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Disseminated Coccidioidomycosis in Immunocompetent Hosts: Opportunities for Increased Recognition and Timely
Anna C H Hoge1, Thomas E Grys1, Erin H Graf1
1Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, AZ, United States.
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.
Insights
Disseminated coccidioidomycosis in immunocompetent hosts often faces diagnostic delays, even with positive antibody tests. Increased awareness of risk factors and symptoms is crucial for timely diagnosis and treatment.
Area of Science:
- Infectious Diseases
- Mycology
- Immunocompromised Host Research
Background:
- Coccidioides spp. infections can cause severe, disseminated disease, particularly in at-risk populations.
- Diagnosis is often delayed due to testing limitations and under-consideration, especially in immunocompetent individuals.
- Extrapulmonary coccidioidomycosis carries high morbidity and mortality without prompt antifungal therapy.
Purpose of the Study:
- To characterize disseminated coccidioidomycosis cases in immunocompetent patients.
- To identify diagnostic delays and their contributing factors.
- To evaluate the utility of primary screening tests for disseminated coccidioidomycosis.
Main Methods:
- Retrospective analysis of 40 immunocompetent patients with disseminated coccidioidomycosis over 7 years.
- Review of diagnostic timelines and initial presentation settings.
- Assessment of Coccidioides spp. immunoglobulin G (IgG) enzyme immunoassay results.
Main Results:
- All 40 cases (100%) showed positive Coccidioides spp. IgG antibodies via FDA-cleared immunoassay.
- A significant delay in diagnosis (87%) was observed, correlating with disease worsening (71%).
- Delayed diagnoses occurred in primary care (56%), emergency departments (33%), and urgent care (11%) within endemic areas.
Conclusions:
- Disseminated coccidioidomycosis diagnosis in immunocompetent hosts is frequently delayed.
- Positive Coccidioides spp. IgG antibodies are consistently present in disseminated cases.
- Enhanced clinician awareness of risk factors, symptoms, and diagnostic testing is essential.
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