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1/18
Growing up in Tucson and going to med school @UAZMedTucson, I thought I knew a lot about #coccidioidomycosis. Definitely not!
Here we discuss history, epidemiology, ecology, some cool facts about #Cocci, and reasons why #fluconazole may not be the best drug for Cocci.
Growing up in Tucson and going to med school @UAZMedTucson, I thought I knew a lot about #coccidioidomycosis. Definitely not!
Here we discuss history, epidemiology, ecology, some cool facts about #Cocci, and reasons why #fluconazole may not be the best drug for Cocci.
2/
In 1892 in Argentina, Alejandro Posadas wrote the first report of a pt w/ disseminated cutaneous cocci
Shortly after, a laborer in San Joaquin valley also had skin lesions
Skin biopsies of both pts revealed protozoa-like orgs, similar to Coccidia
https://academic.oup.com/cid/article/44/9/1202/328906
In 1892 in Argentina, Alejandro Posadas wrote the first report of a pt w/ disseminated cutaneous cocci
Shortly after, a laborer in San Joaquin valley also had skin lesions
Skin biopsies of both pts revealed protozoa-like orgs, similar to Coccidia
https://academic.oup.com/cid/article/44/9/1202/328906
3/
Here are images of the first patient diagnosed with #Cocci, Domingo Escurra, by Alejandro Posadas
@StanDeresinski
https://www.ncbi.nlm.nih.gov/pubmed/30690606
Here are images of the first patient diagnosed with #Cocci, Domingo Escurra, by Alejandro Posadas
@StanDeresinski
https://www.ncbi.nlm.nih.gov/pubmed/30690606
4/
Gilchrist, Rixford & Stiles named the org after its morphologic & clinical features:
Coccidioides (“resembling Coccidia”) immitis (“not mild”)
It is interesting that all 3 US dimorphics (Histo, Blasto, Cocci) were initially mistaken as protozoa
https://academic.oup.com/cid/article/44/9/1202/328906
Gilchrist, Rixford & Stiles named the org after its morphologic & clinical features:
Coccidioides (“resembling Coccidia”) immitis (“not mild”)It is interesting that all 3 US dimorphics (Histo, Blasto, Cocci) were initially mistaken as protozoa
https://academic.oup.com/cid/article/44/9/1202/328906
5/
Charles Smith had amazing observations about Cocci:
Incubation period 1-3 weeks
People rarely got re-infected
No transmission from person-person
Occurred in summer and fall- other months were more wet & farmers didn't work in winter & spring
https://www.ncbi.nlm.nih.gov/pubmed/30690606
Charles Smith had amazing observations about Cocci:
Incubation period 1-3 weeksPeople rarely got re-infectedNo transmission from person-personOccurred in summer and fall- other months were more wet & farmers didn't work in winter & springhttps://www.ncbi.nlm.nih.gov/pubmed/30690606
6/
The genus consists of 2 species: immitis and posadasii
Natural reservoir of #Cocci is in soil of SW US, Mexico, Central, and South America
In the US, most cases are found in AZ and CA
Animal reservoir has not been identified
https://www.ncbi.nlm.nih.gov/pubmed/31648806
https://www.ncbi.nlm.nih.gov/pubmed/30690599
The genus consists of 2 species: immitis and posadasii
Natural reservoir of #Cocci is in soil of SW US, Mexico, Central, and South America
In the US, most cases are found in AZ and CA
Animal reservoir has not been identified
https://www.ncbi.nlm.nih.gov/pubmed/31648806
https://www.ncbi.nlm.nih.gov/pubmed/30690599
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Why do we see more cases in drier seasons?
When there is moisture, cocci grows as mold with hyphae
When the soil dries, cells
arthroconidia, break off & release
If the early Summer is filled with rainslower incidence of Cocci in later summer
https://www.ncbi.nlm.nih.gov/pubmed/31648806
Why do we see more cases in drier seasons?
When there is moisture, cocci grows as mold with hyphae
When the soil dries, cells
arthroconidia, break off & releaseIf the early Summer is filled with rains
lower incidence of Cocci in later summerhttps://www.ncbi.nlm.nih.gov/pubmed/31648806
8/
We know that fungus don't like to grow in really hot temperatures, how come Cocci is endemic in SW US?
theory: Soil is sterilized by high temps, but Cocci survives by growing deep into soil. Then, when it rains, Cocci can grow back to soil surface https://www.ncbi.nlm.nih.gov/pubmed/30898028
We know that fungus don't like to grow in really hot temperatures, how come Cocci is endemic in SW US?
theory: Soil is sterilized by high temps, but Cocci survives by growing deep into soil. Then, when it rains, Cocci can grow back to soil surface https://www.ncbi.nlm.nih.gov/pubmed/30898028
9/
Here comes the inevitable...
Over the years, temperature will increase, precipitation patterns will change
By 2100-
Cocci endemic area will double
17 states will be affected
# of cases will increase by 50%
https://agupubs.onlinelibrary.wiley.com/doi/epdf/10.1029/2019GH000209
Here comes the inevitable...
Over the years, temperature will increase, precipitation patterns will change
By 2100-
Cocci endemic area will double17 states will be affected# of cases will increase by 50% https://agupubs.onlinelibrary.wiley.com/doi/epdf/10.1029/2019GH000209
10/
60% of patients are asymptomatic
Most recover without dissemination or sequelae
Those that do can develop CNS, skin, MSK, and other complications
https://www.ncbi.nlm.nih.gov/pubmed/31572393
60% of patients are asymptomatic
Most recover without dissemination or sequelae
Those that do can develop CNS, skin, MSK, and other complications
https://www.ncbi.nlm.nih.gov/pubmed/31572393
11/
Did you know...
In endemic areas, 20-30% of CAP can be secondary to Cocci...that's wild!! https://www.ncbi.nlm.nih.gov/pubmed/16707052
Did you know...
In endemic areas, 20-30% of CAP can be secondary to Cocci...that's wild!! https://www.ncbi.nlm.nih.gov/pubmed/16707052
12/
What do we do about primary pulmonary cocci?
2016 @IDSAInfo guidelines recommend therapy for:
- dissemination
- debilitating illness
- frail 2/2 age or comorbidities
- immunosuppressed
- African/Filipino decent
- extensive pulmonary involvement https://academic.oup.com/cid/article/63/6/e112/2389093
What do we do about primary pulmonary cocci?
2016 @IDSAInfo guidelines recommend therapy for:
- dissemination
- debilitating illness
- frail 2/2 age or comorbidities
- immunosuppressed
- African/Filipino decent
- extensive pulmonary involvement https://academic.oup.com/cid/article/63/6/e112/2389093
13/
Similar to #crypto, should we do LPs on pts with newly diagnosed Cocci?
2016 @IDSAInfo guidelines- do LP in patients w/:
unusual, worsening, or persistent HA
AMS
unexplained N/V
new focal neuro deficit after CNS imaging https://academic.oup.com/cid/article/63/6/e112/2389093
Similar to #crypto, should we do LPs on pts with newly diagnosed Cocci?
2016 @IDSAInfo guidelines- do LP in patients w/:
unusual, worsening, or persistent HAAMSunexplained N/Vnew focal neuro deficit after CNS imaging https://academic.oup.com/cid/article/63/6/e112/2389093
14/
#Fluc is recommended in guidelines
But is it the best drug?
There iscomparative trial- Fluc vs Itra
#Itra was better for bone/joint disease, and may have been better overall!
https://www.ncbi.nlm.nih.gov/pubmed/11074900
It is interesting that IDSA first line for #Histo & #Blasto is ITRA.
#Fluc is recommended in guidelines
But is it the best drug?
There is
comparative trial- Fluc vs Itra#Itra was better for bone/joint disease, and may have been better overall!
https://www.ncbi.nlm.nih.gov/pubmed/11074900
It is interesting that IDSA first line for #Histo & #Blasto is ITRA.
15/
Just wait for it...
A 2017 in-vitro study noted increased fluconazole MIC for 37% of isolates, raising concerns for therapy in serious infections!
https://www.ncbi.nlm.nih.gov/pubmed/28096163
Just wait for it...
A 2017 in-vitro study noted increased fluconazole MIC for 37% of isolates, raising concerns for therapy in serious infections!
https://www.ncbi.nlm.nih.gov/pubmed/28096163
16/
A retrospective review of 35 patients who initially received fluconazole, looked at treatment of refractory cases with #Vori and #Posa
21 changed to #Vori -> 67% improved
16 changed to #Posa -> 75% improved
https://www.ncbi.nlm.nih.gov/pubmed/22045955
A retrospective review of 35 patients who initially received fluconazole, looked at treatment of refractory cases with #Vori and #Posa
21 changed to #Vori -> 67% improved 16 changed to #Posa -> 75% improvedhttps://www.ncbi.nlm.nih.gov/pubmed/22045955
17/
Here is a nice table of the available antifungals with the benefits, weaknesses, and adverse effects
There are novel therapies coming (just to name a few):
#Fosmanogepix
#Olorofim
#SUBA-itra
#nikkomycin Z
#rezafungin ( @DxRxEdu)
#ibrexafungerp
https://www.ncbi.nlm.nih.gov/pubmed/31572393
Here is a nice table of the available antifungals with the benefits, weaknesses, and adverse effects
There are novel therapies coming (just to name a few):
#Fosmanogepix
#Olorofim
#SUBA-itra
#nikkomycin Z
#rezafungin ( @DxRxEdu)
#ibrexafungerp
https://www.ncbi.nlm.nih.gov/pubmed/31572393
18/
Summary:
60% asympt, others have CAP
95% recover w/o sequelae
Infxn results in lifelong immunity
Temp & change in precipitation will expand endemic regions
Fluconazole may not be the best
Other triazoles may be better
We need prospective & randomized studies!
Summary:
60% asympt, others have CAP95% recover w/o sequelaeInfxn results in lifelong immunityTemp & change in precipitation will expand endemic regionsFluconazole may not be the bestOther triazoles may be betterWe need prospective & randomized studies!
EXTRA:
Would love to hear how others tackle #Cocci.
@InduPartha
@GRThompsonMD
@Valleyfeverkc
@AlobaidiMD
@DrValleyFever
@DrH_flu
@Darcy_ID_doc
@DocSaimaAslam
@jschaenman
@AnnieC_ID_MD
@abaseenafghan
Would love to hear how others tackle #Cocci.
@InduPartha
@GRThompsonMD
@Valleyfeverkc
@AlobaidiMD
@DrValleyFever
@DrH_flu
@Darcy_ID_doc
@DocSaimaAslam
@jschaenman
@AnnieC_ID_MD
@abaseenafghan
