infectious diseases
Coccidioidomycosis
Symptoms and Signs of Coccidioidomycosis
Most patients with primary coccidioidomycosis are asymptomatic, but nonspecific respiratory symptoms resembling those of influenza, acute bronchitis, or, less often, acute pneumonia or pleural effusion sometimes occur. Symptoms of primary coccidioidomycosis, in decreasing order of frequency, include fever, cough, chest pain, chills, sputum production, sore throat, and hemoptysis. Physical signs may be absent or limited to scattered rales with or without areas of dullness to percussion over lung fields. Some patients develop hypersensitivity to the localized respiratory infection, manifested by arthritis, conjunctivitis, Erythema Nodosum , or Primary pulmonary lesions sometimes leave nodular coin lesions that must be distinguished from tumors, tuberculosis, and other granulomatous infections. Sometimes residual cavitary lesions develop; they may vary in size over time and often appear thin-walled. A small percentage of these cavities fail to close spontaneously. Hemoptysis or the threat of rupture into the pleural space occasionally necessitates surgery. Nonspecific symptoms develop a few weeks, months, or occasionally years after primary infection; they include low-grade fever, anorexia, weight loss, and weakness. Cutaneous manifestations are due to immunologically induced reactive eruptions, dissemination of the organisms from the lungs, or direct inoculation (primary cutaneous infection). Erythema nodosum is the most frequent reactive eruption associated with coccidioidomycosis. Erythema nodosum is characterized by multiple, self-limited, erythematous, painful, subcutaneous nodules usually on the lower extremities that appear 1 to 3 weeks after the initial respiratory symptoms. A generalized toxic exanthem and erythema multiforme have also been reported. Extensive pulmonary involvement is uncommon in otherwise healthy people and occurs mainly in those who are immunocompromised. It may cause progressive cyanosis, dyspnea, and mucopurulent or bloody sputum. Symptoms of extrapulmonary lesions depend on the site. Draining sinus tracts sometimes connect deeper lesions to the skin. Localized extrapulmonary lesions often become chronic and recur frequently, sometimes long after completion of seemingly successful antifungal therapy. Untreated disseminated coccidioidomycosis is usually fatal and, if meningitis is present, is uniformly fatal without prolonged and possibly lifelong treatment. Case fatality rates in patients with advanced HIV infection exceed 70% within 1 month of diagnosis; whether treatment can alter mortality rates is unclear. 