Coccidioidomycosis in cirrhosis: A high-risk syndrome with severe outcomes

Patients with cirrhosis and end-stage liver disease (ESLD) are highly susceptible to severe infections due to cirrhosis-associated immune dysfunction (CAID). The clinical features and outcomes of coccidioidomycosis in this population remain poorly described.

We conducted a retrospective cohort study of adults with cirrhosis and/or ESLD diagnosed with coccidioidomycosis between 2010 and 2025 at a tertiary referral center in California's San Joaquin Valley. Demographics, clinical features, diagnostics, management, and outcomes were abstracted from electronic health records.

Forty-six patients met inclusion criteria. The mean age was 52 years, 74 % were male, and 67 % identified as Hispanic. Alcohol-related liver disease was the most common etiology, and 67 % had decompensated cirrhosis. Respiratory symptoms predominated, with cough, dyspnea, and fever most frequent; 96 % had abnormal chest imaging, most commonly diffuse infiltrates. Disseminated or complicated pulmonary disease occurred in 35 %. Median diagnostic delay was 28 days. Antifungal therapy was given to 89 % (primarily fluconazole); hepatotoxicity occurred in 26 %. Hospitalization was required in 63 %, ICU care in 24 %, and relapse occurred in 24 %. All-cause mortality was 33 %, with a median time-to-death of 369 days.

Coccidioidomycosis in cirrhosis represents a high-risk clinical syndrome marked by delayed diagnosis, high rates of hospitalization, treatment complications, and significant mortality. Early recognition and optimized anti-fungal management are urgently needed, and prospective studies should define best practices for this vulnerable population.