Disseminated Coccidioidomycosis in Immunocompetent Hosts: Opportunities for Increased Recognition and Timely Diagnosis.

BACKGROUND: While most pulmonary infections with Coccidioides spp. are self-limited, a subset of patients is at higher risk for severe disease and extrapulmonary dissemination, including individuals with certain ethnic backgrounds. Disseminated disease can involve soft tissues, bones, and the central nervous system with high morbidity and mortality in the absence of antifungal treatment. Diagnosis of coccidioidomycosis can be challenged by the availability of specimens for culture or histopathology, confusion with, or lack of availability of various antibody tests and overall lack of consideration of Coccidioides spp. as the etiology of disease, especially in immunocompetent hosts.

METHODS: We set out to characterize cases of disseminated coccidioidomycosis at our institution over a 7-year period, solely in immunocompetent hosts, to highlight diagnostic delays and determine which, if any, primary screening test might be the most useful.

RESULTS: A total of 40 cases met our inclusion criteria, and 100% of these cases had positive immunoglobulin G antibodies on a US FDA-cleared Coccidioides spp. enzyme immunoassay. Nearly all of the cases (87%) had a delay in diagnosis and associated worsening of disease (71%). Locations of initial presentations that led to delayed recognition included primary care settings (56%), emergency departments (33%), and urgent care centers (11%), all in the region of Coccidioides spp. endemicity.

CONCLUSIONS: These findings highlight the need for interventions to increase awareness of the risk factors for, the symptoms of, and the appropriate testing options to diagnose disseminated coccidioidomycosis.