Coccidiomycosis Flashcards
What causes coccidioidomycosis?
Coccidioidomycosis is caused by either of two soil-dwelling dimorphic fungi: Coccidioides immitis and Coccidioides posadasii.
In which areas is coccidioidomycosis highly endemic in the United States?
Endemic areas include:
* Lower San Joaquin Valley
* Much of Arizona
* Southern regions of Utah, Nevada, and New Mexico
* Western Texas
* Northern Mexico
What is the relationship between CD4 T lymphocyte counts and the risk of symptomatic coccidioidomycosis in people with HIV?
The risk is increased in people with CD4 counts <250 cells/mm3 and who are not virologically suppressed.
What are the four common clinical syndromes of coccidioidomycosis?
The four common clinical syndromes are:
* Focal pneumonia
* Diffuse pneumonia
* Extrathoracic involvement (including meningitis, osteoarticular infection)
* Positive coccidioidal serology tests without evidence of localized infection
What symptoms are associated with focal pneumonia in coccidioidomycosis?
Symptoms may include cough, fever, and pleuritic chest pain.
True or False: Diffuse pneumonia is more common in immunocompromised patients.
True
What are the cerebrospinal fluid (CSF) profile characteristics in coccidioidal meningitis?
CSF profile shows:
* Low glucose levels
* Elevated protein levels
* Lymphocytic pleocytosis
What is the primary method for diagnosing coccidioidomycosis?
Diagnosis is based on serology, histology, culture, and clinical presentation.
What is a significant laboratory biosafety hazard when culturing Coccidioides species?
The risk of inhalation of dislodged arthroconidia.
Fill in the blank: The enzyme immunoassay (EIA) is used for detecting _______.
immunoglobulin M (IgM) and immunoglobulin G (IgG) antibodies.
What should be done if a patient with a new positive serological test for Coccidioides shows no signs of active disease?
Pre-emptive antifungal therapy with fluconazole 400 mg daily is recommended.
What is the preferred therapy for mild-to-moderate pulmonary infections caused by coccidioidomycosis?
Fluconazole 400 mg PO once daily or Itraconazole 200 mg PO three times daily.
What is the preferred therapy for severe pulmonary or extrapulmonary infection (except meningitis)?
Amphotericin B deoxycholate 0.7–1.0 mg/kg IV daily or lipid formulation amphotericin B 3–5 mg/kg IV daily.
What is the recommended therapy for coccidioidal meningitis?
Fluconazole 800–1,200 mg PO once daily.
What is the recommendation for discontinuation of therapy in focal coccidioidal pneumonia?
Discontinuation can be considered after clinical response to 3-6 months of therapy, CD4 count ≥250 cells/mm3, and virologic suppression on ART.
What percentage of patients experience relapse after stopping treatment for coccidioidal meningitis?
Relapse has been reported in 80% of patients.
True or False: Routine testing for coccidioidomycosis is recommended for asymptomatic patients who have not lived in or traveled to endemic regions.
False
What should be monitored in patients with diffuse pulmonary disease after discontinuation of therapy?
Continued monitoring for recurrence using serial chest radiograph and coccidioidal serology.
What type of therapy is not recommended for individuals with HIV and low CD4 counts living in endemic areas?
Primary antifungal prophylaxis or pre-emptive therapy.
What is the indication for primary prophylaxis or pre-emptive therapy in coccidioidomycosis?
Previously tested negative with a new positive IgM or IgG test for Coccidioides, CD4 count <250 cells/mm3, and no signs of active disease.
What is the preferred therapy for treating coccidioidomycosis in pregnant women during the first trimester?
Lipid formulation amphotericin B 3–5 mg/kg IV daily or Amphotericin B deoxycholate 0.7–1.0 mg/kg IV daily.
Fill in the blank: Elevated coccidioidal antibody titers can indicate risk of subsequent symptomatic diseases when CD4 count decreases to _______.
10 cells/mm3 or less.
What is the significance of a coccidioidomycosis-specific antigen assay?
It detects antigen in urine, serum, and other body fluids from individuals with active coccidioidomycosis.
What is the recommended therapy for mild-to-moderate pulmonary coccidioidal infection?
Oral triazole antifungal agent, such as fluconazole 400 mg daily or itraconazole 200 mg three times daily for 3 days followed by 200 mg twice daily
Itraconazole is preferred for those with bone or joint disease.
What should be monitored to ensure adequate absorption of itraconazole?
Serum itraconazole concentrations should be measured after 2 weeks
Target levels should be between 1.0 to 2.0 mg/mL.
What is the preferred initial therapy for severe pulmonary coccidioidal infection?
Amphotericin B
Most experience is with the deoxycholate formulation at a dose of 0.7 to 1.0 mg/kg IV daily.
What is the recommended treatment for patients with coccidioidal meningitis?
Treatment with a triazole antifungal, preferably fluconazole 800 to 1,200 mg daily
Intravenous amphotericin B alone is ineffective.
What is the significance of monitoring CF antibody titer in therapy?
It assesses response to therapy, with a more than twofold rise suggesting recurrence
Should be measured every 12 weeks.
True or False: Delaying ART initiation is always necessary when treating coccidioidomycosis in HIV patients.
False
In general, delaying initiation of ART may not be necessary.
What should be the goal therapeutic concentration of itraconazole in severe coccidioidomycosis?
1.0 mg/mL to 2.0 mg/mL
If treatment fails with these concentrations, switch to IV amphotericin B.
What is the recommended treatment for non-meningeal coccidioidomycosis during the first trimester of pregnancy?
Intravenous amphotericin B, either deoxycholate or lipid formulation
Extensive use has not been associated with teratogenicity.
What is the risk associated with fluconazole during the first trimester of pregnancy?
Teratogenic potential
Congenital malformations, including craniofacial and limb abnormalities, have been reported.
What should be monitored in patients taking posaconazole?
Blood pressure and serum potassium levels
A syndrome of mineralocorticoid excess has been reported.
What is the recommendation for treating patients who do not respond to fluconazole or itraconazole?
Use posaconazole, voriconazole, or isavuconazole
These are recommended for patients with limited data supporting their use.
Fill in the blank: Coccidioidomycosis relapse occurs in ______% to ______% of individuals without HIV who have diffuse pulmonary coccidioidomycosis.
25% to 33%
Relapses may also occur in people with HIV who have CD4 counts ≥250 cells/mm3.
What is the preferred monitoring strategy for patients with coccidioidal meningitis?
Continue treatment doses of azole for life
This is necessary even in those with immune reconstitution.
What should be done if a patient with coccidioidal meningitis requires intrathecal therapy?
Administer by someone experienced in the technique
Intrathecal amphotericin B deoxycholate is recommended.
What is the impact of maternal fluconazole use during the first trimester according to meta-analysis?
Increased prevalence of heart defects
Associated with both low dose and any dose exposure.
What is the preferred dosage form of posaconazole for better tolerability?
Delayed-release tablet formulation
Recommended dosage is 300 mg twice on the first day and then 300 mg once daily.
What is the recommended duration of antifungal therapy for diffuse pulmonary disease in HIV patients?
At least 12 months
Usually much longer based on clinical and immunological response.
What is the association of fluconazole exposure during the first trimester with congenital malformations?
Marginal association with increased risk (OR 1.09; 95% CI, 0.99–1.2, P = 0.088)
This includes heart defects and spontaneous abortion; exposure to more than 150 mg is associated with an overall increase in congenital malformations.
What did a nationwide cohort study in Denmark find regarding fluconazole exposure during pregnancy?
Increased risk of spontaneous abortion (HR 1.48; 95% CI, 1.23–1.77) compared to unexposed pregnancies
Higher risk observed with topical azole exposure (HR 1.62; 95% CI, 1.26–2.07).
What was the adjusted odds ratio (OR) for spontaneous abortion with fluconazole doses of ≤150 mg?
2.23 (95% CI, 1.96–2.54)
This indicates a higher risk of spontaneous abortion compared to unexposed pregnancies.
What did the cohort study using Swedish and Norwegian registry data conclude about fluconazole use during pregnancy?
No association with risk of stillbirth or neonatal death
This was noted despite other studies showing risks associated with fluconazole.
What is the recommendation regarding fluconazole use in the first trimester?
Consider only if benefits clearly outweigh risks
This is based on reported birth defects associated with fluconazole.
What did a systematic review and meta-analysis of itraconazole exposure during pregnancy find?
No significant difference in overall risk of birth defects compared to non-exposure
Limb and congenital heart defects were common but within published rates.
What is the finding regarding eye defects in infants exposed to itraconazole?
Rate of eye defects was higher than that published by EUROCAT
EUROCAT is the European network for congenital anomalies surveillance.
What should be considered when using itraconazole during pregnancy?
Cost-benefit analysis
This indicates that itraconazole use should be carefully evaluated.
What is the teratogenic status of voriconazole, posaconazole, and isavuconazole in animal studies?
Teratogenic and embryotoxic
No adequately controlled human studies have assessed their teratogenicity.
What is the recommendation for using voriconazole, posaconazole, and isavuconazole during pregnancy?
Not recommended, especially in the first trimester (AIII)
This is due to their teratogenic effects observed in animal studies.
