Pulmonary coccidioidomycosis, also known colloquially as valley fever, refers to lung involvement of the dimorphic fungus Coccidioides spp, mainly Coccidioides immitis and Coccidioides posadasi.
Coccidioidomycosis is endemic to many parts of North, Central, and South America 1. When this disease does manifest, pulmonary involvement is very common, and has been reported to occur in 95% of all cases.
The clinical features are in-keeping with a severe pneumonia 2. The most common clinical manifestations are chest pain, cough, fever, and fatigue 2. In many patients, there are often associated constitutional symptoms and cutaneous manifestations such as erythema nodosum. The disease can also spread haematogenously to bones, joints, and the central nervous system (see CNS coccidioidomycosis) 2.
The overall pathology of coccidioidomycosis is discussed elsewhere (see coccidioidomycosis and Figure 1).
Plain radiograph and CT chest
There can be many findings which include consolidation (most common - 75%), multiple nodules, interlobular septal thickening, lymph node enlargement (including bilateral hilar lymphadenopathy), and pleural effusions 3-6. When a nodular pattern is present, it may have a predominance towards the inferior pulmonary lobes 4. Nodule diameters may range from 0.5 to 3 cm and generally tend to have ill defined contours 4. Some nodules may coalescence or cavitate 4. Rarely a miliary pattern may develop, especially in immunocompromised patients 5. It is also important to be aware of the pulmonary complications, as detailed below 3.
Treatment and prognosis
The mainstay of medical treatment of pulmonary coccidioidomycosis is with anti-fungal agents such as fluconazole 7.
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- 3. Jude CM, Nayak NB, Patel MK, Deshmukh M, Batra P. Pulmonary coccidioidomycosis: pictorial review of chest radiographic and CT findings. Radiographics : a review publication of the Radiological Society of North America, Inc. 34 (4): 912-25. doi:10.1148/rg.344130134 - Pubmed
- 4. Capone D, Marchiori E, Wanke B et-al. Acute pulmonary coccidioidomycosis: CT findings from 15 patients. Br J Radiol. 2008;81 (969): 721-4. Br J Radiol (full text) - doi:10.1259/bjr/12054884 - Pubmed citation
- 5. Arsura EL, Kilgore WB. Miliary coccidioidomycosis in the immunocompetent. Chest. 117 (2): 404-9. Pubmed
- 6. Gupta NA, Iv M, Pandit RP, Patel MR. Imaging manifestations of primary and disseminated coccidioidomycosis. Applied Radiology. The Journal Of Practical Medical Imaging Management. 2015.
- 7. Galgiani JN, Ampel NM, Blair JE, Catanzaro A, Geertsma F, Hoover SE, Johnson RH, Kusne S, Lisse J, MacDonald JD, Meyerson SL, Raksin PB, Siever J, Stevens DA, Sunenshine R, Theodore N. 2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Treatment of Coccidioidomycosis. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 63 (6): e112-46. doi:10.1093/cid/ciw360 - Pubmed