Pulmonary coccidioidomycosis mimicking malignancy associated with Sweet's syndrome (acute febrile neutrophilic dermatosis)

“…Definitive diagnostic testing may be performed with histopathology of biopsy specimens, revealing granulomatous inflammation and spherules of endospores upon cytological staining. 7,8 Finally, fungal culture from patient respiratory samples may be used for definitive diagnosis, since Coccidioides spp. are not part of the normal human microbiota.…”

“…Immunodiffusion testing is typically performed after an initial positive EIA test to quantify coccidioidal antibody concentration and support the diagnosis. Definitive diagnostic testing may be performed with histopathology of biopsy specimens, revealing granulomatous inflammation and spherules of endospores upon cytological staining 7,8 . Finally, fungal culture from patient respiratory samples may be used for definitive diagnosis, since Coccidioides spp.…”

“…However, it is important to classify between primary pulmonary and disseminated infection to decide on the duration of treatment. 7 Several studies indicated that CF titers of 1:32 were considered a specific indication of heightened activity and possible dissemination. 7,8 Our patient showed no clinical evidence of disseminated infection, but with a high yeast phase Ab titer (1:32), which is infectious, the infectious disease consultant decided to pursue the treatment for disseminated coccidioidomycosis with Fluconazole 800 mg for at least 3 months.…”

Lung infections due to emerging fungal pathogens

“…Archeologists and construction workers are at risk of severe pulmonary disease from large conidial inhalation [48]. Patterns of pulmonary disease include focal infiltrates with or without mediastinal adenopathy, disseminated pneumonia, acute respiratory distress syndrome, pleural effusions, empyema, residual nodules and cavities [47 ▪ ,48]. Accordingly, clinical outcomes vary from spontaneous resolution in asymptomatic or mildly symptomatic cases to significant morbidity and mortality in severe cases.…”

“…The clinical spectrum of pulmonary coccidioidomycosis ranges from asymptomatic infection and a mild flu-like illness to severe respiratory infection; the former presentation is most common, seen in approximately 60–75% of patients [47 ▪ ,48]. Hosts at risk of severe disease and secondary dissemination include people 65 years and older, pregnant women, persons of specific ethnic backgrounds (Filipino, Native American), solid organ transplant recipients, people living with HIV and patients on immunomodulators (steroids, TNF-α inhibitors) [47 ▪ ,48]. Archeologists and construction workers are at risk of severe pulmonary disease from large conidial inhalation [48].…”