Musculoskeletal Coccidioidomycosis

 

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ABSTRACT

Coccidioidomycosis (valley fever) is a systemic fungal infection caused by soil fungi, Coccidioides species, and is associated with significant morbidity and mortality. This infection is endemic in northern Mexico, the southwestern United States, and parts of Central and South America. The risk factors include ethnicity (especially African and Pacific Island ancestry), male gender, and immunosuppression. The primary infection occurs in lungs, but fewer than 40% of patients are symptomatic. Fewer than 1% of infections result in disseminated disease, which may involve any organ. Skeletal infection occurs in 10 to 50% of these patients and is frequently multicentric with axial skeleton involvement. The diagnosis can be confirmed by culture of the organism or visual detection from cytological or histological specimens obtained from sites of disease. A presumptive diagnosis can be made in patients with a compatible illness and a positive serologic test. Imaging plays a significant role in diagnosis and follow-up treatment of musculoskeletal coccidioidomycosis and includes radiography, magnetic resonance imaging, computed tomography, and bone scintigraphy. Skeletal coccidioidomycosis is difficult to treat and frequently requires a combination of medical therapy and surgical debridement. Medical therapy must be continued for a prolonged period of time, potentially for a lifetime in some patients.

REFERENCES

• 1 Taljanovic M S. Fungal and higher bacterial infections. In: Pope T L, Bloem H L, Beltran J, Morrison W B, Wilson D J, eds. Imaging of the Musculoskeletal System. Philadelphia, PA: WB Saunders; 2008: 1357-1379
  Google Scholar
• 2 Chiller T M, Galgiani J N, Stevens D A. Coccidioidomycosis.  Infect Dis Clin North Am. 2003;  17 (1) 41-57 viii
  Google Scholar
• 3 Drutz D J, Catanzaro A. Coccidioidomycosis. Part II.  Am Rev Respir Dis. 1978;  117 (4) 727-771
  Google Scholar
• 4 McGahan J P, Graves D S, Palmer P E, Stadalnik R C, Dublin A B. Classic and contemporary imaging of coccidioidomycosis.  AJR Am J Roentgenol. 1981;  136 (2) 393-404
  Google Scholar
• 5 Adam R D, Elliott S P, Taljanovic M S. The spectrum and presentation of disseminated coccidioidomycosis.  Am J Med. 2009;  122 (8) 770-777
  Google Scholar
• 6 McNabb S J, Jajosky R A, Hall-Baker P A Centers for Disease Control and Prevention (CDC) et al. Summary of notifiable diseases—United States, 2006. [Erratum appears in Morb Mortal Wkly Rep 2008;57:466].  MMWR Morb Mortal Wkly Rep. 2008;  55 (53) 1-92
  Google Scholar
• 7 Centers for Disease Control and Prevention (CDC) . Increase in Coccidioidomycosis—California, 2000–2007.  MMWR Morb Mortal Wkly Rep. 2009;  58 (5) 105-109
  Google Scholar
• 8 Dodge R R, Lebowitz M D, Barbee R, Burrows B. Estimates of C. immitis infection by skin test reactivity in an endemic community.  Am J Public Health. 1985;  75 (8) 863-865
  Google Scholar
• 9 Larwood T R. Coccidioidin skin testing in Kern County, California: decrease in infection rate over 58 years.  Clin Infect Dis. 2000;  30 (3) 612-613
  Google Scholar
• 10 Bergstrom L, Yocum D E, Ampel N M et al.. Increased risk of coccidioidomycosis in patients treated with tumor necrosis factor alpha antagonists.  Arthritis Rheum. 2004;  50 (6) 1959-1966
  Google Scholar
• 11 Vikram H R, Blair J E. Coccidioidomycosis in transplant recipients: a primer for clinicians in nonendemic areas.  Curr Opin Organ Transplant. 2009;  14 (6) 606-612
  Google Scholar
• 12 Kafka J A, Catanzaro A. Disseminated coccidioidomycosis in children.  J Pediatr. 1981;  98 (3) 355-361
  Google Scholar
• 13 Forbus W D, Bestebreurtje A M. Coccidioidomycosis; a study of 95 cases of the disseminated type with special reference to the pathogenesis of the disease.  Mil Surg. 1946;  99 (5) 653-719
  Google Scholar
• 14 Huntington R W, Waldman W J, Sargent J A, O'Connell H H, Wybel R, Croll D. Pathologic and clinical observation of septic joints: 142 cases of fatal coccidioidomycosis with necroscopy. In: Ajello L, ed. Coccidioidomycosis. Tucson: University of Arizona Press; 1967: 143-167
  Google Scholar
• 15 Bried J M, Galgiani J N. Coccidioides immitis infections in bones and joints.  Clin Orthop Relat Res. 1986;  (211) 235-243
  Google Scholar
• 16 Kushwaha V P, Shaw B A, Gerardi J A, Oppenheim W L. Musculoskeletal coccidioidomycosis. A review of 25 cases.  Clin Orthop Relat Res. 1996;  (332) 190-199
  Google Scholar
• 17 Galgiani J N. Coccidioidomycosis.  West J Med. 1993;  159 (2) 153-171
  Google Scholar
• 18 Stevens D A. Coccidioidomycosis.  N Engl J Med. 1995;  332 (16) 1077-1082
  Google Scholar
• 19 Zeppa M A, Laorr A, Greenspan A, McGahan J P, Steinbach L S. Skeletal coccidioidomycosis: imaging findings in 19 patients.  Skeletal Radiol. 1996;  25 (4) 337-343
  Google Scholar
• 20 Arkun R. Parasitic and fungal disease of bones and joints.  Semin Musculoskelet Radiol. 2004;  8 (3) 231-242
  Google Scholar
• 21 Resnick D. Osteomyelitis, septic arthritis, and soft tissue infection. In: Resnick D, ed. Diagnosis of Bone and Joint Disorders. Philadelphia, PA: WB Saunders; 2002: 2510-2624
  Google Scholar
• 22 Dalinka M K, Dinnenberg S, Greendyk W H, Hopkins R. Roentgenographic features of osseous coccidioidomycosis and differential diagnosis.  J Bone Joint Surg Am. 1971;  53 (6) 1157-1164
  Google Scholar
• 23 Iger M, Coppola A J. Review of 135 cases of bone and joint coccidioidomycosis. In: Einstein H, Catanzaro A, eds. Coccidioidomycosis: Proceedings of the 4th International conference. Washington, DC: National Foundation for Infectious Diseases; 1985: 379-389
  Google Scholar
• 24 Dalinka M K, Greendyke W H. The spinal manifestations of coccidioidomycosis.  J Can Assoc Radiol. 1971;  22 (1) 93-99
  Google Scholar
• 25 Carter R A. Coccidioidal granuloma: roentgen diagnosis.  AJR Am J Roentgenol. 1931;  25 715-738
  Google Scholar
• 26 Carter R A. Infectious granulomas of bone and joints, with special reference to coccidioidal granuloma.  Radiology. 1934;  23 1-16
  Google Scholar
• 27 Mazet Jr R. Skeletal lesions in coccidioidomycosis.  AMA Arch Surg. 1955;  70 (4) 497-507
  Google Scholar
• 28 May D A, Disler D G. Diagnosis please. Case 50: primary coccidioidal synovitis of the knee.  Radiology. 2002;  224 (3) 665-668
  Google Scholar
• 29 Lund P J, Chan K M, Unger E C, Galgiani T N, Pitt M J. Magnetic resonance imaging in coccidioidal arthritis.  Skeletal Radiol. 1996;  25 (7) 661-665
  Google Scholar
• 30 Holley K, Muldoon M, Tasker S. Coccidioides immitis osteomyelitis: a case series review.  Orthopedics. 2002;  25 (8) 827-831 831-832
  Google Scholar
• 31 Reid G D, Klinkhoff A, Bozek C, Denegri J F. Coccidioidomycosis tenosynovitis: case report and review of the literature.  J Rheumatol. 1984;  11 (3) 392-394
  Google Scholar
• 32 Iverson R E, Vistnes L M. Coccidioidomycosis tenosynovitis in the hand.  J Bone Joint Surg Am. 1973;  55 (2) 413-417
  Google Scholar
• 33 Drutz D J, Catanzaro A. Coccidioidomycosis. Part I.  Am Rev Respir Dis. 1978;  117 (3) 559-585
  Google Scholar
• 34 Li L, Dial S M, Schmelz M, Rennels M A, Ampel N M. Cellular immune suppressor activity resides in lymphocyte cell clusters adjacent to granulomata in human coccidioidomycosis.  Infect Immun. 2005;  73 (7) 3923-3928
  Google Scholar
• 35 Pappagianis D, Zimmer B L. Serology of coccidioidomycosis.  Clin Microbiol Rev. 1990;  3 (3) 247-268
  Google Scholar
• 36 Wieden M A, Galgiani J N, Pappagianis D. Comparison of immunodiffusion techniques with standard complement fixation assay for quantitation of coccidioidal antibodies.  J Clin Microbiol. 1983;  18 (3) 529-534
  Google Scholar
• 37 Wright E T, Winer L H. The natural history of experimental primary-inoculation Coccidioides immitis infection.  Int J Dermatol. 1971;  10 (1) 17-23
  Google Scholar
• 38 Blair J E, Logan J L. Coccidioidomycosis in solid organ transplantation.  Clin Infect Dis. 2001;  33 (9) 1536-1544
  Google Scholar
• 39 Blair J E. Coccidioidomycosis in patients who have undergone transplantation.  Ann N Y Acad Sci. 2007;  1111 365-376
  Google Scholar
• 40 Bronnimann D A, Adam R D, Galgiani J N et al.. Coccidioidomycosis in the acquired immunodeficiency syndrome.  Ann Intern Med. 1987;  106 (3) 372-379
  Google Scholar
• 41 Ampel N M, Ryan K J, Carry P J, Wieden M A, Schifman R B. Fungemia due to Coccidioides immitis. An analysis of 16 episodes in 15 patients and a review of the literature.  Medicine (Baltimore). 1986;  65 (5) 312-321
  Google Scholar
• 42 Perera P, Stone S. Coccidioidomycosis in workers at an archeologic site—Dinosaur National Monument, Utah, June–July 2001.  Ann Emerg Med. 2002;  39 (5) 566-569
  Google Scholar
• 43 Benninghoven C D, Miller E R. Coccidioidal infection in bone.  Radiology. 1942;  38 663-666
  Google Scholar
• 44 Turecki M B, Taljanovic M S, Stubbs A Y et al.. Imaging of musculoskeletal soft tissue infections.  Skeletal Radiol. 2010;  39 (10) 957-971
  Google Scholar
• 45 Christian S, Kraas J, Conway W F. Musculoskeletal infections.  Semin Roentgenol. 2007;  42 (2) 92-101
  Google Scholar
• 46 Pineda C, Vargas A, Rodríguez A V. Imaging of osteomyelitis: current concepts.  Infect Dis Clin North Am. 2006;  20 (4) 789-825
  Google Scholar
• 47 Taljanovic M S, Hunter T B, Fitzpatrick K A, Krupinski E A, Pope T L. Musculoskeletal magnetic resonance imaging: importance of radiography.  Skeletal Radiol. 2003;  32 (7) 403-411
  Google Scholar
• 48 Nguyen B D. F-18 FDG PET/CT imaging of disseminated coccidioidomycosis.  Clin Nucl Med. 2006;  31 (9) 568-571
  Google Scholar
• 49 Blair J E. State-of-the-art treatment of coccidioidomycosis skeletal infections.  Ann N Y Acad Sci. 2007;  1111 422-433
  Google Scholar
• 50 Galgiani J N, Catanzaro A, Cloud G A Mycoses Study Group et al. Comparison of oral fluconazole and itraconazole for progressive, nonmeningeal coccidioidomycosis. A randomized, double-blind trial.  Ann Intern Med. 2000;  133 (9) 676-686
  Google Scholar
• 51 Catanzaro A, Galgiani J N, Levine B E NIAID Mycoses Study Group et al. Fluconazole in the treatment of chronic pulmonary and nonmeningeal disseminated coccidioidomycosis.  Am J Med. 1995;  98 (3) 249-256
  Google Scholar
• 52 Galgiani J N, Catanzaro A, Cloud G A The NIAID-Mycoses Study Group et al. Fluconazole therapy for coccidioidal meningitis.  Ann Intern Med. 1993;  119 (1) 28-35
  Google Scholar
• 53 Graybill J R, Stevens D A, Galgiani J N, Dismukes W E, Cloud G A. NAIAD Mycoses Study Group . Itraconazole treatment of coccidioidomycosis.  Am J Med. 1990;  89 (3) 282-290
  Google Scholar
• 54 Antony S J, Jurczyk P, Brumble L. Successful use of combination antifungal therapy in the treatment of coccidioides meningitis.  J Natl Med Assoc. 2006;  98 (6) 940-942
  Google Scholar
• 55 Prabhu R M, Bonnell M, Currier B L, Orenstein R. Successful treatment of disseminated nonmeningeal coccidioidomycosis with voriconazole.  Clin Infect Dis. 2004;  39 (7) e74-e77
  Google Scholar
• 56 Proia L A, Tenorio A R. Successful use of voriconazole for treatment of Coccidioides meningitis.  Antimicrob Agents Chemother. 2004;  48 (6) 2341
  Google Scholar
• 57 Catanzaro A, Cloud G A, Stevens D A et al.. Safety, tolerance, and efficacy of posaconazole therapy in patients with nonmeningeal disseminated or chronic pulmonary coccidioidomycosis.  Clin Infect Dis. 2007;  45 (5) 562-568
  Google Scholar
• 58 Anstead G M, Corcoran G, Lewis J, Berg D, Graybill J R. Refractory coccidioidomycosis treated with posaconazole.  Clin Infect Dis. 2005;  40 (12) 1770-1776
  Google Scholar
• 59 Galgiani J N, Ampel N M, Blair J E Infectious Diseases Society of America et al. Coccidioidomycosis.  Clin Infect Dis. 2005;  41 (9) 1217-1223
  Google Scholar
• 60 Wrobel C J, Chappell E T, Taylor W. Clinical presentation, radiological findings, and treatment results of coccidioidomycosis involving the spine: report on 23 cases.  J Neurosurg. 2001;  95 (1, Suppl) 33-39
  Google Scholar

Mihra S TaljanovicM.D. 

Department of Radiology, The University of Arizona Health Network

1501 N. Campbell Ave., Tucson, AZ 85724-5067

Email: mihrat@radiology.arizona.edu