Coccidioidomycosis in a reference center in Northeast Brazil: clinical/epidemiological profile and most common radiological findings

Abstract INTRODUCTION: Coccidioidomycosis, a disease caused by Coccidioides immitis or Coccidioides posadasii, is endemic in arid climatic regions in Northeast Brazil. Its prevalence is higher among young adult males living in rural areas. Existing literature about this disease in Ceará, a Northeast Brazilian state, are scarce. Here, we aimed to outline the clinical and epidemiological profiles, radiological patterns, and therapeutic responses of patients with coccidioidomycosis in a reference center in Ceará, Brazil. METHODS This is a descriptive study with quantitative analysis. Patients who underwent medical follow-up in São José Hospital of Infectious Diseases and received confirmed mycological diagnosis of coccidioidomycosis between January, 2007 and December 2017 were included. Epidemiological, clinical, radiological, and therapeutic response data were collected from medical charts. RESULTS Thirty patients were included. The patients were males with median age of 30 years, and 73% were considered to have high-risk exposure to Coccidioides owing to professional activities. Cough (96.7%), dyspnea (63.3%), fever (86.7%), and pleuritic pain (60%) were the most prevalent clinical manifestations. Interstitial pattern (91.3%) was the most frequent pulmonary radiological finding. Fluconazole, amphotericin B, and itraconazole were administered for treatment (in 82.1%, 42.8%, and 21.4% of cases, respectively). A favorable outcome was observed in 83.8% of patients. CONCLUSIONS Coccidioidomycosis was more prevalent in the central and southern regions of the State of Ceará. Understanding the local epidemiology and clinical manifestations of the disease, in addition to the pulmonary radiologic findings, may aid the early detection of coccidioidomycosis and facilitate early diagnosis.

Clinical Features of Coccidioidomycosis:Analysis of 33 Chinese Cases / 中国医学科学院学报

Objective To summarize the characteristics of Chinese coccidioidomycosis cases, improve the diagnosis and treatment of this disease and prevent misdiagnosis as well as therapeutic error.Methods Search in databases including Medline,Wanfang,and CNKI using "Coccidioidomycosis" and "China" as index words yielded 23 articles that reported a total of 32 Chinese coccidioidomycosis cases.In addition,one patient with disseminated coccidioidomycos was treated in our center in April 2016.The demographic data,site of infection,clinical manifestations,past medical history,exposure history,imaging and laboratory findings,and pathological features of these 33 patients were analyzed.Results Among these 33 patients,7(21.2%)had visited an epidemic area and 6(18.2%)were immunocompromised.The disease involved the respiratory system,skin,bone,central nervous system,cornea,and stomach in 24,6,3,2,1,and 1 patients,respectively.Eight patients (24.2%) had multiple system involvement,and three of them died.The imaging findings included pulmonary nodules(=14),mediastinal lymphadenopathy(=5),solid shadow(=4),cavity(=4),pleural effusion(=3),multiple plaques(=2)and masses(=2).Coccidiolys cysts were detected in the affected tissues(=28)or in pus,exudate or pleural smear(=3);in addition,coccidioides mycelium and spores were found in the sputum,pus,and tissue cultures in 4 cases,among whom only 2 cases were confirmed by serological examination.The treatments included triazoles(=20),systemic or local administration of amphotericin B(=13),surgical resection of the lesion(=8),and intravenous gamma globulin(=1).Five patients died,among whom three had underlying diseases that caused immunosuppression and one was an infant.The prognoses were relatively good in the remaining patients.Conclusions Early diagnosis and proper treatment can achieve good prognosis in coccidioidomycosis patients.Multi-system involvement and immunosuppression are risk factors for poor prognosis of coccidioidomycosis.For these patients,adequate and full-course medication may prevent rapid disease progression.

Manifestaciones de salud asociadas a elementos medio ambientales: el caso de la ocurrencia de coccidioidomicosis en México 2004-2015 / Manifestations of health associated with environmental elements: the case of the occurrence of coccidioidemycosis in Mexico 2004-2015

Resumen Objetivo: Analizar la dinámica temporal de la coccidioido micosis en México, durante el periodo comprendido entre 2004-2015, en el contexto de sus determinantes socio ambientales e identificar su distribución actual en el territorio nacional mediante la construcción de indicadores de concentración geográfica. Métodos: Se conduce análisis exploratorio de datos a partir de microdatos sobre egresos hospitalarios en el periodo 2004-2015. En términos teóricos, la presente investigación se ubica en el paradigma sobre determinantes sociales y ambientales de las condiciones de salud pública. Resultados: La evolución temporal durante 11 años de información analizada permite identificar un patrón persistente en la concentración de casos, que afecta principalmente a cuatro estados en el país, con una clara carga para la población masculina. Se identifica al estado de Sonora como la entidad de mayor incidencia en México, una entidad cuyos determinantes ambientales analizados sugieren la necesidad de implementar políticas públicas preventivas. Conclusiones: Dada la evolución temporal de egresos hospitalarios por coccidiodomicosis en México y el vínculo ambiental de la enfermedad, la evidencia obtenida representa un área de oportunidad para intervenir mediante estrategias de control focalizadas en territorios específicos, siendo el estado de Sonora un sitio prioritario de atención.

Abstract Objective: To analyze the temporal dynamics of coccidioide mycosis in Mexico, during the period between 2004-2015 in the context of its socio-environmental determinants and to identify its actual distribution in the national territory by means of the construction of geographical concentration indicators. Methods: An exploratory analysis of data was made from micro data on hospital discharges in the period 2004-2015. In theoretical terms, this research is located in the paradigm on social and environmental determinants of public health conditions. Results: The time evolution during 11 years of analyzed information allows to identify a persistent pattern in the concentration of cases, which mainly affects four states in the country, with a clear burden for the male population. The state of Sonora was identified as the entity with the highest incidence in Mexico, an entity that determines the environmental factors analyzed and the need to implement preventive public policies. Conclusions: Given the temporal evolution of hospital discharges due to coccidioid mycosis in Mexico and the environmental link of the disease, the evidence obtained represents an opportunity to intervene through control strategies focused on specific territories, with the State of Sonora being a priority site of attention.

Acute Pulmonary Coccidioidomycosis and Review of Published Cases with Lung Involvement in Korea

Coccidioidomycosis is a fungal infection caused by Coccidioides immitis. The endemic area is mostly south-western United States. As increasing in overseas travel to endemic areas, the incidence rate has been recently increased in non-endemic areas. The diagnosis may be delayed in non-endemic area. It is important to elicit traveling histories and to differentiate lung consolidation with eosinophilia, for timely diagnosis of coccidioidomycosis. Recently, we experienced a case with pulmonary coccidioidomycosis in a Korean American who visited Korea showed consolidation in right lower lobe on chest X-ray and prolonged eosinophilia. In the case, a confirmatory diagnostic method was percutaneous transthoracic needle biopsy of lung. We report acute pulomonary coccidioidomycosis case and review previous published reports with pulmonary manifestation in Korea.

Insights from paleomicrobiology into the indigenous peoples of pre-colonial America - A Review

This review investigates ancient infectious diseases in the Americas dated to the pre-colonial period and considers what these findings can tell us about the history of the indigenous peoples of the Americas. It gives an overview, but focuses on four microbial pathogens from this period: Helicobacter pylori, Mycobacterium tuberculosis, Trypanosoma cruzi and Coccidioides immitis, which cause stomach ulceration and gastric cancer, tuberculosis, Chagas disease and valley fever, respectively. These pathogens were selected as H. pylori can give insight into ancient human migrations into the Americas, M. tuberculosis is associated with population density and urban development, T. cruzi can elucidate human living conditions and C. immitis can indicate agricultural development. A range of methods are used to diagnose infectious disease in ancient human remains, with DNA analysis by polymerase chain reaction one of the most reliable, provided strict precautions are taken against cross contamination. The review concludes with a brief summary of the changes that took place after European exploration and colonisation.

Viability and molecular authentication of Coccidioides spp. isolates from the Instituto de Medicina Tropical de São Paulo culture collection, Brazil / Viabilidade e autenticação molecular de isolados de Coccidioides spp. da coleção de culturas do Instituto de Medicina Tropical de São Paulo, Brasil

Coccidioidomycosis is an emerging fungal disease in Brazil; adequate maintenance and authentication of Coccidioides isolates are essential for research into genetic diversity of the environmental organisms, as well as for understanding the human disease. Seventeen Coccidioides isolates maintained under mineral oil since 1975 in the Instituto de Medicina Tropical de São Paulo (IMTSP) culture collection, Brazil, were evaluated with respect to their viability, morphological characteristics and genetic features in order to authenticate these fungal cultures. Only five isolates were viable after almost 30 years, showing typical morphological characteristics, and sequencing analysis using Coi-F and Coi-R primers revealed 99% identity with Coccidioides genera. These five isolates were then preserved in liquid nitrogen and sterile water, and remained viable after two years of storage under these conditions, maintaining the same features.

Coccidioidomicose é uma doença emergente no Brasil; a manutenção adequada e autenticação de isolados de Coccidioides spp são essenciais para a pesquisa em diversidade genética de micro-organismos, bem como para a compreensão da doença em humanos. Dezessete isolados de Coccidioides preservados em óleo mineral desde 1975 na coleção de culturas do Instituto de Medicina Tropical de São Paulo (IMTSP) foram avaliados com relação à viabilidade, características morfológicas e genéticas, com o objetivo de autenticação das culturas fúngicas. Dos 17 isolados, apenas cinco foram viáveis após quase 30 anos mantidos em óleo mineral, apresentando características morfológicas e moleculares típicas do gênero, o sequenciamento utilizando os oligonucleotídeos Coi-F e Coi-R revelou identidade de 99% com isolados de Coccidioides. Estes cinco isolados foram preservados em nitrogênio líquido e água destilada esterilizada, e permaneceram viáveis após dois anos de armazenamento sob estas condições, mantendo as mesmas características.

Vaccines against Coccidioides

Vaccines against fungal diseases are gaining attention because of their growing impact on modern medicine. Development of these vaccines should incorporate immunological tools that integrate with or replace chemotherapy to minimize antibiotic use and consequent resistance. In this review, we evaluate the current developmental status of fungal vaccines against coccidioidomycosis. There is a need for a vaccine that sufficiently prevents disease, without eradicating the fungus, by neutralizing adhesions and enzymes or other low penetrance virulence traits.

Coccidioidomycosis in armadillo hunters from the state of Ceará, Brazil

Coccidioidomycosis is a systemic mycosis with a variable clinical presentation. Misdiagnosis of coccidioidomycosis as bacterial pneumopathy leads to inappropriate prescription of antibiotics and delayed diagnosis. This report describes an outbreak among armadillo hunters in northeastern Brazil in which an initial diagnosis of bacterial pneumonia was later confirmed as coccidioidomycosis caused by Coccidioides posadasii. Thus, this mycosis should be considered as an alternative diagnosis in patients reporting symptoms of pneumonia, even if these symptoms are only presented for a short period, who are from areas considered endemic for this disease.

A Case of Disseminated Coccidioidomycosis Involving the Lymph Nodes, the Skin, and the Brain / 대한내과학회지

Coccidioidomycosis, a fungal infection caused by the fungus known as Coccidioides immitis, can affect many species of mammals and some reptiles. The fungus is endemic in the soil of the southwestern United States, Mexico, and parts of Central and South America. Most infections in humans are relatively mild or asymptomatic, but severe or fatal illness can also occur, especially in the elderly or immunocompromised. We report on a patient with disseminated coccidioidomycosis whose lymph nodes, skin, and especially brain were infected at diagnosis; however, the lung parenchyme was not infected. Because the brain infection could have been a fatal complication in this peculiar case, we recommended life-long fluconazole treatment for the patient. After 2 months of high doses of fluconazole, the patient's clinical signs were greatly improved with respect to fever, headache, skin lesions, and mediastinal widening on the chest X-ray.

A Case of Disseminated Coccidioidomycosis Involving the Lymph Nodes, the Skin, and the Brain / 대한내과학회지

Coccidioidomycosis, a fungal infection caused by the fungus known as Coccidioides immitis, can affect many species of mammals and some reptiles. The fungus is endemic in the soil of the southwestern United States, Mexico, and parts of Central and South America. Most infections in humans are relatively mild or asymptomatic, but severe or fatal illness can also occur, especially in the elderly or immunocompromised. We report on a patient with disseminated coccidioidomycosis whose lymph nodes, skin, and especially brain were infected at diagnosis; however, the lung parenchyme was not infected. Because the brain infection could have been a fatal complication in this peculiar case, we recommended life-long fluconazole treatment for the patient. After 2 months of high doses of fluconazole, the patient's clinical signs were greatly improved with respect to fever, headache, skin lesions, and mediastinal widening on the chest X-ray.

Cotrimoxazole enhances the in vitro susceptibility of Coccidioides posadasii to antifungals

The aim of the present study was to evaluate the effect of cotrimoxazole on the in vitro susceptibility of Coccidioides posadasii strains to antifungals. A total of 18 strains of C. posadasii isolated in Brazil were evaluated in this study. The assays were performed in accordance with the Clinical and Laboratory Standards Institute guidelines and the combinations were tested using the checkerboard method. The minimum inhibitory concentrations were reduced by 11, 2.4, 4.3 and 3.5 times for amphotericin B, itraconazole, fluconazole and voriconazole, respectively. Moreover, it was seen that cotrimoxazole itself inhibited C. posadasii strains in vitro. The impairment of folic acid synthesis may be a potential antifungal target for C. posadasii.

Capítulo 2: coccidioidomicose / Chapter 2: coccidioidomycosis

A coccidioidomicose é uma micose sistêmica causada pelos fungos dimórficos Coccidioides immitis e Coccidioides posadasii. A infecção é adquirida pela inalação de artroconídios infectantes presentes no solo. Usualmente apresenta-se como infecção benigna de resolução espontânea em 60 por cento dos casos. A micose é encontrada em regiões áridas e semiáridas do continente americano entre os paralelos 40ºN e 40ºS, principalmente no sudoeste dos Estados Unidos e no norte do México. A coccidioidomicose foi diagnosticada recentemente na região semiárida do nordeste do Brasil em quatro estados: Piauí (100 casos), Ceará (20 casos), Maranhão (6 casos) e Bahia (2 casos). A micose se manifesta sob três formas clínicas principais: forma pulmonar primária, forma pulmonar progressiva ou forma disseminada. Os sintomas de infecção respiratória manifestam-se, em média, 10 dias após a exposição. O diagnóstico faz-se pelo isolamento do Coccidioides sp. em cultivo ou pelo exame direto positivo (hidróxido de potássio a 10 por cento) de qualquer material suspeito (escarro, líquido cefalorraquidiano, exsudato de tegumento, linfonodos, etc.), ou corados por ácido periódico de Schiff ou impregnação argêntea. A imunodifusão em gel de ágar é o teste imunológico mais empregado na rotina diagnóstica. As manifestações radiológicas e tomográficas mais frequentes são nódulos pulmonares múltiplos, a maioria escavados, distribuídos difusamente. As drogas indicadas para o tratamento são fluconazol e itraconazol, com doses médias variando de 200 a 400 mg/dia, podendo chegar a 1.200 mg/dia. Nos casos graves, a anfotericina B pode ser a droga de escolha inicial. Na manifestação neurológica, o fluconazol é a droga preferida na dose mínima de 400 mg/dia.

Coccidioidomycosis is a systemic mycosis caused by the dimorphic fungi Coccidioides immitis and Coccidioides posadasii. Infection is acquired by inhalation of infective arthroconidia that live in the soil. In 60 percent of cases, the infection is benign and resolves spontaneously. In the northern hemisphere, coccidioidomycosis is endemic to arid and semi-arid regions at latitudes between 40ºN and 40ºS, particularly in the southwestern United States and in northern Mexico. In the semi-arid northeastern region of Brazil, cases of coccidioidomycosis have recently been reported in four states: Piauí (100 cases); Ceará (20 cases); Maranhão (6 cases); and Bahia (2 cases). The illness manifests in one of three clinical forms: the primary pulmonary form; the progressive pulmonary form; or the disseminated form. On average, the symptoms of respiratory infection appear 10 days after exposure. The diagnosis is made by the isolation of Coccidioides sp. in culture or by positive results from smear microscopy (10 percent potassium hydroxide test), periodic acid-Schiff staining or silver staining of any suspect material (sputum, cerebrospinal fluid, skin exudate, lymph node aspirate, etc.) Agar gel immunodiffusion is the diagnostic test most widely used. The most common finding on X-rays and CT scans is diffuse distribution of multiple pulmonary nodules, most of which are cavitated. The recommended treatment is fluconazole or itraconazole, the mean dose ranging from 200 to 400 mg/day, although as much as 1,200 mg/day is used in certain cases. In severe cases, amphotericin B can be the drug of choice. In cases of neurological involvement, the recommended treatment is administration of fluconazole, at a minimum dose of 400 mg/day.

Identidad genética del hongo causante del primer caso de coccidioidomicosis descripto por Alejandro Posadas en 1892 / Genetic characterization of the fungus involved in the first case of coccidioidomycosis described by Alejandro Posadas in 1892

En 1892, Alejandro Posadas documentó el primer caso mundial de coccidioidomicosis en un paciente argentino de nombre Domingo Escurra. Con el objetivo de identificar la especie de Coccidioides involucrado en ese caso, analizamos una pieza de necropsia del paciente, conservada en el Museo de Patología de la Facultad de Medicina de la Universidad de Buenos Aires, Argentina. La porción del tejido con mayor número de endosporas del hongo libres e integras fue elegida utilizando una coloración inmunohistoquímica específica. El ADN fúngico fue amplificado usando una PCR anidada que reconoce un fragmento del gen Ag2/PRA cuyo polimorfismo diferencia Coccidioides immitis y C. posadasii. Se amplificó además, el ADN de dos cepas de referencia: C. immitis (M38-05) y C. posadasii (1-NL) y de cuatro aislamientos de Coccidioides de pacientes argentinos. Los fragmentos amplificados fueron secuenciados en ambas hebras. Las secuencias fueron editadas, alineadas y comparadas con las depositadas en GenBank C. posadasii (Acceso N° AY536446, cepa Silveira) y C. immitis (Acceso N° AY536445). Las secuencias del Coccidioides del caso Escurra, de los aislamientos argentinos y de la cepa 1-NL fueron idénticos entre sí y mostraron una mutación puntual de C→G en la posición 1228 en comparación con la secuencia de C. posadasii, cepa Silveira. Este es el primer trabajo donde se busca ADN de Coccidioides en una pieza anatómica de museo con más de 100 años de antigüedad. Los resultados confirman que el primer caso de coccidioidomicosis o enfermedad de Posadas documentado mundialmente fue producido por el recientemente descripto C. posadasii.

In 1892 Alejandro Posadas described the first worldwide case of coccidioidomycosis in a patient named Domingo Escurra. A preserved necropsy piece from the patient's remains is conserved in the Museum of Pathology of the Medical School, Buenos Aires University. Paraffin-embedded specimens obtained from this piece served to identify the fungus involved in the case. Histological slices from different lesion sites were submitted to a genus-specific immunohistochemical staining in order to select the more suited areas in terms of abundance/integrity of fungal esporangia and endospora. Fungal DNA was amplified from selected deparaffinated slices using a nested PCR designed to amplify a segment of the gen Ag2/PRA and differentiate C. immitis from C. posadasii. This PCR was also applied to two reference strains (C. immitis M38-05, C. posadasii 1-NL) and isolates obtained from four recent coccidioidomycosis cases occurred in Argentina. Amplified products were submitted to sequencing of both DNA strands. The obtained sequences were edited, aligned and compared with C. posadasii (Access N° AY536446, strain Silveira) and C. immitis (Access N° AY536445) deposited in GenBank. DNA sequences from Escurra's lesions were 100% homologous to the recent Argentinean cases and the reference strain 1-NL. A single point C→G difference in position 1228 was observed with respect to sequence of strain C. posadasii Silveira. For the first time, Coccidioides DNA is recovered from a museum piece which is more than 100-year-old. Our results confirm that the original case of Posadas's disease was caused by the recently described C. posadasii.

Coccidioidomicose pulmonar e extrapulmonar: três casos em zona endêmica no interior do Ceará / Pulmonary and extrapulmonary coccidioidomycosis: three cases in an endemic area in the state of Ceará, Brazil

A coccidioidomicose, uma doença fúngica adquirida através da inalação do agente Coccidioides sp. sob a forma de artroconídio, foi pela primeira vez descrita em 1894. Restringe-se principalmente a áreas de clima árido, solo alcalino e regiões de baixo índice pluviométrico. Não por acaso, a maioria dos casos descritos no Brasil ocorreu na região Nordeste. Relatam-se três casos de coccidioidomicose pulmonar ocorridos nos anos de 2005 e 2006, em zona endêmica no interior do Ceará. Todos eram homens imunocompetentes de idade adulta, adeptos à prática de caça a tatus (Dasypus novemcinctus) com queixas de tosse, febre, dispneia e dor pleurítica. Houve evoluções com comprometimento pulmonar e lesão cutânea foi observada em apenas um paciente. Todos apresentaram radiografia e TC de tórax com lesões características da coccidioidomicose. O diagnóstico foi confirmado através de teste sorológico. Todos evoluíram para cura após tratamento com antifúngico.

Coccidioidomycosis, a fungal illness acquired by the inhalation of arthroconidia of Coccidioides sp., was first described in 1894. Coccidioidomycosis is mainly restricted to areas with arid climate, alkaline soil and low rainfall. Consequently, most of the reported cases in Brazil have occurred in the northeastern region. We report three cases of pulmonary coccidioidomycosis occurring between 2005 and 2006 in an endemic area in the state of Ceará, Brazil. The three patients were immunocompetent adult males, hunters of armadillos (Dasypus novemcinctus), with complaints of cough, fever, dyspnea and pleuritic pain. All three patients presented pulmonary involvement, and only one also presented cutaneous lesions. Chest X-rays and CT scans of the patients revealed characteristic coccidioidomycosis lesions. The diagnosis was confirmed by serological testing. All of the patients evolved to cure after antifungal treatment.

Pulmonary Coccidioidomycosis in Immunocompetent Patient / 결핵및호흡기질환

Coccidioidomycosis is a fungal infection caused by the soil fungus, Coccidioides immitis, which is endemic to the south-western United States. However, the incidence of coccidioidomycosis has recently increased due to the increase in overseas travel to endemic areas. We report a case of pulmonary coccidioidomycosis diagnosed in an immunocompetent person. A 28-year-old female, who had lived in Phoenix, Arizona, USA for 2 years, was admitted for an evaluation of persistent cough with fever lasting for 2 weeks. The chest X-ray and Chest CT revealed multifocal patchy consolidation and ground-glass opacity in both lungs as well as multiple enlarged right hilar and paratracheal lymph nodes. A percutaneous needLe biopsy of the main mass-like consolidation confirmed mature spherules of Coccidioides immitis in lung tissue. Pulmonary coccidioidomycosis should be considered in patients presenting with persistent cough with fever and a history of travel to or immigration from an endemic area.

Recurrent Coccidioidomycosis Manifesting as Osteomyelitis in Korea

Coccidioidomycosis is a fungal infection that results from inhaling the airborne arthroconidia of the Coccidioides species. It is an endemic disease in the southwest part of North America and rarely diagnosed in Korea. As tourism to endemic areas and the number of immunocompromised patients have been increasing, the incidence of this infection has increased in non-endemic areas. Treatment is usually successful with antifungal agents; however, recurrence is common. It is difficult to decide when to discontinue the antifungal treatment especially in non-endemic areas where doctors are not familiar with the disease. We report a case of recurrent coccidioidomycosis manifesting as osteomyelitis after the treatment of the patient for disseminated coccidioidal infection. The complement fixation test was a useful tool for the assessment of patient response and to evaluate suspected recurrence.

Recurrent Coccidioidomycosis Manifesting as Osteomyelitis in Korea

Coccidioidomycosis is a fungal infection that results from inhaling the airborne arthroconidia of the Coccidioides species. It is an endemic disease in the southwest part of North America and rarely diagnosed in Korea. As tourism to endemic areas and the number of immunocompromised patients have been increasing, the incidence of this infection has increased in non-endemic areas. Treatment is usually successful with antifungal agents; however, recurrence is common. It is difficult to decide when to discontinue the antifungal treatment especially in non-endemic areas where doctors are not familiar with the disease. We report a case of recurrent coccidioidomycosis manifesting as osteomyelitis after the treatment of the patient for disseminated coccidioidal infection. The complement fixation test was a useful tool for the assessment of patient response and to evaluate suspected recurrence.

Coccidioidomicose: estudo clínico / Coccidiioidomycosis: clinicar study

Coccidioidomicose - infecção endêmica com distribuição geográfica relativamente limitada - é adquirida através da inalação de fungos do gênero Coccidioides, o qual tem atração por terrenos arenosos, alcalinos e de elevada salinidade. No Brasil, a região com maior quantidade de diagnósticos é o Nordeste. O quadro clínico varia de uma infecção respiratória leve à fatalidade. A infecção afeta os pulmões, e por disseminação linfática, pode afetar outros órgãos. Quando atinge o sistema nervoso central causa quadro de meningoencefalite crônica. O diagnóstico presuntivo pode ser baseado na detecção de anticorpos específicos no soro, fixação do complemento, além de teste cutânea de hipersensibilidade retardada à coccidioidina. Deve-se tratar apenas pacientes com fator de risco para a forma disseminada - sintomatologia há mais de dois meses e alterações à telerradiografia. O tratamento deve ser feito com itraconazol ou fluconazol, com duração de três meses, podendo se estender até seis meses.

Coccidioidomycosis - an endemic infection somewhat geographically limited - is acquired by inhaling spores of coccidioides fungi, which are common in alkaline highly saline sandy soils. In Brazil, the area with prevaling coccidioidosis diagnostics is the northeast region. Clinical signs range from mild respiratory disorders to mortality. From the lungs the disease may spread to other organs through the lymphatic system; when affecting the central nervous system it causes chronic meningoencephalitis. Presumptive diagnosis may be bases on the presence of specific antibodies in the serum level, complement fixation or skin tests of delayed hypersensibility to coccidioidin. Only the patients with risk factors for the disseminated form are treated - those who have been symptomatic for more than two months or show sign or alterations on teleradiography. Treatment of choice is itraconazole or fluconazole for three to six months.

Eco-epidemiologia e manifestações clínicas da coccidioidomicose nos Estados do Piauí e do Maranhão / Echo-epidemiological and clinical manifestations of coccidioidomycosis in the States of the Piauí and the Maranhão

Foi realizado estudo retrospectivo e prospectivo sobre aspectos clínicos e epidemiológicos de todos os pacientes com diagnóstico laboratorial de coccidioidomicose procedentes dos Estados do Piauí e do Maranhão no período de 1978 a 2007. Foram estudados cem casos da doença, procedentes de 43 municípios piauienses (94 casos) e cinco municípios maranhenses (seis casos). A maioria dos casos ocorreu em homens (97 por cento), de etnia parda ou negra (78 por cento), com mediana de idade de 30 anos, lavradores (58 por cento) e com escolaridade média de 3,2 anos. A micose ocorreu na forma de 51 casos isolados e de 15 microepidemias envolvendo 49 pacientes. A principal atividade de risco identificada foi exposição à poeira de habitat de tatus (Dasypus spp.) durante caçada a esses animais (87 por cento). A maioria dos pacientes foi diagnosticada através de exame micológico direto (KOH 10 por cento) e de cultivo de escarro, positivos em 86,8 por cento e 88,9 por cento, respectivamente, dos indivíduos testados. Todos os pacientes apresentaram comprometimento pulmonar, a maioria na forma pulmonar aguda (81 por cento). Tosse (93 por cento), febre (90 por cento) e dor torácica (72 por cento) foram os sintomas predominantes. Padrão nodular múltiplo foi a alteração mais frequente, tanto no radiograma simples (86,3 por cento) quanto na tomografia computadorizada de tórax (91,3 por cento). Manifestações de hipersensibilidade cutânea ocorreram em 19 por cento dos pacientes, sendo eritema nodoso a mais frequente. Sete pacientes (7 por cento) apresentaram disseminação extrapulmonar, acometendo pele e TCS (3 por cento), SNC (2 por cento), glânglios linfáticos periféricos (2 por cento) e sistema ósteo-articular (1 por cento). Os fatores de risco identificados para disseminação foram etnia indígena e sexo feminino. Evolução para cura foi observada em 91 por cento dos casos. A letalidade foi de 8 por cento, sendo etnia indígena, disseminação para SNC e pneumonia grave os fatores de risco para óbito...Piauí.

Coccidioidomicosis extrapulmonar: Presentación de un caso y revisión de la literatura / Extrapulmonary coccidioidomycosis: Case report and review

La coccidioidomicosis es una micosis endémica en el sudoeste de los Estados Unidos, México y ciertas áreas de centro y Sudamérica. Los agentes causales son hongos del género Coccidioides. La infección primaria, habitualmente, involucra los pulmones, ocurriendo su diseminación en menos de 1 por ciento de los casos. Si bien la enfermedad extrapulmonar, usualmente, involucra la piel, el sistema nervioso central, los huesos y las articulaciones, tiene la capacidad de infectar cualquier órgano o tejido. Presentamos un caso de coccidioidomicosis extrapulmonar en un paciente masculino, con 20 años de edad, cuyo diagnóstico se estableció en una biopsia de ganglio linfático. La historia clínica no fue relevante y la biopsia se realizó debido a los hallazgos físicos sugerentes de linfoma.

Coccidioidomycosis is a deep mycotic infection endemic in the Southwestern part of the United States and Mexico and certain areas of Central and South America. The causative agents are fungi of the genus Coccidioides. Primary infection usually involves the lungs, and dissemination occurs in less than 1 percent of cases. While the extrapulmonary disease usually involves the skin, central nervous system, bones or joints, it can involve any tissue or organ. We present a case of extrapulmonary coccidioidomycosis in a 20-year-old male, in whom the diagnosis was made by a lymph node biopsy. His past history was not significant and the biopsy was performed because the physical findings were suggestive of lymphoma.