Coccidioidomycosis (Valley Fever) in Primary Care

Kevin R. Herrick; Madison E. Trondle; Taynet T. Febles

Feb 15, 2020 Issue

Coccidioidomycosis (Valley Fever) in Primary Care

KEVIN R. HERRICK, MD, PhD, Foothill Community Health Center, San Jose, California; Loma Linda University School of Medicine, Loma Linda, California; Stanford University School of Medicine, Palo Alto, California

MADISON E. TRONDLE, DVM, Banfield Pet Hospital, Upland, California

TAYNET T. FEBLES, MD, Hazel Hawkins Memorial Hospital, Hollister, California

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.1–3 There have been reports, however, of nonrespiratory spread via solid organ transplant or percutaneous transfer of infected fomites, but such cases are rare.4–7

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Evidence rating	Comment
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	C	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}	C	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	C	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	C	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	C	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 https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Evidence rating	Comment
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	C	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}	C	Expert opinion and consensus guideline in the absence of clinical trials
When indicated, antifungals for the treatment of primary pulmonary coccidioidomycosis include oral fl

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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