Neonatal management and outcomes in the setting of disseminated coccidioidomycosis in pregnancy.

Coccidioidomycosis is a dimorphic fungal infection endemic to the southwestern United States and parts of the Americas. Pregnant individuals have an increased risk of disseminated disease, yet the diagnosis and management of neonatal coccidioidomycosis remain poorly defined. Neonatal coccidioidomycosis is rare but associated with significant morbidity and mortality. Transmission may occur via transplacental spread, aspiration of infected decidua at delivery, or early postnatal exposure. Diagnosis is challenging due to overlapping signs with prematurity and limitations of current serologic, antigen-based, and molecular assays. Placental pathology can provide insight, but does not reliably predict neonatal infection. Herein, we review the current literature on neonatal coccidioidomycosis and propose a risk-stratified, multidisciplinary approach to the evaluation and management of at-risk neonates, using illustrative cases to demonstrate the challenges of diagnosis and management. This practical approach includes maternal history, placental evaluation, targeted neonatal testing, and consideration of empiric antifungal therapy.