History and exam

Key diagnostic factors

common

presence of risk factors

Key risk factors include residence or recent visit to endemic area, male sex, occupational or recreational activities causing dust exposure, immunosuppression, pregnancy, ethnicity, and HLA types.

asymptomatic

Sixty percent of infections are asymptomatic.[39]

fever

A feature of acute or disseminated coccidioidomycosis.

cough

Generally dry and non-productive cough.

rash

Around 10% to 50% of patients develop a rash, which is generally transient.[40] Erythema nodosum or erythema multiforme are commonly seen. Skin nodules and lesions are a sign of disseminated infection.

Other diagnostic factors

common

headache

Twenty percent of coccidioidal pneumonia is associated with significant headache.[40]

fatigue

A feature of acute coccidioidomycosis.

pleuritic chest pain

Usually inspiratory, pleuritic discomfort.

dyspnoea

A feature of acute coccidioidomycosis.

myalgia or arthralgia

A feature of acute coccidioidomycosis.

weight loss

May be >10% of body weight in acute disease.[5][41]

Patients with chronic fibrocavitary pneumonia may have weight loss in addition to pulmonary symptoms.

night sweats

Associated with chronic fibrocavitary coccidioidomycosis or acute pulmonary infection.

chills

Associated with chronic fibrocavitary coccidioidomycosis or, more likely, acute pulmonary infection.

rales, rhonchi, wheeze, or rub

Associated with chronic fibrocavitary coccidioidomycosis.

bronchial breathing

Sign of lung consolidation.

uncommon

haemoptysis

Associated with nodules and cavities.

pyopneumothorax

Can develop if a cavity bursts.

lymphadenopathy

Extrathoracic lymphadenopathy suggests dissemination.

abnormal mental status or neurological examination

Suggests disseminated coccidioidomycosis.

Risk factors

strong

immunosuppression, especially suppression of cell-mediated immunity

Strong risk for developing severe and disseminated infection but not for acquisition of infection.

Conditions included in this group are HIV (especially with CD4 count of ≤250 cells/microlitre), organ transplantation, and haematological malignancies.[18][19][20][21]

pregnancy

Strong risk factor for dissemination‚ likely due to altered immune function associated with pregnancy. Of all coccidioidal cases diagnosed in the first trimester of pregnancy, 50% were disseminated.[12]

The risk of disseminated disease increases as pregnancy progresses: one literature review found that 96% of all coccidioidomycosis cases diagnosed in the third trimester were disseminated. The figures for the first and second trimester were 50% and 62%, respectively.[12] 

Among pregnant women with coccidioidomycosis, African-American women have a 13-fold higher risk of dissemination than white women.[11][12]

weak

occupation involving digging or construction

Increases the likelihood of infection from inhalation of airborne fungal arthroconidia (spores).

recreational activities that increase likelihood of dust inhalation

Increase the likelihood of infection from inhalation of airborne fungal arthroconidia.

extremes of age

Young children or older adults may develop more severe infection.[3]

male sex

Due to increased occupational or recreational dust exposure.

residing in or visiting endemic areas

The southwestern deserts of the US (California, Arizona, New Mexico, and western Texas) and northern deserts of Mexico are considered to be endemic areas.[3] Infection is also endemic in limited areas of Utah, Nevada, Eastern Washington, and Central and South America.

African-American or Filipino ancestry

Race is a strong risk factor for developing severe and disseminated infection but not for acquisition of infection.[3]

African-Americans and Filipinos have the highest risk for dissemination, approximately 10 to 175 times more often than in other races.[3][11]

The evidence is poor on whether there exists an increased risk of dissemination for Asians, Hispanics, and American Indians. It is likely that race per se is not the predisposing risk but rather the associated genetic makeup that dictates the immune response.

Among pregnant women with coccidioidomycosis, African-American women have a 13-fold higher risk of dissemination than white women.[11][12]​​

blood group B

A significant association has been identified between blood group B and disseminated coccidioidomycosis; this blood group is more common among people of African and Filipino ancestry.[3]

This association is likely a marker of genetic influences that dictate the immune response (see HLA risk factor).

HLA groups

Human leukocyte antigen (HLA) class II alleles have been identified as markers for risk of dissemination. However, while this information is useful in further study, it has limited use in clinical situations.[3]

diabetes mellitus

Associated with cavitary lung disease and relapsed infection.[22]

Patients with diabetes mellitus and poorly controlled glucose levels may have increased risk of dissemination.[22]

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