Periampullary Mass as an Unusual Manifestation of Coccidioidomycosis. Case Report and Literature Review

In Colombia, coccidioidomycosis is a rare entity, and the intestinal manifestation is infrequent, with around a dozen cases reported in the world literature. This article reports the case of a 29-year-old male Venezuelan immigrant with a 4-month history of abdominal pain, jaundice, nausea, and vomiting. The tomography and the endoscopic study revealed a circumferential exophytic mass in the second portion of the duodenum. The biopsy revealed multiple spherules filled with round fungal endospores with a final diagnosis of disseminated coccidioidomycosis. The patient was discharged before the final pathology report with fluconazole doses of 200 mg every other day and an order for outpatient magnetic resonance cholangiography for outpatient follow-up, which he has not attended.

La coccidioidomicosis en Colombia es una entidad infrecuente y la presentación intestinal es extremadamente rara, con alrededor de una docena de casos reportados en la literatura mundial. En el presente artículo se reporta el caso de un paciente inmigrante venezolano masculino de 29 años con historia de dolor abdominal, ictericia, náuseas y vómito de 4 meses de evolución. La tomografía y el estudio endoscópico evidenciaron una masa exofítica circunferencial en la segunda porción del duodeno. La biopsia reveló múltiples esférulas llenas de endosporas fúngicas redondas con diagnóstico final de coccidioidomicosis diseminada. El paciente fue dado de alta antes del reporte final anatomopatológico con dosis de fluconazol de 200 mg interdiario y orden de colangiorresonancia ambulatoria para control ambulatorio, mismo al cual no ha asistido.

Systemic coccidioidomycosis in a dog in Northeastern Brazil / Coccidioidomicose sistêmica em um cão no Nordeste do Brasil

ABSTRACT: We described a case of systemic infection by Coccidioides sp. in a dog. An adult, mixed breed, free-ranging male dog presented with clinical signs that included apathy, cachexia, anorexia, limited mobility with sternal recumbency, bilateral mucopurulent ocular discharge, dyspnoea, pulmonary crepitation, erosive and nodular lesions on the skin, and swelling and stiffness of the left tibiotarsal joint. The dog was submitted to a postmortem examination. Grossly, there were multiple yellow to white nodules in various organs. Histologically, the lesions were characterized as pyogranulomatous inflammation associated with fungal spherules morphologically consistent with Coccidioides sp. The dog was concomitantly diagnosed with undifferentiated sarcoma affecting the skin, lymph nodes, liver, and testicles. The diagnosis of coccidioidomycosis was made based on the histologic changes associated with morphotintorial features and positive immunolabeling of organisms with anti-Coccidioides immunohistochemistry. This case demonstrated that Coccidioides sp. can infect dogs that inhabit urban centers in the semiarid region of Northeastern Brazil, likely due to exposure to dust from contaminated environments.

RESUMO: Descreve-se um caso de infecção sistêmica por Coccidioides em um cão. Um cão adulto, sem raça definida e errante, atendido com sinais clínicos que incluíram apatia, caquexia, anorexia, dificuldade de locomoção com decúbito esternal, secreção ocular bilateral mucopurulenta, dispneia, crepitação pulmonar, lesões erosivas e nodulares na pele, aumento de volume e rigidez na articulação tibiotársica do membro pélvico esquerdo. O cão foi submetido a um exame post-mortem. Macroscopicamente, haviam múltiplos nódulos amarelo-brancacentos em vários órgãos. Histologicamente, as lesões foram caracterizadas por inflamação piogranulomatosa associada a esférulas fúngicas morfologicamente consistentes com Coccidioides sp. O cão foi diagnosticado concomitantemente com sarcoma indiferenciado afetando a pele, linfonodos, fígado e testículos. O diagnóstico de coccidioidomicose foi realizado com base nas alterações histológicas associadas as características morfotintoriais e imunomarcação positiva dos organismos com anti-Coccidioides na imuno-histoquímica. Esse caso demonstra que Coccidioides sp. pode infectar cães que habitam centros urbanos no semiárido do Nordeste do Brasil, provavelmente devido à exposição a poeira de ambientes contaminados.

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.

Coccidioidomycosis: skin manifestations and hypersensitivity syndromes / Coccidioidomicosis: manifestaciones cutáneas y síndromes de hipersensibilidad

Abstract Coccidioidomycosis is caused by Coccidioides immitis and Coccidioides posadasii fungi, which are endemic in certain locations in the American continent. They produce an asymptomatic infection in the majority of the exposed population, and in a lower proportion, a self-limited influenza-like illness, pneumonia or dissemination. Skin compromise could be secondary to the infection by the fungus or by a hypersensitivity reaction to the pulmonary infection. Primary skin compromise produces a chancriform, self-limited lesion, and the dissemination to the skin commonly produces nodules and abscesses, with a tendency to form fistulas. The most common hypersensitivity reaction is erythema nodosum, which is considered a marker of good prognosis. Treatment depends on the localization of the infection, the presence of dissemination, and the clinical conditions of the patient.

Resumen La coccidioidomicosis es causada por los hongos Coccidioides immitis y Coccidioides posadasii, los cuales son endémicos en determinadas localizaciones del continente americano. Producen infección asintomática en la mayoría de expuestos y en menor proporción cuadros gripales autolimitados, neumonía o diseminación. El compromiso en piel puede ser secundario a la infección por el hongo o por una reacción de hipersensibilidad a la infección pulmonar. El compromiso primario en piel produce una lesión chancreiforme, autolimitada y la diseminación a piel produce comúnmente nódulos y abscesos, con tendencia a la fistulización. La reacción de hipersensibilidad más común es el eritema nodoso, considerándose un marcador de buen pronóstico. El tratamiento depende de la localización de la infección, la presencia de diseminación y las condiciones clínicas del paciente.

Infecciones micóticas del tracto urogenitalmasculino, importantes aunque poco frecuentes: revisión sistemática / Fungal infections of male genitourinary tract, important though infrequent: a systematic review

Introducción: las infecciones del tracto urogenital son una de las causas más frecuentes durante las consultas por infertilidad masculina. Comúnmente se evalúan aquellas causadas por bacterias y virus, mientras que las producidas por hongos han sido subvaloradas; sin embargo, en las últimas décadas su frecuencia ha aumentado. Objetivo: describir algunas micosis del tracto urogenital masculino y su posible efecto sobre la fertilidad. Materiales y métodos: se realizó una revisión sistemática de la literatura publicada sobre las micosis del tracto urogenital masculino y la fertilidad en las bases de datos PubMed, ScienceDirect, SciELO, Redalyc, Springer y Google Académico. Resultados: se encontraron un total de 3.426 publicaciones que hablaban sobre el tema. Entre la información revisada se comprobó que el 90% de las micosis reportadas en el tracto urogenital masculino son ocasionadas por Candida spp., Aspergillus spp., Cryptococcus spp. y Coccidioides spp., microorganismos que podrían ser los causantes de uretritis, balanopostitis, úlceras, pseudotumores, orquitis y prostatitis; además de afectar negativamente la calidad espermática, lo que causa alteraciones en la fecundación. Conclusiones: las infecciones fúngicas del tracto urogenital pueden desatar infertilidad, que si se tratan correctamente disminuirán la diseminación, morbilidad y mortalidad a causa de estos microrganismos. (AU)

Introduction: Urogenital tract infections are one of the most frequent causes during male infertility consults. Infections caused by bacteria and virus are commonly evaluated, but those caused by fungi are usually ignored. However, in the last decades urogenital tract fungi infections have increased. Objective: analyze the effect of several mycoses in the urogenital tract and male fertility. Materials and methods: It was explored about mycoses and male fertility in databases as PubMed, ScienceDirect, SciELO, Redalyc, Springer, and Google scholar. Results: We found a total of 3,426 manuscripts about mycoses and male fertility. Ninety percent of reported mycoses in the male reproductive tract are caused by Candida spp., Aspergillus spp., Cryptococcus spp., and Coccidioides spp., generating urethritis, balanoposthitis, ulcers, pseudotumors, orchitis, and prostatitis. Furthermore negatively affecting seminal quality. Conclusion: Fungal infections of urogenital system could cause male infertility, if that are properly treated, would reduce dissemination, morbidity and mortality, because this microorganisms. (AU)

Coccidioidomycosis and the skin: a comprehensive review

AbstractCoccidioidomycosis is a highly prevalent disease in the Western hemisphere. It is considered one of the most virulent primary fungal infections. Coccidioides species live in arid and semi-arid regions, causing mainly pulmonary infection through inhalation of arthroconidia although many other organs can be affected. Primary inoculation is rare. Since the first case of coccidioidomycosis was reported in 1892, the skin has been identified as an important target of this disease. Knowledge of cutaneous clinical forms of this infection is important and very useful for establishing prompt diagnosis and treatment. The purpose of this article is to provide a review of this infection, emphasizing its cutaneous manifestations, diagnostic methods and current treatment.

Coccidiodomicosis diseminada: reporte de un caso en miranda / Diseminated coccidiodomicosis: report of a case in estado miranda, Venezuela

Se presenta el caso de un hombre de 46 años con antecedente de linfoma de Hodgkin, cuya enfermedad actual comienza 6 meses previos a su ingreso con diarrea y fiebre, sin moco ni sangre. Un mes más tarde se asocia rinorrea verdosa acompañada de tos no productiva, sintomatología que persistió en el tiempo por lo cual acude a nuestro centro. Al examen físico se evidenciaron lesiones costrosas a nivel de la mucosa nasal de las cuales se tomaron muestras para biopsia y cultivo, aislándose en el cultivo Coccidiodes inmitis. La Coccidiodomicosis es una infección poco frecuente dentro de las micosis profunda, es endémica en Estados Unidos en Arizona y California. En Venezuela se han reportado pocos casos, únicamente en 3 estados: Lara, Zulia y Falcón. El paciente vive en Guarenas, negó viajes fuera del área de Miranda en los últimos 10 años y su ocupación es recolectar bolsas en supermercado. Posterior a los hallazgos clínicos, paraclínicos y revisión bibliográfica, se concluye como el primer caso reportado de Coccidiodomicosis diseminada en el estado Miranda(AU)

We present the case a 46 year- old man with a history of Hodgkin´s lymphoma, who refers 6 months before admission, watery stools without mucus or blood and fever. One month after the onset of the gastrointestinal symptoms, he presented nasal discharge and nonproductive cough, which persisted until he consulted to our hospital. On physical examination scabby lesions in nasal mucosa were found, biopsy and culture samples were taken. The culture reported Coccidiodes immitis. Coccidioidomycosis is a rare deep mycosis infection; it is endemic in the United States in Arizona and California. In Venezuela cases have been reported only in 3 states: Lara, Zulia and Falcon and he denied, trips outside the area in the last 10 years. He worked as and collector in a supermarket. This is the first reported case of disseminated coccidioidomycosis in Miranda state(AU)

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.

Diarrea recurrente por Cystoisopora belli en pacientes con infección por VIH con TARGA / Recurrent diarrhea due to Cystoisopora belli in HIV/AIDS patients receiving HAART

La Cystoisospora belli, antes denominada Isospora belli, es el agente etiológico de la cystoisosporiasis, una infección oportunista que afecta a pacientes inmunodeprimidos, caracterizada por diarrea crónica y pérdida ponderal. La incidencia de diarrea crónica por este agente, en pacientes infectados por el VIH, ha disminuido considerablemente. Ello gracias al advenimiento de la terapia antirretroviral de gran actividad (TARGA), con la que se ha logrado mejorar la respuesta inmunológica del paciente y disminuir su carga viral. Se presentan seis casos de cystoisosporiasis recurrente y refractaria en pacientes con infección por VIH, en quienes se diagnosticó cystoisosporiasis pese a que previamente se encontraban recibiendo profilaxis con trimetropin/sulfametoxazol (TMP/SMX). Cinco de ellos evolucionaron de manera tórpida y fallecieron, a pesar de una buena respuesta al TARGA (adecuado incremento de CD4 y disminución de la carga viral hasta rangos indetectables), y de tratamiento con TMP/SMX por vía oral y otros medicamentos de segunda línea.

The Cystoisospora belli, before denominated as Isospora belli, is the etiologic agent of cystoisosoporiasis, an opportunistic infection affecting immunocompromised patients, characterized by chronic diarrhea and weight loss. The incidence of chronic diarrhea for this agent, in HIV patients, has decreased considerably. This thanks to the advent of highly active antiretroviral therapy (HAART), which has improved the patient’s immune response and decrease viral load. We present six cases of cystoisosoporiasis recurrent and refractory to treatment in HIV patients, who was being treated with with trimethoprim / sulfamethoxazole (TMP / SMX) orally as a prophylaxis. Five of these patients passed away due to the infection, despite of the fact that they had a good response to HAART (adequate increase in CD4 and viral load undetectable) and they had been treated with second line drugs.

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.

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.

La coccidioidomicosis en Argentina, 1892-2009 / Coccidioidomycosis in Argentina, 1892-2009

Los casos clínicos de coccidioidomicosis en Argentina son pocos y han tenido lugar fundamentalmente en la extensa región árida precordillerana. Este trabajo tiene como objetivos realizar una revisión retrospectiva del total de casos de coccidioidomicosis documentados en Argentina desde el año 1892 hasta 2009 y describir una serie de casos ocurridos en los últimos 4 años. En 117 años se documentaron 128 casos. Desde la primera descripción de la enfermedad en 1892 hasta 1939 se registraron 6 casos; desde 1940 hasta 1999, 59 casos (6-14 casos cada 10 años); y los 63 casos restantes (49% del total histórico) se produjeron en el último decenio. La mediana de edad de los 34 pacientes registrados en el período 2006-2009 fue de 31 años (rango: 7-89), la relación hombre:mujer fue 1,3:1; 12 de estos individuos eran inmunocomprometidos. Veintiséis casos se confirmaron por examen microscópico, por cultivo o por ambos procedimientos; los casos restantes se confirmaron por serología. Todos los aislamientos recuperados fueron identificados como Coccidioides posadasii. Treinta pacientes residían en una amplia área geográfica con epicentro en el valle de Catamarca. Entre 2006 y 2009, la tasa de incidencia en la provincia de Catamarca se incrementó desde valores históricos inferiores a 0,5 casos cada 100 000 habitantes hasta 2,0 casos cada 100 000 habitantes. Este aumento sugiere una emergencia de la coccidioidomicosis en el área.

Clinical cases of coccidioidomycosis are rare in Argentina and are generally found in the large arid precordilleran area of the country. This study aims to perform a retrospective review of all coccidioidomycosis cases documented in the country from 1892 to 2009, and to describe those occurring in the last 4 years. One hundred and twenty eight cases were documented in the 117 year-period. Since the original description of the disease in 1892 until 1939, only 6 cases were registered; between 1940 and 1999, 59 (6-14/10 yrs) and the remaining 63 (49% of total cases) occurred in the last decade. The median age of 34 patients registered in 2006-2009 was 31 years (range: 7-89), male/female ratio was 1.3:1 and 12 patients were immunocompromised. Twenty-six cases were confirmed by direct microscopy and/or culture whereas the remaining ones by serology. All isolates were identified as Coccidioides posadasii. Thirty patients lived in a vast geographic region with epicenter in Catamarca Valley. Between 2006 and 2009, annual disease incidence rates in Catamarca Province increased from historical values below 0.5/100,000 to 2/100,000 inhabitants. Such increase suggests an emergency of coccidioidomycosis in that region.

Ecología de la coccidioidomicosis en el municipio Falcón de la Península de Paraguaná, estado Falcón, Venezuela / Ecology of coccidioidomycosis at the Falcon municipality of Paraguana Peninsula, Falcon State, Venezuela

Se estudiaron las características ecoambientales de poblaciones del municipio Falcón de la Península de Paraguaná, y se cultivaron muestras de suelo para identificación de los aislados sugestivos de Coccidioides spp., mediante examen directo de las muestras de tejido de ratones inoculados con el hongo. Las características ecoambientales del municipio y el análisis químico del suelo favorecen la presencia del hongo en esta zona. Del cultivo de suelos se obtuvo un aislado sugestivo de Coccidioides spp., pero el estudio en animales de experimentación no reveló la formación de esférulas. Se confirmó la existencia de un área de riesgo para la coccidioidomicosis en la Península de Paraguaná.

The eco-environmental characteristics of populations from the Falcon Municipality of the Paraguana Peninsula were studied, and soil samples were taken for identification of isolates suggestive of Coccidioides spp., through direct exam of tissue samples from mice infected with this fungus. The eco-environmental characteristics of the municipality and the chemical analysis of the soil favor the presence of this fungus in this zone. From the soil sample cultures we obtained an isolate suggestive of Coccidioides spp, but the experimental animal study did not reveal spherule formation. The existence of a Coccidioidomycosis risk area at the Paraguana Peninsula was confirmed.

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.

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.

A Case of Disseminated Coccidioidomycosis with Pelvic Bone and Paravertebral Abscess / 감염과화학요법

Coccidioidomycosis results from inhaling the spores (arthroconidia) of Coccidioides species (Coccidioides immitis or Coccidioides posadasii), and is endemic in the southern United States. An even smaller proportion of all infections result in illnesses related to extrapulmonary infection. We report a case of coccidioidomycosis manifested as pelvic bone and paravertebral abscess in a Korean who has visited LA. Culture and pathology from the pelvic bone and paravertebral mass revealed Coccidioides immitis, and a diagnosis of disseminated coccidioidomycosis was made.

A Case of Disseminated Coccidioidomycosis with Pelvic Bone and Paravertebral Abscess / 감염과화학요법

Coccidioidomycosis results from inhaling the spores (arthroconidia) of Coccidioides species (Coccidioides immitis or Coccidioides posadasii), and is endemic in the southern United States. An even smaller proportion of all infections result in illnesses related to extrapulmonary infection. We report a case of coccidioidomycosis manifested as pelvic bone and paravertebral abscess in a Korean who has visited LA. Culture and pathology from the pelvic bone and paravertebral mass revealed Coccidioides immitis, and a diagnosis of disseminated coccidioidomycosis was made.

Coccidioidomicosis diseminada en pacientes infectados con el virus de inmunodeficiencia humana: reporte de dos casos y revisión de la litertura / Coccidioidomicosis disseminated in patients infected with the human immunodeficiency: report of two cases and revision of the literature

En Venezuela las zonas xerófilas del estado Falcón, Lara y Zulia son endémicas para Coccidioides immitis. Dentro de las micosis profundas es la menos frecuente; según Albornoz se describieron 61 casos de coccidioidomicosis hasta 1966. En zonas endémicas, la coccidioidomicosis suele ser una enfermedad oportunista frecuente en pacientes con virus de inmunodeficiencia humana (VIH). Por lo tanto, podría esperarse una alta incidencia de esta entidad en pacientes infectados con el VIH, sin embargo, hasta donde sabemos, no se ha reportado ningún caso en la literatura local. En este trabajo se describen dos casos de pacientes VIH positivos que presentaron coccidioidomicosis diseminada.

Coccidioidomicose: novo caso brasileiro / Coccidioidomycosis: a new brazilian case

A case of pulmonary coccidioidomycosis from the rural zone of Bertolinia, PI, is reported. The patient, a farm worker, attributed his illness to the dust inhaled while digging a water well during the dry season of the year, some weeks before the onset of the clinical manifestations. The main symptoms of the disease were severe chest pain and moderate fever. The diagnosis was made histopathologically: tissue phase fungal organisms--immature spherules and spherules with endospores--were observed in histological sections of a lung fragment obtained by open chest biopsy. This is the twelfth autochthonous case of coccidioidomycosis found so far in Brazil. All of them involved native inhabitants of the semi-arid part of Northeastern Brazil. The hot and dry environment of the region seems to favor the development of C. immitis in the soil. Humans and animals probably acquire the infection by digging the soil, when they become exposed to the conidium-bearing dust raised by this activity.

É descrito um caso de coccidioidomicose pulmonar oriundo da zona rural de Bertolínia, PI. A manifestação clínica principal consistiu em dor torácica e o diagnóstico teve por base o achado do agente ¾ Coccidioides immitis ¾ em cortes histológicos. Formas teciduais do microrganismo ¾ esférulas imaturas e maduras ¾ estavam presentes nas lesões observadas em fragmento pulmonar removido do paciente por biópsia a céu aberto. Este novo caso autóctone da doença, como os outros anteriormente descritos no Brasil, procedia do interior semi-árido da Região Nordeste. O ambiente quente e seco do sertão nordestino oferece, sem dúvida, condições propícias ao desenvolvimento de C. immitis, um habitante do solo. As pessoas e animais do local devem adquirir a infecção ao revolver a terra, ato que os expõe à poeira contendo os propágulos do fungo.