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Anthony Fossaceca Anthony Nuzzi Swati Vasireddy

Coccidioidomycosis By Team Aspergillus

Coccidioidomycosis    Coccidioidomycosis  is  an  infection,  usually  of  the  lungs,  caused  by  the  fungus  Coccidioides  immitis/posadasii.    

  Caused  by  inhaling  spores  of  the  fungus    Usually  mild,  with  :lu-­‐like  symptoms  and  rashes  

http://microbewiki.kenyon.edu/index.php/Coccidioides_immitis Spherule with endospores of Coccidioides immitis. FA stain

lung showing a large fibrocaseous nodule

History  of  Coccidioidomycosis

 Wernicke  and  Posadas  :irst  described  a  case  of  coccidioidomycosis  in  1892  in  South  America  

  Two  years  later  Rixford  and  Gilchrist  reported  a  case  in  California  around  1894-­‐96  

commons.wikimedia.org/wiki/File:Alejandro_Pos.

History  of  Coccidioidomycosis  

 Also  known  as   Valley  fever,  San  Joaquin  Valley  fever,  California  disease,  and  desert  fever  

 The  :irst  effective  therapy     Used  Amphotericin  B  in  1957  

Etiology/Causative  of    Coccidioides  sp.  

 Coccidioides  immitis  (name  most  commonly  used)  

 Coccidioides  posadasii  

http://www.mycology.adelaide.edu.au/Fungal_Descriptions/Dimorphic_Pathogens/Coccidioides/

Coccidioides  immitis/posadasii  Difference  

  Little  known  about  Pathogenicity     (pathogen  to  produce  infections)  

 Morphologically  identical    Distinguished  only  by    

 genetic  analysis   Rates  of  growth  in  the  presence  of  high  salt  concentrations   C.  posadasii  grows  more  slowly  

 Location  in  the  world  

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Taxonomy  of  Coccidioides  immits/posadasii  

 Kingdom:  Fungi   Phylum:  Ascomycota   Class:    Euascomycetes   Order:    Onygenales   Family:    Onygenaceae   Genus:    Coccidioides  

Biology  of  Coccidioides  immitis/posadasii    Fungi  

 Arthroconidia   spores  typically  produced  by  segmentation  of  pre-­‐existing  fungal  hyphae  

 Asexual   Spherules  (Circular  Spores)   Asexual   Haploid  

  In  sabouraud  dextrose  agar  (25  to  37O  C)   Grayish  initially,  later  producing  white  aerial  mycelium.  With  age  colonies  become  tan  to  brown  

Biology  of  Coccidioides  immitis/posadasii    Thermal  Dimorphic    Coccidioides  immitis/posadasii  

 Arthroconidia  found  within  the  mycelial  (25O  C)   Thick  walled,  barrel  or  cask  shaped  

 Once  inhaled  by  a  living  organism,  arthroconidia  develops  into  thick-­‐walled  spherule  :illed  with  endospores  (37O  C)  

 Endospores  are  released  which  causes  an  infection  in  the  organism  • Known  as  coccidioidomycosis  

Life  Cycle  

http://www.metapathogen.com/coccidioides/

Life  Cycle  

http://www.cdc.gov/ncidod/EID/vol2no3/kirkland.htm

Ecology  of  Coccididiode  Sp.  

  C.  immitis   Located  in  California’s  San  Joaquin  Valley  region  

  C.  posadasii   Southwest  desert  of  U.S.,  Mexico,  and  S.  America  

  Lives  in  High  summer  temperatures  and  low  altitude   Dry  areas  with  low  rain  fall  

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Ecology  of  Coccididiode  Sp.  

  Coccidioides  immitis/posadasii   Arthroconidia   Forms  in  the  soil  as  mycelium   Around  25O  C  

 Spherules  (Spherical  Spores)   Develops  infection  once  inhaled  by  animal  or  human  7  to  21  days  

 Around  37-­‐40O  C  

http://www.doctorfungus.org/thefungi/Coccidioides.htm

Ecology  of  Coccididiode  

http://en.wikipedia.org/wiki/Coccidioidomycosis

Disease  Manifestation  of  Coccidioidomycosis  

  Disease  in  humans   Men  more  likely  to  be      infected  than  women   Also,  those  who  are    immunocompromised.  Such  as  Aids  victims  

 60%  of  people  who  are  infected  show  no  symptoms  (asymptomatic).  

 40%  symptoms  appear  10-­‐30  days  after  exposure  

 Patients  may  not  show  symptoms  for  20  or  more  years  

http://www.mycology.adelaide.edu.au/Mycoses/Dimorphic_systemic/Coccidioidomycosis/

Disease  Manifestation  of  Coccidioidomycosis  

  Symptoms   Malaise   Myalgia   Chest  pain   Fatigue   Erthema  multiforme   Erythema  nodosum   Arthralgia   Regional  lymphadenitis  

 Common  Cold   Flu-­‐like  symptoms   Fever   Cough   Headaches   Rash   Myalgias   Asymptomatic   Infuenza-­‐like  symptoms  

Disease  Manifestation  of  coccidioidomycosis  

  In  Animals   Life  threatening   Fever   Loss  of  appetite   Loss  of  energy    Swollen  joints    Swollen  lymph  nodes   Cough   Attacks  lung  

http://www.cfsph.iastate.edu/DiseaseInfo/disease-images.php?name=coccidioidomycosis

Description: Dog lung (Right) and wallaby (Left) kidney. Cross section of lung reveals multifocal to coalescing pale firm areas (granulomas).

Disease  Prevention    Only  method  of  prevention  is  to  avoid  visiting  areas  where  it  is  found  (Impossible)   Endemic  in  Arizona,  California,  Nevada,  New  Mexico,  Texas,  Utah,  North  Western  Mexico,  South  Africa,  and  Asia  

  Stay  away  from  dust  storms,  Farming,  and  high  construction  areas.  

 Maintain  good  health      and  protect  yourself      from  HIV  infection.  

http://www.abc.net.au/reslib/200804/r237411_957564.jpg http://en.wikipedia.org/wiki/File:Magic_Lipofsky.jpg

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Works  Cited    http://emedicine.medscape.com/article/297976-overview   http://www.absoluteastronomy.com/topics/Coccidioidomycosis   http://www.ajronline.org/cgi/reprint/136/2/393.pdf   http://www.cdc.gov/ncidod/EID/vol2no3/kirkland.htm   https://online.epocrates.com/u/2924558/Coccidioidomycosis/

Basics/Etiology   http://www.medicinenet.com/valley_fever/article.htm   http://jcm.asm.org/cgi/content/full/38/2/807   http://www.doctorfungus.org/thefungi/Coccidioides.htm   http://www.mycology.adelaide.edu.au/

Epidemiology   Begins  as  a  respiratory  illness   May  progress  to  a  persistent  infection  

 Disseminated  coccidioidomycosis  is  the  most  severe  form  of  the  disease   Often  fatal  

 C.  immitis  was  a  potential  biological  weapon  

Epidemiology     Mostly  restricted  to  America   Currently  an  endemic  disease  

 Immunocompromised  individuals  are  more  susceptible  to  the  disease  

Coccidioidomycosis  

Virulence  Factors    The  parasitic  cell  surface  glycoprotein   Functions  as  an  adhesion    

  Branching  septate  hyphae  that  are  2  to  4m  in  diameter  

  production  of  chitinase  and  ß-­‐glucanase   during  the  transition  from  the  mycelial  to  parasitic  form  

Host  Response   T  lymphocytes   inhibits  the  growth  of  arthroconidia  and  endospores  

 Cytokines   Antibody   Little  attention  given  

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Diagnosis   Septum  culture  is  most  effective   PCR  is  also  used  

 Primary  lung  infection  is  asymptomatic  in  60%  of  individuals   The  other  40%  develop  a  mild  to  moderate  in:luenza-­‐like  syndrome  1  to  3  weeks  after  exposure  

Disease  management   Antifungal  therapy     Occasional  chest  radiographs  

 Biopsy  of  nonhealing  ulcers  and  lesions  

WORKS  CITED    http://health.utah.gov/epi/fact_sheets/cocci.html   http://www.scielo.br/scielo.php?

pid=S0036-46651998000300001&script=sci_arttext   http://cmr.asm.org/cgi/content/full/17/4/804   http://www.images.missionforvisionusa.org/anatomy/

2007/02/coccidiodomycosis.html

CASE  REPORTS  

CASE  REPORT  1   37-­‐year-­‐old  female   Emergency  room  complaining  of  swollen  right  thumb  

 Bitten  2  weeks  ago  by  stray  cat   Whole  right  hand  now  erythmetous,  swollen,  tender  

  Initial  physical  examination  indicated  no  problems   Admitted  to  operating  room  to  see  hand  surgeon   Exploratory  surgery  showed  extreme  swelling  of  right  arm  but  minimal  purulence  

 Tissue  specimens  submitted  for  culture  and  staining  

CASE  REPORT  1    Initial  stains  showed  no  organisms  

 Gram  stain  for  bacteria,  Kinyoun  stain  for  mycobacteria,  calco:luor  white  stain  for  fungi  

 Histopathology  showed  only  perivascular  dermatitis    Started  on  vancomycin  and  ceftriaxone    Condition  worsened,  taken  back  to  surgery   Original  cultures  showed  waxy  mold  on  :ifth  day    Identi:ied  next  day  as  Coccidioides  sp.  using  genus-­‐speci:ic  ribosomal  probe  

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CASE  REPORT  1   Started  on  :luconazole   Condition  improved  dramatically   Discharged  6  days  after  admission   Serum  enzyme  immunoassay  serology  results  for  Coccidioides  IgM  and  IgG  antibodies  negative  at  discharge  and  at  6  weeks  

 Remained  symptom-­‐free,  taken  off  :luconazole  after  2  months  

CASE  REPORT  1   Cat  died  shortly  after  biting  patient   Veterinary  pathologist  noted  pyogranuloma  with  lots  of  spherules  

 Final  diagnosis  on  cat:  multifocal  granulomatous  splenitis  and  disseminated  disease  with  Coccidioides  spp.  as  the  etiologic  organisms  

 Etiologic  agents  now  considered  two  different  species  in  genus  Coccidioides   Coccidioides  immitis  and  Coccidioides  posadasii  

Gaidici,  Adriana,  and  Michael  A.  Saubolle.  "Transmission  of  Coccidioidomycosis  to  a  Human  via  a  Cat  Bite."  Journal  of  Clinical  Microbiology  47.2  (2009).  ISI  Web  of  Knowledge.  Web.  <http://apps.isiknowledge.com/full_record.do?product=UA&search_mode=Re:ine&qid=2&SID=2EgAgPNeL9LjNeOHibe&page=1&doc=5&colname=MEDLINE&cacheurlFromRightClick=no>.  

CASE  REPORT  2   39-­‐year-­‐old  male   At  routine  follow-­‐up,  complained  of  swelling  in  face,  prominent  veins  on  chest  

  2  years  before,  diagnosed  with  HIV  when  presented  with  Coccidioides  pneumonia  

  Started  on  :luconazole    41  days  later,  started  highly  active  antiretroviral  therapy  (HAART)  

  CD4  count  improved,  HIV  viral  load  dropped  

CASE  REPORT  2    Facial  swelling  started  27  months  after  HAART  initiation  

  Chest  x-­‐ray  showed  widened  mediastinum,  right  middle  lobe    

  Coccidioides  complement  :ixation  was  1:32   Was  1:8  at  time  of  HIV  diagnosis  

 Underwent  core  needle  biopsy  of  RML  lesion   Spherules  consistent  with  Coccidioidomycosis  

  Fungal  culture  and  acid-­‐fast  negative  

CASE  REPORT  2   Underwent  VATS  to  biopsy  mediastinal  nodes   Video-­‐assisted  thoracoscopic  surgery  

 Nodes  demonstrated  consistency  with  Coccidioidomycosis  but  no  evidence  of  malignancy  

 Recovered  well  from  surgery,  facial  swelling  resolved  

 Received  1g  Amphotericin  B  after  :inal  biopsy  

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CASE  REPORT  2   Coccidioidomycosis  seemed  to  be  cause  of  SVC  problems,  but  not  common  :inding   Tuberculosis  more  common  infectious  agent  

 First  published  case  of  Coccidioides  causing  SVC  syndrome  

 Mortimer,  Roger  B.,  Robert  Libke,  Babak  Eghbalieh,      and  John  F.  Bilello.  "Immune  Reconstitution      In:lammatory  Syndrome  Presenting  as  Superior      Vena  Cava  Syndrome  Secondary  to  Coccidioides      Lymphadenopathy  in  an  HIV-­‐infected  Patient."      Journal  of  the  International  Associaton  of      Physicians  in  AIDS  Care  7.6  (2008).  ISI  Web  of      Knowledge.  Web.      <http://apps.isiknowledge.com/full_record.do?pr    oduct=UA&search_mode=Re:ine&qid=10&SID=2E    gAgPNeL9LjNeOHibe&page=1&doc=7&colname=    MEDLINE&cacheurlFromRightClick=no>.  

QUESTION  1  

Coccidioide  differ  in  what  way?  

A.  Pathogencity  B.  Morphology  C.  Genetic  Analysis  D.  None  of  the  above  

QUESTION  2  

Coccidioide  immitis  is  most  known  in  what  region?  

A.  Mexico  B.  S.  America  C.  Off  the  coast  of  the  Balkan  Islands  near  Michigan  

D.  California's  San  Joaquin  Valley  

QUESTION  3  

Coccidioidomycosis  begins  as  a  

A.  respiratory  illness  B.  digestive  illness  C.  cutaneous  infection  D.  urinary  infection  

QUESTION  4  

Which  is  not  a  type  of  coccidioide?  

A.  C.  immitis  B.  C.  posadasii  C.  C.  Blavens  D.  C.  fumigatus  

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QUESTION  5  

The  :irst  effective  therapy  for  Coccidioidomycosis  was  

A.  Amphotericin  B  B.  Fluconazole  C.  Itraconazole  D.  Vancomycin