Cocky Cocci
There’s a plague brewing in the salty southern desert lands of Arizona, along the Mexican border, that goes beyond politics, national origins, or the color of one’s skin. While not communicable from beast to human or human to human, it is no less dangerous because carried on the winds of all-too-common dust and sandstorms. Its calling card of profound fatigue, cough, shortness of breath, fever, and night sweats leaves one prostrate at best, and, when it instigates nodules, cavities, and pneumonia in the lungs, or dissemination to other organs far and wide, its hapless victim can be down for the count for anywhere from 4 months to over a year. The alarm and call to arms has been sounded in south-central Arizona, the southern San Joaquin Valley in California, the southwestern Rio Grande Valley of Texas, and northern Mexico where the scourge is endemic, and perhaps it is none too soon for El Paso, Juárez, and Las Cruces to heed indicators pointing to a possible spread of this cocky adversary, otherwise known as Coccidioidomycosis, “Cocci,” or Valley Fever, to the unsuspecting bosom of virgin territory.
Coccidioidomycosis, unaffectionately known as Cocci, is a soil-dwelling fungus as hard to isolate from dry southwestern dirt as the elusive gold of the old prospecting days. It is there, though, just waiting to be borne into the channels and hidden pockets of elderly lungs by a sudden gust of wind. While it is asymptomatic in 60% of its predominant prey, elderly male retirees spending their golden years in new homestead and construction development sites in the more populated central and southern regions of Arizona, other groups such as HIV and immunocompromised patients, transplant patients and those taking immunosuppressors and glucocorticoids, those placed on tumor necrosis factor alpha therapy by their physicians for a score of maladies, and pregnant women in their second and third trimesters are also fertile terrains for the finicky fungus. The nodules and cavities it produces in the lungs may produce no signs or symptoms, but may become evident on a chest x-ray or CT scan performed for another reason, and therefore require no medical or surgical intervention. Potential spread to distant organs like the skin, bones, joints, soft tissues, and meninges, however, can become a nightmare for 1% of the unlucky souls whose path and airways the arthroconidial (barrel-shaped) adversary has crossed. Even though dissemination to recesses far and wide of the human body and possible subsequent downward spiral into the abyss of fatal meningitis are so rare as to make choking to death on a fast-food French fry more common, the acute pneumonia and chronic symptomatology of the mangy microbe are by no means trouble free. In fact, a 2-3-month history, with no signs of improvement, of night sweats, extreme fatigue, cough, and a fever that may or may not be present, should trigger a closer look. As some clinicians like to put it, a low threshold for suspicion of Cocci should be in the front, not back, of the mind when a patient states that those symptoms have not improved over time. Couple that with increased eosinophils (a type of white blood cell alarm) on blood work, enlarged lymph nodes known as hilar or mediastinal lymphadenopathy in the center of the chest between the lungs on chest x-ray, and positive, if not dubious and unreliable, serologic tests performed on the sputum, and both the most experienced stalwart doubter and the most inexperienced, off-the-beaten-track, rural, bumpkin physician reach the same forgone conclusion that Cocky Cocci cometh.
Were that not all! Asymptomatic Cocci presents an additional series of problems, not the least of which are the emotional concerns it engenders in those who fall victim to its innocuous lung nodules, that just so happen to resemble and cannot be easily distinguishable on chest x-ray from pulmonary malignancies. The verdict is still out on treatment, too. Most would agree that primary pulmonary Cocci usually requires no therapy, with signs and symptoms gradually disappearing over a 2-4-month period. Extensive, disseminated disease with no signs of improvement, local pulmonary disease provoking fatigue and night sweats that just don’t seem to get better over time, and dreaded meningitis, on the other hand, require medical treatment of sometimes up to and over one year, as well as surgical intervention when the sky starts falling. While oral triazole antifungal drugs, such as fluconazole, itraconazole, and newer formulations, are the name of the game, they can cause birth defects in the offspring of pregnant women taking them. The primitive big gun, intravenous Amphotericin B, when used in more serious and resistant cases of cantankerous Cocci, is not without its problems either for the kidneys. So, damned if one has to treat 1% of the time, and fingers crossed 99% of the time that Cocky Cocci will fade into the sunset on its own, the clinician is left with some hard decisions.
Cocci and its distant, yet all-too-common cousin, the athlete’s foot fungus, are as different as night and day in their ramifications. Yet they both need to be stepped on!
© 2010, Albert M. Balesh, M.D. All rights reserved.
Coccidioidomycosis, unaffectionately known as Cocci, is a soil-dwelling fungus as hard to isolate from dry southwestern dirt as the elusive gold of the old prospecting days. It is there, though, just waiting to be borne into the channels and hidden pockets of elderly lungs by a sudden gust of wind. While it is asymptomatic in 60% of its predominant prey, elderly male retirees spending their golden years in new homestead and construction development sites in the more populated central and southern regions of Arizona, other groups such as HIV and immunocompromised patients, transplant patients and those taking immunosuppressors and glucocorticoids, those placed on tumor necrosis factor alpha therapy by their physicians for a score of maladies, and pregnant women in their second and third trimesters are also fertile terrains for the finicky fungus. The nodules and cavities it produces in the lungs may produce no signs or symptoms, but may become evident on a chest x-ray or CT scan performed for another reason, and therefore require no medical or surgical intervention. Potential spread to distant organs like the skin, bones, joints, soft tissues, and meninges, however, can become a nightmare for 1% of the unlucky souls whose path and airways the arthroconidial (barrel-shaped) adversary has crossed. Even though dissemination to recesses far and wide of the human body and possible subsequent downward spiral into the abyss of fatal meningitis are so rare as to make choking to death on a fast-food French fry more common, the acute pneumonia and chronic symptomatology of the mangy microbe are by no means trouble free. In fact, a 2-3-month history, with no signs of improvement, of night sweats, extreme fatigue, cough, and a fever that may or may not be present, should trigger a closer look. As some clinicians like to put it, a low threshold for suspicion of Cocci should be in the front, not back, of the mind when a patient states that those symptoms have not improved over time. Couple that with increased eosinophils (a type of white blood cell alarm) on blood work, enlarged lymph nodes known as hilar or mediastinal lymphadenopathy in the center of the chest between the lungs on chest x-ray, and positive, if not dubious and unreliable, serologic tests performed on the sputum, and both the most experienced stalwart doubter and the most inexperienced, off-the-beaten-track, rural, bumpkin physician reach the same forgone conclusion that Cocky Cocci cometh.
Were that not all! Asymptomatic Cocci presents an additional series of problems, not the least of which are the emotional concerns it engenders in those who fall victim to its innocuous lung nodules, that just so happen to resemble and cannot be easily distinguishable on chest x-ray from pulmonary malignancies. The verdict is still out on treatment, too. Most would agree that primary pulmonary Cocci usually requires no therapy, with signs and symptoms gradually disappearing over a 2-4-month period. Extensive, disseminated disease with no signs of improvement, local pulmonary disease provoking fatigue and night sweats that just don’t seem to get better over time, and dreaded meningitis, on the other hand, require medical treatment of sometimes up to and over one year, as well as surgical intervention when the sky starts falling. While oral triazole antifungal drugs, such as fluconazole, itraconazole, and newer formulations, are the name of the game, they can cause birth defects in the offspring of pregnant women taking them. The primitive big gun, intravenous Amphotericin B, when used in more serious and resistant cases of cantankerous Cocci, is not without its problems either for the kidneys. So, damned if one has to treat 1% of the time, and fingers crossed 99% of the time that Cocky Cocci will fade into the sunset on its own, the clinician is left with some hard decisions.
Cocci and its distant, yet all-too-common cousin, the athlete’s foot fungus, are as different as night and day in their ramifications. Yet they both need to be stepped on!
© 2010, Albert M. Balesh, M.D. All rights reserved.
posted by Dr. Al at
5/27/2010 08:54:00 AM
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