Travel associated human coccidioidomycosis in Germany 2011-2023

Area of Science:

• Medical Mycology
• Infectious Diseases
• Epidemiology

Background:

• Coccidioidomycosis is a fungal infection endemic to specific regions.
• Cases in non-endemic areas like Germany are typically linked to travel history.
• Understanding the epidemiology and diagnostics in such settings is crucial.

Purpose of the Study:

• To review and characterize coccidioidomycosis cases in Germany between 2011-2023.
• To analyze clinical presentation, diagnostic methods, antifungal susceptibility, and molecular epidemiology.
• To evaluate diagnostic test performance in a non-endemic setting.

Main Methods:

• Retrospective review of confirmed coccidioidomycosis cases.
• Culture and histology for diagnosis.
• Serologic testing (lateral flow assay, immunodiffusion) and in vitro antifungal susceptibility testing.
• Whole-genome sequencing for molecular epidemiology.

Main Results:

• Fifteen cases of coccidioidomycosis were confirmed, caused by Coccidioides posadasii (10) and C. immitis (2).
• Clinical presentations included pulmonary, CNS, and disseminated disease, often in immunocompetent individuals.
• Lateral flow assays demonstrated 100% sensitivity, outperforming immunodiffusion (82%).
• Amphotericin B and azoles showed strong in vitro activity.
• Whole-genome sequencing linked most infections to Arizona.

Conclusions:

• Coccidioidomycosis is infrequently diagnosed in Germany but occurs in travelers, even those without comorbidities.
• Lateral flow assay is a highly sensitive and useful screening tool for coccidioidomycosis diagnosis in non-endemic regions.
• Molecular data suggests a strong link to Arizona as the source of infection for these German cases.