Off the Map: A Ten-Year Review of Coccidioidomycosis in Southeastern Michigan

Recent studies suggest coccidioidomycosis can be found outside regions not considered to be endemic for Coccidioides species. We reviewed our experience with coccidioidomycosis at a large quaternary medical center in southeastern Michigan, an area not typically considered to be endemic for this infection. In the last decade, we cared for 18 patients with proven (11) or probable (7) coccidioidomycosis. All patients had a history of travel or prior residence in areas known to be endemic for Coccidioides species; for 16, the presumed source of exposure to Coccidioides was in southern Arizona. The median age was 64 (36-80) years. Thirteen patients had pulmonary coccidioidomycosis; manifestations included multiple lung nodules, consolidated pneumonia, diffuse reticulonodular infiltrates, chronic thick-walled cavitary lesions, and pleural involvement. Five patients had disseminated infection, including two with isolated coccidioidal meningitis, one with osteoarticular coccidioidomycosis, one with extra-thoracic lymphadenopathy in addition to diffuse lung infiltrates, and one with involvement of lung, mediastinal lymph nodes, and skin. Proven coccidioidomycosis was established by growth of Coccidioides species in culture in five patients, histopathological examination in five patients (one of whom also had a positive culture), and positive complement fixation (CF) test for Coccidioides antibody in cerebrospinal fluid for two patients. Probable coccidioidomycosis was documented for seven patients by positive titers for CF antibody to Coccidioides in serum. A careful travel and exposure history remains crucial for patients presenting outside Coccidioides-endemic regions, in which coccidioidomycosis may not be readily suspected and the diagnosis missed.