The Invisible Killer - Coccidioidomycosis

Coccidioidomycosis is a fungal infection that can develop into a very painful and long-lasting disease. Coccidioides immitis and C. posadasii are two very similar species of fungi that are highly pathogenic and only distinguished by genetic polymorphisms. Coccidioidomycosis is acquired from inhaling the spores of these fungi, their spores enter the respiratory tract and begin to destroy the lungs.

Who is susceptible to this disease?

As mentioned above, inhalation of Coccidioides immitis and C. posadasii spores is what causes this disease. These fungi are commonly found in dry regions that don’t experience a lot of rain such as the Southwest United States, Mexico and parts of Central America. After the inhalation it would be termed as acute Coccidioidomycosis and if left untreated especially to those with compromised immune systems such as patients with HIV, diabetes or transplant recipients and pregnant women.

What makes Coccidioidomycosis frightening?

To begin with, the spores of Coccidioides are invisible to the naked eye therefore it is impossible to know where they are inhaled until it becomes quite serious. Next, these deadly spores kill in silence. In most cases, at the start, patients are asymptomatic or develop influenza-like symptoms so even if you have consulted a doctor it can easily be missed allowing the infection to become more aggressive. At this stage, the infection has progressed and one’s fate relies on the chance that dissemination(spreading) won’t occur.

Coccidioidomycosis is so hard to detect studies suggest its true ubiquity is underestimated and as much as 30 % of diagnosed community-acquired cases of pneumonia in southern Arizona are actually coccidioidomycosis.

What are some of the symptoms?

When the infection develops, into a more serious and less curable one, patients commonly experience a chronic cough, weight loss, wheezing, chest pain, muscle aches and headaches. From that list, you can see how it can be mistaken for many other diseases, the closest and most misdiagnosed one being tuberculosis.

Case Study

The world of medicine is full of twists and turns, each human body reacts differently to medications and pathogens. Now that we have covered the basics of Coccidioidomycosis let’s take a look at the case of a 16-year-old female from the United States of America. This case truly exemplifies the complexity of medicine.

Medical history:

Hypothyroidism (a common condition where the thyroid doesn't create and release enough thyroid hormone into your bloodstream)
Fibromyalgia (Fibromyalgia is a disorder characterized by widespread musculoskeletal pain)
Polyarticular juvenile idiopathic arthritis(inflammation or degeneration of more than four affected joints during the first six months of illness joints)
Several months prior she had pneumonia that resolved from antibiotic treatment

Reported to the emergency room with:

Frontal headaches
Photophobia and phonophobia (fear of light and sound)
Emesis (vomiting)
Nighttime fevers to 38.9C
Black spot in her left field of vision due to ocular pain

An ophthalmology consult concluded a diagnosis of chorioretinitis(inflammation of the lining of the retina deep in the eye [choroid]) due to facial numbness and weakness with the worry of AMPEE(Acute posterior multifocal placoid pigment epitheliopathy) that can be caused due to neurological issues such as the headaches she was experiencing.

Medications taken

Various medications to treat her Polyarticular juvenile idiopathic arthritis such as 10 mg of prednisone daily,10 mg of methotrexate weekly and 10 mg/kg infliximab infusions every six weeks

Note: patient opted for intravenous infusions over injectable medications. She was also undergoing occupational therapy.

Tests and Scans and their results

OCT exams (uses light waves to take pictures of the cross-sectional area of the retina) upon presentation exposed nonspecific bilateral choroidal lesions
Brain and spine MRI showed enhancement of the left temporal lobe, a small infarct in the left medial temporal area, and a thickened and infiltrated infundibulum (The infundibulum catches and channels the released eggs)
Additional imaging revealed a right lower lobe necrotizing pneumonia(a severe form of community-acquired pneumonia)

Travel History

Attended a summer camp on a farm in Alabama: after which ocular pain was said to start
Travel to Arizona, New Mexico and El Paso: after which the patient experienced pneumonia

Final Tests and Results

cerebrospinal fluid (CSF), right lung aspirate and urine culture resulted positive for the fungal species Coccidioides immitis
Serology (a test that looks for antibodies in the body which have the specific protein to “fight” the pathogen) revealed the presence of Coccidioides IgG (antibody of the Coccidioides immitis)
An extensive necrotizing granulomatous inflammation was found in her right lung biopsy.

Sequentially, a diagnosis of disseminated coccidioidomycosis with Coccidioides meningitis was drawn.

I hope this labyrinthine case of the 16-year-old girl contrasts with the simple information of Coccidioidomycosis found at the beginning of this article and other websites on the internet about coccidioidomycosis to teach you about the disease moreover provide you with a foretaste of the transfixing medical world.

The case study used is authentic.

Written by: Sakshi Nitin Deshpande

Edited by: Svasti Tewari, Subhagata Mandal