Coccidioidomycosis Where It Shouldn't Be

Summary and Comment |
July 2, 2015

Coccidioidomycosis Where It Shouldn't Be

  1. Stephen G. Baum, MD

Although coccidioidomycosis is not believed to be endemic in Missouri, cases have markedly increased there in recent years.

  1. Stephen G. Baum, MD

Coccidioidomycosis — or valley fever — is caused by a fungus found in soil and is endemic in the southwestern U.S., Mexico, and Central and South America. In endemic areas of the U.S., reported cases increased eightfold between 1998 and 2012. Incidence has also increased in nonendemic areas (NEJM JW Infect Dis May 27 2014; [e-pub] and MMWR Morb Mortal Wkly Rep 2014; 63:450).

Retrospective analysis of data from the Missouri Department of Health and Senior Services revealed that 93 confirmed coccidioidomycosis cases were reported in the state between 2004 and 2013, with incidence per 100,000 increasing from 0.05 to 0.28 during that period. The median age of the patients was 58, and the median time to diagnosis in those with a known symptom-onset date was 25 days. Many patients were asymptomatic; among those with symptoms, 37% had pneumonia and 31% had influenza-like illness. Forty-eight percent of the patients had traveled to an endemic area, but 26% did not report such travel, suggesting the possibility of coccidioidomycosis endemicity in Missouri. Cases in travelers to endemic areas were more likely to be confirmed by culture or polymerase chain reaction (PCR), whereas other cases were generally confirmed serologically.

Comment

The authors note that some of the apparent increase may be due to initiation of mandatory coccidioidomycosis reporting in 2003 or to increasing awareness of the illness. In addition, because serologic tests are less accurate than culture or PCR for diagnosing recent coccidioidomycosis, some of the patients without recent travel may not be experiencing current infection. Nonetheless, occurrence in nontravelers — in Missouri and elsewhere — raises the possibility that the causative fungus may be spreading to new geographic areas. If that is the case, travel history, although useful, will have decreased predictive value in diagnosis.

Editor Disclosures at Time of Publication

  • Disclosures for Stephen G. Baum, MD at time of publication Consultant / Advisory board Clinical Infectious Diseases (Editorial Advisory Board) Speaker’s bureau UpToDate (author) Editorial boards Medical Letter (Board of Directors, Chairman)

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