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        Valley Fever (Coccidioidomycosis)
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    Clinical Overview Clinical Testing Algorithm for Coccidioidomycosis View All
  Fungal Diseases
April 24, 2024
January 31, 2025
  Clinical Overview of Valley Fever
          What to know
            * About 40% of cases of Valley fever develop lung infection symptoms.
            * Infections are usually self-limiting but 5-10% develop complications. Disseminated disease is rare.
            * Serologic tests to detect IgM and IgG antibodies are the most common diagnostics.
            * Infections are usually treated with fluconazole or amphotericin B.
        Etiology
        Two species of Coccidioides cause infection: Coccidioides immitis (typically in California) and Coccidioides posadasii (typically outside of California). Clinical differences between the two species have not been observed.
        Coccidioide lives in the soil in the southwestern United States and parts of Mexico, Central America, and South America. Valley fever is considered highly endemic in southern Arizona and California’s southern San Joaquin Valley.
                Biology of Coccidiomycosis (Valley fever)
                Biology of Coccidiomycosis- Inhaled mold spores from Coccidioides turn into yeast in the lungs.
              May 10, 2024
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        At-risk populations
        Risk factors for severe or disseminated coccidioidomycosis include:
          * African-American race or Filipino ethnicity
          * HIV/AIDS
          * Organ transplant
          * Diabetes mellitus
          * Pregnancy
          * Pregnancy in women
          * Use of immunosuppressive medications
        Exposure risks
        In endemic areas, risk factors include occupations and activities that increase exposure to dust, such as:
          * Construction
          * Agricultural work
          * Archaeology
          * Military training
                Testing Algorithm for Coccidioidomycosis
                Clinical algorithm to guide testing and treatment for Valley fever in patients with pneumonia.
              May 10, 2024
        How it spreads
        Coccidioidomycosis is typically acquired via inhalation of airborne arthroconidia. Arthroconidia often become airborne after contaminated soil is disturbed. Disturbance can result from small-scale activities including construction or excavation, or large-scale events such as dust storms and earthquakes.
        Primary cutaneous coccidioidomycosis, solid organ donor-derived coccidioidomycosis, and fomite-transmitted coccidioidomycosis can also occur but are very uncommon.
          Clinical features
          Expand All
        Symptomatic persons (approximately 40% of cases) usually present 1 to 3 weeks after exposure. Typical symptoms include fatigue, cough, dyspnea, headache, night sweats, myalgias, and rash.
        Primary pulmonary disease is often self-limiting. However, approximately 5 to 10% of patients fail to recover and develop complications or chronic pulmonary disease. Disseminated disease occurs in an estimated 1% of cases. Higher rates of dissemination are observed in certain risk groups, with bones/joints, soft tissues, and meninges most commonly affected.
            Expand All
              Sequelae
                  In persons who develop progressive, chronic, or disseminated disease, symptoms may persist for months or even longer. Meningitis can lead to permanent neurologic damage. Mortality is high in HIV-infected persons with diffuse lung disease.
          Diagnosis
        Serologic tests to detect IgM and IgG antibodies are most often used to diagnose coccidioidomycosis. Other methods include culture and microscopy.
            Expand All
        Serologic tests to detect IgM and IgG antibodies are most often used to diagnose coccidioidomycosis. Other methods include culture and microscopy.
              Serology
                  Enzyme immunoassay (EIA)
                  EIA is a very sensitive and commonly used method for diagnosing coccidioidomycosis. Two EIAs for detection of specific IgM and IgG antibodies against Coccidioides are currently available:
                    * Premier ® Coccidioides EIA – Meridian Bioscience, Inc.
                    * Enzyme Immunoassay for detection of specific antibodies against Coccidioides spp – Immuno Mycologics, Inc. (IMMY)
                  Immunodiffusion (ID)
                  ID detects IgM antibodies; positive early in the course of infection.
                  Complement Fixation (CF)
                  CF etects IgG antibodies and allows for assessment of disease severity.
                  Lateral Flow Assay (LFA)
                  The Sona Coccidioides Antibody LFA (Immuno Mycologics, Inc. [IMMY]) is a rapid test (~30 minutes). It detects the presence of total antibodies against Coccidioides spp (IgM or IgG).
              Culture
                  Culture can be performed on tissue and respiratory specimens. However, sputum can be difficult to obtain for culture since patients' coughs are often non-productive. Processing and manipulation of cultures should be done in a biosafety level 3 laboratory.
              Microscopy
                  Microscopy can be used for detection of spherules in tissue or respiratory secretions; low sensitivity.
              Urinary antigen detection
                  Urinary antigen detection is not widely used. They may have some utility in diagnosing coccidioidomycosis in immunocompromised patients with severe forms of the disease.
              Polymerase Chain Reaction (PCR)
                  FDA approved a PCR for detection of Coccidioides directly from lower respiratory specimens (GeneSTAT.MDx Coccidioides – DxNA, LLC). Other PCR tests are still experimental but appear promising.
        Treatment and recovery
        No evidence from randomized trials exists to determine whether antifungal treatment for uncomplicated coccidioidal infections reduces symptom duration or prevents complications. Some infections will resolve without antifungal treatment. Infectious Diseases Society of America (IDSA) guidelines suggest treatment for primary pulmonary coccidioidomycosis in patients who:
          * Are immunosuppressed
          * Have severe or significantly debilitating illness
          * Have diabetes or are frail because of age or comorbidities
          * Are pregnant
          * Are pregnant women
          * Are of African or Filipino ancestry
        Disseminated coccidioidomycosis requires antifungal treatment, typically fluconazole or amphotericin B. For more detailed treatment guidelines, please refer to the Infectious Diseases Society of America's Practice Guidelines for the Treatment of Coccidioidomycosis.
        Surveillance and statistics
        Coccidioidomycosis is reportable in certain states. Check with your health department for more information about disease reporting requirements and procedures in your area. See facts and stats about coccidioidomycosis.
        Areas for further research
        Many aspects of coccidioidomycosis are being researched to better understand risk and distribution, and improve surveillance, testing and treatment.
        Research areas to better understand risk include identifying:
          * Host factors in select racial and ethnic groups that increase risk
          * Influence of climate change on Coccidioides' geographic distribution.
          * Improved methods for environmental detection.
        To improve patient outcomes researchers are working to:
          * Establish optimal treatment regimen for primary pulmonary infections.
          * Develop an effective vaccine.
        Resources
          * MMWR: Summary of Notifiable Diseases, United States
          * Valley Fever Center for Excellence Tutorial for Primary Care Professionals [PDF – 40 Pages]
          * The most recent case definition published by the Council of State and Territorial Epidemiologists (CSTE)
        On This Page
            * Etiology
            * At-risk populations
            * Exposure risks
            * How it spreads
            * Clinical features
            * Diagnosis
            * Treatment and recovery
            * Surveillance and statistics
            * Areas for further research
            * Resources
          Related PagesClinical Testing Algorithm for Coccidioidomycosis
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            * Clinical Testing Algorithm for Coccidioidomycosis
  April 24, 2024
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    Clinical Testing Algorithm for Coccidioidomycosis
  January 31, 2025
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          Content Source:
        National Center for Emerging and Zoonotic Infectious Diseases (NCEZID)
        Sources
          * Fisher MC, Koenig GL, White TJ, Taylor JW. Molecular and phenotypic description of Coccidioides posadasii nov., previously recognized as the non-California population of Coccidioides immitis. Mycologia. 2002 Jan-Feb;94(1):73-84.
          * Rosenstein NE, Emery KW, Werner SB, Kao A, Johnson R, Rogers D, et al. Risk factors for severe pulmonary and disseminated coccidioidomycosis: Kern County, California, 1995-1996. Clin Infect Dis. 2001 Mar 1;32(5):708-15.
          * Crum NF, Lederman ER, Stafford CM, Parrish JS, Wallace MR. Coccidioidomycosis: a descriptive survey of a reemerging disease. Clinical characteristics and current controversies. Medicine 2004;83:149-75.
          * Woods CW, McRill C, Plikaytis BD, Rosenstein NE, Mosley D, Boyd D, et al. Coccidioidomycosis in human immunodeficiency virus-infected persons in Arizona, 1994-1997: incidence, risk factors, and prevention. J Infect Dis. 2000 Apr;181(4):1428-34.
          * Bergstrom L, Yocum DE, Ampel NM, Villanueva I, Lisse J, Gluck O, et al. Increased risk of coccidioidomycosis in patients treated with tumor necrosis factor alpha antagonists. Arthritis 2004 Jun;50(6):1959-66.
          * Blair JE, Logan JL. Coccidioidomycosis in solid organ transplantation. Clin Infect Dis. 2001 Nov 1;33(9):1536-44.
          * Bercovitch RS, Catanzaro A, Schwartz BS, Pappagianis D, Watts DH, Ampel NM. Coccidioidomycosis during pregnancy: a review and recommendations for management. Clin Infect Dis. 2011 Aug;53(4):363-8.
          * Chang A, Tung RC, McGillis TS, Bergfeld WF, Taylor JS. Primary cutaneous coccidioidomycosis. J Am Acad Dermatol. 2003 Nov;49(5):944-9.
          * Dierberg KL, Marr KA, Subramanian A, Nace H, Desai N, Locke JE, et al. Donor-derived organ transplant transmission of coccidioidomycosis. Transpl Infect Dis. 2012 Jun;14(3):300-4.
          * Dweik M, Baethge BA, Duarte AG. Coccidioidomycosis pneumonia in a nonendemic area associated with infliximab. South Med J. 2007 May;100(5):517-8.
          * Stagliano D, Epstein J, Hickey P. Fomite-transmitted coccidioidomycosis in an immunocompromised child. The Pediatric Infect Dis J. 2007 May;26(5):454-6.
          * Galgiani JN, Ampel NM, Blair JE, Catanzaro A, Johnson RH, Stevens DA, et al. Coccidioidomycosis. Clin Infect Dis 2005;41:1217-23.
          * Crum NF, Lederman ER, Stafford CM, Parrish JS, Wallace MR. Coccidioidomycosis: a descriptive survey of a reemerging disease. Clinical characteristics and current controversies. Medicine 2004;83:149-75.
          * Thompson GR, 3rd. Pulmonary coccidioidomycosis. Semin Respir Crit Care Med 2011;32:754-63.
          * Ampel NM. The diagnosis of coccidioidomycosis. F1000 Med Rep. 2010
          * Durkin M, Connolly P, Kuberski T , Myers R, Kubak BM, Bruckner D, et al. Diagnosis of coccidioidomycosis with use of the Coccidioides antigen enzyme immunoassay. Clin Infect Dis. 2008;47:e69-73.
          * Saubolle MA, Wojack BR, Wertheimer AM, Fuayagem AZ, Young S, Koeneman BA. Multicenter clinical validation of a cartridge-based real-time PCR system for detection of Coccidioides in lower respiratory specimens. J Clin Microbiol. 2018 Jan 24;56(2). pii: e01277-17.
          * Binnicker MJ, Buckwalter SP, Eisberner JJ, Stewart RA, McCullough AE, Wohlfiel SL, et al. Detection of Coccidioides species in clinical specimens by real-time PCR. J Clin Microbiol. 2007 Jan;45(1):173-8.
          * Sheff KW, York ER, Driebe EM, Barker BM, Rounsley SD, Waddell VG, et al. Development of a rapid, cost-effective TaqMan real-time PCR assay for identification and differentiation of Coccidioides immitis and Coccidioides posadasii. Med Mycol 2009;48:466-469.
      Related PagesClinical Testing Algorithm for Coccidioidomycosis
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    Valley Fever
    Valley fever (coccidioidomycosis) is a lung infection from a fungus in soil in parts of the US.
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