Coccidioides immitis fungemia: Clinical features and survival in 33 adult patients

doi:10.1016/j.hrtlng.2006.10.001

Heart & Lung

Volume 36, Issue 1, January 2007, Pages 64-71

Presented in-part in Critical Care Medicine 2001;29:12 (supplement) A106¹ and Critical Care Medicine 1999;27:A122.²

https://doi.org/10.1016/j.hrtlng.2006.10.001 Get rights and content

Coccidioides immitis is a fungus endemic to the southwestern United States. Susceptible hosts, including blacks, Hispanics, Filipinos, Native Americans, and those with compromised immunity, may develop disseminated disease, including fungemia. We retrospectively reviewed the records of all patients (n = 33) with Coccidioides immitis fungemia (CIF) at a 550-bed public hospital in Phoenix, Arizona, from 1990 to 2002. This is the largest reported series of CIF. The purpose of the study was to review the incidence, signs, symptoms, and outcomes of CIF. Twenty-nine patients had human immunodeficiency virus infection. CIF was associated with sepsis, end-stage alcoholic liver disease, and diabetes in four patients. Survival was poor; 24 of the 33 patients died within 28 days. CIF manifested as a systemic inflammatory response syndrome with progressive cardiorespiratory failure. Despite fluid loading, infusion of vasoactive agents, and mechanical ventilation with positive end-expiratory pressure, patients typically experienced a rapidly progressive course and death. CIF portends an ominous prognosis and typically occurs in the setting of advanced human immunodeficiency virus or medical or surgical crises.

Section snippets

Methods

We retrospectively reviewed the clinical features, demographics, course, microbiologic findings, outcome, and follow-up of all adult patients with CIF from 1990 to 2002 at a 550-bed county hospital that provides services to a large urban population, including many socially and medically disadvantaged individuals. The hospital is also the primary referral hospital for a large HIV outpatient center. Institutional review was not required for this study, and patient identity was protected and

Results

A total of 33 adult patients (aged 24–61 years; median = 37 years) with CIF were identified (Table I). All but two subjects were male. Twenty-nine of the 33 patients were seropositive for HIV (88%, ages 28–57 years; median = 37 years). An additional 27-year-old man presented with features compatible with HIV (patient 18). The CD₄+ lymphocyte counts in 17 patients ranged from less than 1 to 82 × 10⁶/μL (mean 15.28 × 10⁶/μL). The CD₄+ lymphocyte count was greater than 36 × 10⁶/μL (113 × 10⁶/μL in

Discussion

The study was performed in a major growing metropolitan area within the endemic region for C. immitis. Susceptible hosts, especially those with HIV/AIDS, are at risk for more severe respiratory infections and/or disseminated disease. The present study is the largest review of CIF to date and highlights the poor prognosis of patients with CIF, particularly those with advanced HIV infection.

CIF is an ominous manifestation of disseminated coccidioidomycosis. In a study of 15 patients, Ampel et al⁴

Acknowledgments

The authors are grateful for the advice of Dr. Peter Kelly, Arizona Department of Health, and Dr. Neil Ampel, Professor of Medicine, University of Arizona, and member of the Coccidioidomycosis Study Group; the assistance of Judy Hodgkins of the Department of Medicine, and Jerry Freeman, BS, of the Microbiology Laboratory; and the staffs of the Medical Library, Medical Records, and Pathology Departments of Maricopa Medical Center.

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As with other endemic fungi, isolation of Coccidioides from the blood is rare but portends a poor prognosis. In the largest available case series, drawn primarily from untreated HIV patients with low CD4 counts, 22 of 33 patients with fungemia died,84 with a mean survival of less than 2 weeks from presentation. Miliary coccidioidomycosis seems indistinguishable from miliary tuberculosis on chest imaging and may represent underlying fungemia with hematogenous spread (Fig. 6).
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Although we did not obtain positive PCR results using blood from infected mice, for 1 patient, the PCR was positive for both the clot and serum. It has been reported that Coccidioides fungemia is associated with immunosuppression and high mortality (Adam et al., 2009; Keckich et al., 2010; Rempe et al., 2007). For 1 of the patients diagnosed with coccidioidal meningitis, we obtained a positive PCR result, although no signs of acute infection were noted at the time the clinical sample was obtained.
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All authors were at the Maricopa Medical Center at the time of their contribution to this article.

Drs. Sachdev and Rempe contributed equally to the article.

The authors state that this material has not received commercial support and is not under submission at another publication. We do not have any personal financial interests in the material.

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Issues in infectious diseaseCoccidioides immitis fungemia: Clinical features and survival in 33 adult patients

Section snippets

Methods

Results

Discussion

Acknowledgments

Diagn Microbiol Infect Dis

Diagn Microbiol Infect Dis

Am J Med

Case series of 29 patients with C. immitis fungemia (CIF)

Crit Care Med

The ominous implications of Coccidioides immitis fungemia (CIF): review of 21 patients at a single institution

Crit Care Med

Epidemiology of coccidioidomycosis

Curr Top Med Mycol

Fungemia due to Coccidioides immitisAn analysis of 16 episodes in 15 patients and a review of the literature

Medicine

Coccidioidomycosis during human immunodeficiency virus infectionA review of 77 patients

Medicine

Risk factors for fungemia in children infected with human immunodeficiency virus: a case-control study

Clin Infect Dis

Symptoms and routine laboratory abnormalities associated with coccidioidomycosis

West J Med

The arterial-alveolar oxygen tension ratioAn index of gas exchange applicable to varying inspired oxygen concentrations

Am Rev Respir Dis

Corticosteroid insufficiency in acutely ill patients

N Engl J Med

Coccidioidomycosis in patients infected with human immuno-deficiency virus: review of 91 cases at a single institution

Clin Infect Dis

Hemodynamic responses to gram-positive versus gram-negative sepsis in critically ill patients with and without circulatory shock

Crit Care Med

Epidemiology and prognosis of bacteremia: a 10-y study in a community hospital

Scand J Infect Dis

Bacteremia in HIV-infected patients: short-term predictors of mortality

J Acquir Immune Defic Syndr

Secular trends of candidemia over 12 years in adult patients at a tertiary care hospital

Medicine

Issues in infectious disease
Coccidioides immitis fungemia: Clinical features and survival in 33 adult patients