Coccidioidomycosis (Valley Fever) in Primary Care


Am Fam Physician. 2020 Feb 15;101(4):221-228.

  Patient information: See related handout on valley fever, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Primary pulmonary coccidioidomycosis (valley fever) is caused by inhaling airborne spores of the fungus Coccidioides immitis or Coccidioides posadasii. Residing in or traveling to areas endemic for Coccidioides is required for the diagnosis; no person-to-person or zoonotic contagion occurs. The incidence of coccidioidomycosis is increasing in endemic areas, and it has been identified as the cause of as many as 17% to 29% of all cases of community-acquired pneumonia in some regions. Obtaining a travel history is recommended when evaluating patients with community-acquired pneumonia. Diagnosis usually relies on enzyme immunoassay with immunodiffusion confirmation, but these tests may not be positive for one to three weeks after disease onset. Antifungal agents are not recommended for treatment unless the patient is at risk of or shows signs of complicated or disseminated infection. When antifungals are used, fluconazole and itraconazole are most commonly recommended, except during pregnancy. Treatment may continue for as long as three to 12 months, although lifetime treatment is indicated for patients with coccidioidal meningitis. Monitoring of complement fixation titers and chest radiography is recommended until patients stabilize and symptoms resolve. In patients who are treated with antifungals, complement fixation titers should be followed for at least two years. (Am Fam Physician. 2020;101(4):221–228. Copyright © 2020 American Academy of Family Physicians.)

Primary pulmonary coccidioidomycosis, also known as valley fever, is an acute pulmonary infection that presents one to three weeks after a person inhales airborne spores of the fungus Coccidioides immitis or Coccidioides posadasii. These fungi normally grow in the soil, but when the soil is mechanically disturbed, airborne spores are released that can be inhaled and begin a parasitic existence in a human or animal host. Person-to-person or zoonotic contagion does not occur, and transplacental infection in humans has never been documented.13 There have been reports, however, of nonrespiratory spread via solid organ transplant or percutaneous transfer of infected fomites, but such cases are rare.47

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Clinical recommendationEvidence ratingComment

Include a travel and residence history when assessing patients presenting with suspected community-acquired pneumonia, and consider primary pulmonary coccidioidomycosis in those who have visited endemic areas in the previous two months.8,9


Expert opinion and consensus guideline in the absence of clinical trials

Antifungal agents are not recommended for the treatment of uncomplicated primary pulmonary coccidioidomycosis unless risks for disseminated disease are present.9,29,36,37,50


Expert opinion and consensus guideline in the absence of clinical trials

When indicated, antifungals for the treatment of primary pulmonary coccidioidomycosis include oral fluconazole (Diflucan) or itraconazole (Sporanox) for nonpregnant, nonbreastfeeding adults; oral fluconazole for breastfeeding women; oral fluconazole for children; and intravenous amphotericin B for pregnant women.9,29


Expert opinion and consensus guideline in the absence of clinical trials

If primary pulmonary coccidioidomycosis is confirmed, monitor complement fixation titers and chest radiography every one to three months for at least one year, and evaluate any symptoms of dissemination, including fungal meningitis.9,30,36


Expert opinion and consensus guideline in the absence of clinical trials

Pregnant women with a history of coccidioidomycosis should be monitored with complement fixation titers every six to 12 weeks. Serologic testing should be considered for all women residing in endemic regions at their first antenatal visit.29


Expert opinion and consensus guideline in the absence of clinical trials

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to

The Authors

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KEVIN R. HERRICK, MD, PhD, is director of education and research at the Foothill Community Health Center, San Jose, Calif.; an assistant clinical professor of family medicine at Loma Linda (Calif.) University School of Medicine; and an adjunct clinical instructor at Stanford University School of Medicine, Palo Alto, Calif....

MADISON E. TRONDLE, DVM, is an associate veterinarian at Banfield Pet Hospital, Upland, Calif.

TAYNET T. FEBLES, MD, is an infectious disease attending physician at Hazel Hawkins Memorial Hospital, Hollister, Calif.

Address correspondence to Kevin R. Herrick, MD, PhD, Foothill Community Health Center, 5504 Monterey Hwy., San Jose, CA 95138. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


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1. Brown J, Benedict K, Park BJ, et al. Coccidioidomycosis: epidemiology. Clin Epidemiol. 2013;5:185–197....

2. Spark RP. Does transplacental spread of coccidioidomycosis occur? Report of a neonatal fatality and review of the literature. Arch Pathol Lab Med. 1981;105(7):347–350.

3. McCaffree MA, Altshuler G, Benirschke K. Placental coccidioidomycosis without fetal disease. Arch Pathol Lab Med. 1978;102(10):512–514.

4. Nel JS, Bartelt LA, van Duin D, et al. Endemic mycoses in solid organ transplant recipients. Infect Dis Clin North Am. 2018;32(3):667–685.

5. Dierberg KL, Marr KA, Subramanian A, et al. Donor-derived organ transplant transmission of coccidioidomycosis. Transpl Infect Dis. 2012;14(3):300–304.

6. Gaidici A, Saubolle MA. Transmission of coccidioidomycosis to a human via a cat bite. J Clin Microbiol. 2009;47(2):505–506.

7. Stagliano D, Epstein J, Hickey P. Fomite-transmitted coccidioidomycosis in an immunocompromised child. Pediatr Infect Dis J. 2007;26(5):454–456.

8. Centers for Disease Control and Prevention. Fungal diseases: valley fever (coccidioidomycosis). January 2, 2019. Accessed January 20, 2019.

9. Galgiani JN, Ampel NM, Blair JE, et al. 2016 Infectious Diseases Society of America (IDSA) clinical practice guideline for the treatment of coccidioidomycosis. Clin Infect Dis. 2016;63(6):e112–e146.

10. Wack EE, Ampel NM, Sunenshine RH, et al. The return of delayed-type hypersensitivity skin testing for coccidioidomycosis. Clin Infect Dis. 2015;61(5):787–791.

11. Hedges E, Miller S. Coccidioidomycosis: office diagnosis and treatment. [published correction appears in Am Fam Physician. 1990;42(1):44]. Am Fam Physician. 1990;41(5):1499–1506.

12. Galgiani JN. Coccidioidomycosis. West J Med. 1993;159(2):153–171.

13. Forseth J, Rohwedder JJ, Levine BE, et al. Experience with needle biopsy for coccidioidal lung nodules. Arch Intern Med. 1986;146(2):319–320.

14. Thompson GR III. Pulmonary coccidioidomycosis. Semin Respir Crit Care Med. 2011;32(6):754–763.

15. Garcia Garcia SC, Salas Alanis JC, Flores MG, et al. Coccidioidomycosis and the skin: a comprehensive review. An Bras Dermatol. 2015;90(5):610–619.

16. Mischel PS, Vinters HV. Coccidioidomycosis of the central nervous system: neuropathological and vasculopathic manifestations and clinical correlates. Clin Infect Dis. 1995;20(2):400–405.

17. Centers for Disease Control and Prevention (CDC).. Increase in reported coccidioidomycosis—United States, 1998–2011. MMWR Morb Mortal Wkly Rep. 2013;62(12):217–221.

18. California Department of Public Health. Epidemiologic summary of coccidioidomycosis in California, 2017. Accessed January 22, 2019.

19. Del Rocío Reyes-Montes M, Pérez-Huitrón MA, Ocaña-Monroy JL, et al. The habitat of Coccidioides spp. and the role of animals as reservoirs and disseminators in nature. BMC Infect Dis. 2016;16(1):550.

20. Sharpton TJ, Stajich JE, Rounsley SD, et al. Comparative genomic analyses of the human fungal pathogens Coccidioides and their relatives. Genome Res. 2009;19(10):1722–1731.

21. Valdivia L, Nix D, Wright M, et al. Coccidioidomycosis as a common cause of community-acquired pneumonia [published correction appears in Emerg Infect Dis. 2006;12(8):1307]. Emerg Infect Dis. 2006; 12(6):958–962.

22. Kim MM, Blair JE, Carey EJ, et al. Coccidioidal pneumonia, Phoenix, Arizona, USA, 2000–2004. Emerg Infect Dis. 2009;15(3):397–401.

23. Bayer AS. Recognizing coccidioidomycosis. Am Fam Physician. 1980;22(3):133–141.

24. Lee LA, Yuan J, Vugia D, et al. Increased coccidioidomycosis among inmates at a California prison: initial investigation in 2005 to 2006. J Correct Health Care. 2017;23(3):347–352.

25. Saubolle MA, McKellar PP, Sussland D. Epidemiologic, clinical, and diagnostic aspects of coccidioidomycosis. JClin Microbiol. 2007;45(1):26–30.

26. Pappagianis D; Coccidioidomycosis Serology Laboratory. Coccidioidomycosis in California state correctional institutions. Ann N Y Acad Sci. 2007;1111:103–111.

27. Blair JE, Logan JL. Coccidioidomycosis in solid organ transplantation. Clin Infect Dis. 2001;33(9):1536–1544.

28. Ruddy BE, Mayer AP, Ko MG, et al. Coccidioidomycosis in African Americans. Mayo Clin Proc. 2011;86(1):63–69.

29. Bercovitch RS, Catanzaro A, Schwartz BS, et al. Coccidioidomycosis during pregnancy: a review and recommendations for management. Clin Infect Dis. 2011;53(4):363–368.

30. Kauffman CA. Primary coccidioidal infection. UpToDate. 2019. Accessed October 30, 2018.

31. Yozwiak ML, Lundergan LL, Kerrick SS, et al. Symptoms and routine laboratory abnormalities associated with coccidioidomycosis. West J Med. 1988;149(4):419–421.

32. McCarty JM, Demetral LC, Dabrowski L, et al. Pediatric coccidioidomycosis in central California: a retrospective case series. Clin Infect Dis. 2013;56(11):1579–1585.

33. Stockamp NW, Thompson GR III. Coccidioidomycosis. Infect Dis Clin North Am. 2016;30(1):229–246.

34. Blair JE, Ampel NM. Coccidioidomycosis: laboratory diagnosis and screening. UpToDate. 2019. Accessed October 30, 2018.

35. Kikano GE, Fabien A, Schilz R. Evaluation of the solitary pulmonary nodule. Am Fam Physician. 2015;92(12):1084–1091. Accessed July 28, 2019.

36. Hospenthal DR, Thompson GR III, Oppenheimer AP, et al. Coccidioidomycosis and valley fever. September 20, 2018. Accessed January 30, 2019.

37. Ampel NM. Coccidioidomycosis in compromised hosts. UpToDate. 2019. Accessed October 30, 2018.

38. Blair JE, Coakley B, Santelli AC, et al. Serologic testing for symptomatic coccidioidomycosis in immunocompetent and immunosuppressed hosts. Mycopathologia. 2006;162(5):317–324.

39. Blair JE, Currier JT. Significance of isolated positive IgM serologic results by enzyme immunoassay for coccidioidomycosis. Mycopathologia. 2008;166(2):77–82.

40. Kuberski T, Herrig J, Pappagianis D. False-positive IgM serology in coccidioidomycosis. JClin Microbiol. 2010;48(6):2047–2049.

41. Kaufman L, Sekhon AS, Moledina N, et al. Comparative evaluation of commercial Premier EIA and microimmunodiffusion and complement fixation tests for Coccidioides immitis antibodies. J Clin Microbiol. 1995;33(3):618–619.

42. Nascimento ER, Yamamoto R, Herrick KR, et al. Polymerase chain reaction for detection of Mycoplasma gallisepticum. Avian Dis. 1991;35(1):62–69.

43. Sachse K, Frey J, eds. PCR Detection of Microbial Pathogens. Humana Press; 2003:216.

44. Binnicker MJ, Buckwalter SP, Eisberner JJ, et al. Detection of Coccidioides species in clinical specimens by real-time PCR. J Clin Microbiol. 2007;45(1):173–178.

45. Vucicevic D, Blair JE, Binnicker MJ, et al. The utility of Coccidioides polymerase chain reaction testing in the clinical setting. Mycopathologia. 2010;170(5):345–351.

46. Mitchell M, Dizon D, Libke R, et al. Development of a real-time PCR assay for identification of Coccidioides immitis by use of the BD Max system. J Clin Microbiol. 2015;53(3):926–929.

47. Dizon D, Mitchell M, Dizon B, et al. The utility of real-time polymerase chain reaction in detecting Coccidioides immitis among clinical specimens in the Central California San Joaquin Valley. Med Mycol. 2019;57(6):688–693.

48. Saubolle MA, Wojack BR, Wertheimer AM, et al. Multicenter clinical validation of a cartridge-based real-time PCR system for detection of Coccidioides spp. in lower respiratory specimens. J Clin Microbiol. 2018;56(2):e01277–17.

49. Ampel NM, Giblin A, Mourani JP, et al. Factors and outcomes associated with the decision to treat primary pulmonary coccidioidomycosis. Clin Infect Dis. 2009;48(2):172–178.

50. Twarog M, Thompson GR III. Coccidioidomycosis: recent updates. Semin Respir Crit Care Med. 2015;36(5):746–755.

51. Santelli AC, Blair JE, Roust LR. Coccidioidomycosis in patients with diabetes mellitus. Am J Med. 2006;119(11):964–969.

52. Johnson RH, Einstein HE. Coccidioidal meningitis. Clin Infect Dis. 2006;42(1):103–107.

53. Sondermeyer Cooksey GL, Wilken JA, McNary J, et al. Dust exposure and coccidioidomycosis prevention among solar power farm construction workers in California. Am J Public Health. 2017;107(8):1296–1303.

54. Trinh SA, Echenique IA, Penugonda S, et al. Safety and efficacy of chronic suppressive azole therapy for endemic fungal infections in solid organ transplant recipients. Transpl Infect Dis. 2018;20(5):e12963.

55. Cole GT, Hurtgen BJ, Hung CY. Progress toward a human vaccine against coccidioidomycosis. Curr Fungal Infect Rep. 2012;6(4):235–244.



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