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Coccidioidomycosis

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of coccidioidomycosis are prepared by our editorial team based on guidelines from the Infectious Diseases Society of America (IDSA/CDC/NIH/HIVMA 2024), the American Academy of Family Physicians (AAFP 2020), the Infectious Diseases Society of America (IDSA 2016), and the American Thoracic Society (ATS 2011).
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Diagnostic investigations

Travel history: as per AAFP 2020 guidelines, ask for travel and residence history when assessing patients presenting with suspected community-acquired pneumonia. Suspect primary pulmonary coccidioidomycosis in patients mentioning a visit to endemic areas in the previous 2 months.
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Diagnostic procedures

CSF analysis: as per IDSA 2016 guidelines, perform lumbar puncture with CSF analysis in patients with recently diagnosed coccidioidal infection only if having unusual, worsening or persistent headache, altered mental status, unexplained nausea or vomiting, or new focal neurologic deficit after adequate imaging of the CNS.
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Medical management

General principles
As per IDSA 2016 guidelines:
Ensure that patients with uncomplicated pulmonary coccidioidomycosis have a management plan incorporating regular medical follow-up, health education, and a plan for physical reconditioning.
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Offer patient education, close observation, and supportive measures such as reconditioning physical therapy in patients with mild or non-debilitating symptoms, or substantially improved or resolved clinical illness by the time of diagnosis.
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  • Indications for treatment

  • Azoles

  • Amphotericin B

Surgical interventions

Indications for surgery: as per IDSA 2016 guidelines, consider offering surgical options in patients with persistently symptomatic pulmonary cavities despite antifungal treatment. Consider performing surgery in patients with pulmonary cavities persisting for > 2 years and if symptoms recur whenever antifungal treatment is stopped.
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Specific circumstances

Pregnant patients
As per AAFP 2020 guidelines:
Obtain monitoring with complement fixation titers every 6-12 weeks in pregnant patients with a history of coccidioidomycosis. Consider obtaining serologic testing in all females residing in endemic regions at their first antenatal visit.
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Administer IV amphotericin B, if antifungal therapy is indicated, in pregnant patients with primary pulmonary coccidioidomycosis. Administer oral fluconazole in breastfeeding patients.
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  • Infant patients

  • Patients with HIV (screening)

  • Patients with HIV (prevention)

  • Patients with HIV (antifungal therapy)

  • Patients with HIV (antiretroviral therapy)

  • Patients with HIV (pregnant patients)

  • Patients with HIV (pediatric patients)

  • Transplant recipients

  • Recipients of biological response modifiers

  • Patients with diffuse pulmonary coccidioidomycosis

  • Patients with chronic pulmonary coccidioidomycosis

  • Patients with non-meningeal disseminated disease

  • Patients with coccidioidal meningitis

  • Patients with bone and joint coccidioidomycosis

  • Patients with extrapulmonary soft tissue coccidioidomycosis

Follow-up and surveillance

Follow-up: as per AAFP 2020 guidelines, obtain monitoring of complement fixation titers and CXR every 1-2 months for at least 1 year and evaluate any symptoms of dissemination, including fungal meningitis, in patients with confirmed primary pulmonary coccidioidomycosis.
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