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Rp_CommonC_231

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ERROR: type should be string, got "https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMTA5MjAxNy1vdmVydmlldw==\nDrugs & Diseases > Dermatology\nDermatologic Manifestations of Coccidioidomycosis\nAuthor: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD more...\nSections Dermatologic Manifestations of Coccidioidomycosis\nPatient History\nSkin Testing\nHistologic Findings\nCoccidioidomycosis is caused by Coccidioides immitis, a dimorphic soil fungus native to the San Joaquin Valley of California, southern portions of Arizona, northern portions of Mexico, and scattered areas in Central America and South America, including Colombia. [1, 2, 3] There is a possible endemic focus in China. [4] Imported endemics can occur anywhere along with migratory movements, with 94 patients described in Spain from clinical records in the years 1997-2014. [5] Coccidioidomycosis in California has increased more than 213%, from 6 cases per 100,000 population in 2014 to 18.8 cases per 100,000 population in 2017 and continues to do so. [6]\nC immitis propagates as a saprophyte and as a parasite. In soil, it grows as a mold with branching septate hyphae. When the soil is disturbed, the hyphae fragment, which forms extremely hardy structures called arthroconidia, can become airborne. If inhaled by animals or humans, the arthroconidia can reach the pulmonary alveoli and transform into thick-walled, multinucleate spherules, which form septa and produce hundreds to thousands of uninucleate endospores. Each endospore is capable of producing new spherules or mycelia. With large-scale soil disturbance in Southern California’s Antelope Valley due to increased population, an increased incidence should be anticipated if land developers ignore the risk of grading land without implementing long-term dust mitigation plans. [7] In addition, global temperature rise has allegedly enhanced the geographic distribution of this fungus. [8]\nMost infected individuals are without symptoms. Disseminated coccidioidomycosis is unusual. Immunosuppressed people and pregnant women with coccidioidomycosis should receive special attention because of the increased risk of dissemination. US military service members of Asian/Pacific Islander race assigned in endemic regions of the American Southwest have a significantly higher incidence rate of extrapulmonary disease compared with members of other racial/ethnic groups. [9] Rarely, disseminated coccidioidomycosis with cutaneous involvement may clinically mimic a cutaneous T-cell lymphoma. Primary cutaneous coccidioidomycosis is rare. [10]\nNote the images below.\nSoft tissue abscess due to cocci.\nPulmonary cocci spherule (hematoxylin and eosin stain).\nSee A Chronic, Scaly Rash Mistaken for MRSA: Case Presentation, a Critical Images slideshow, to review additional images and details of a case of Coccidioidomycosis.\nGo to Coccidioidomycosis, Ocular Coccidioidomycosis, and Coccidioidomycosis Imaging for complete information on these topics.\nThe triad of fever, erythema nodosum, and erythema multiform may occur. Erythema nodosum and erythema multiform have a strong predilection for female patients. Migratory arthralgias are common.\nThere may be a history of travel or residence in an endemic area. It may also be considered an occupational disorder, as exemplified by an outbreak among highway construction crews in a highly endemic area, Kern County, California. [11] Although one tends to think of spores aerosolized in dust storms in Arizona and California producing outbreaks of coccidioidomycosis, an outbreak has been linked to a California earthquake. [12] In HIV-infected and other immunocompromised patients, one should be particularly concerned about possible mycotic co-infections, including with coccidioidomycosis, [13] which, in nonendemic areas, may be particularly perplexing. [14] Diabetes mellitus and black race may be risk factors for disseminated disease, justifying a California court decision exclusion of black inmates and those with diabetes from the two California prisons. [15]\nThe skin is the most common site of dissemination. Involvement ranges from superficial maculopapules, keratotic nodules, and verrucous ulcers to subcutaneous fluctuant abscesses. (Nonhealing skin lesions may need to be evaluated by means of biopsy.) Cold subcutaneous abscesses may be the first or only sign of disseminated infection. [16] The morphology varies. Dissemination should be especially considered in the immunosuppressed, including liver transplant recipients, and may appear as firm, violaceous subcutaneous nodules. [17]\nThe lesions have a predilection for the nasolabial fold.\nErythema nodosum and erythema multiforme may occur; as previously stated, these have a strong predilection for female patients. Erythema nodosum may manifest as painful subcutaneous nodules and are typically located on the lower extremities. Erythema nodosum may be the first sign of systemic disease. Less commonly, erythema multiforme may develop instead of erythema nodosum, resulting in the typical target lesions. The triad of fever, erythema nodosum, and arthralgias is called desert rheumatism.\nBuot et al reported finding specific cutaneous lesions of coccidioidomycosis during placement of a ventricular cardiac shunt for chronic meningitis. [18]\nTesting is available in the United States for assessing the cellular immune response in persons with coccidioidomycosis. Data suggest that archived coccidioidin retains its potency and specificity and that in vitro tests of coccidioidal immunity may have utility in the measurement of coccidioidal cellular immunity.\nA dermal delayed-type hypersensitivity reaction to coccidioidin is highly specific for coccidioidal infection. However, a positive result may not be related to currently acquired disease, because, in most persons, this skin test result remains positive for life after infection.\nAlthough skin test results are useful for epidemiologic studies, the test has important limitations when it is used as a screening procedure for recent infections with C immitis.\nIn patients in whom coccidioidomycosis is diagnosed with the help of other tests, the results of skin testing may have prognostic significance.\nWith skin testing, the induration of the skin is measured at 24 hours and 48 hours after coccidioidin is injected intradermally. An induration greater than 5 mm is considered reactive. Erythema at the injection site does not aid in the diagnosis of coccidioidomycosis.\nCutaneous coccidioidomycosis with verrucous nodules tends to have an overlying hyperplastic epidermis with a dermal granuloma. Characteristic spores may be evident in the granuloma. Caseation necrosis may also be present. [19]\nPrimary inoculation disease results in a dense, mixed, inflammatory dermal infiltrate with occasional giant cells and the formation of small abscesses. Spores may be evident, although hyphae are less likely to be present.\nThe occasionally associated erythema nodosum has typical histologic features, with no alterations suggestive of coccidioidomycosis. The same is true of erythema multiforme, which is less commonly linked to coccidioidomycosis.\nTreatment & Management\nThe need for surgery is determined by the nature of specific lesions on a case-by-case basis, because the manifestations, locations, and severity of progressive forms of coccidioidomycosis vary greatly among patients. Scanning with the F18-fluorodeoxyglucose (FDG) PET/CT imaging modality may be well suited to evaluate the extent of disseminated infection. [20] Fluconazole, the most commonly used antifungal for various forms of coccidioidomycosis, may be associated with a variety of skin effects, including dry skin and lips and alopecia. [21]\nIn some patients, especially those with extensive dermal involvement, debridement and drainage of the infected sites may be critical in controlling the infection.\nA reason for performing this procedure may be that the spherule wall, a strong stimulus for inflammation, cannot be degraded easily or cleared from large coccidioidal lesions by macrophages and other elements of the reticuloendothelial system.\nTherefore, even if therapy is effective in arresting fungal proliferation, fungal debris that is already present may continue to cause tissue destruction until it is surgically removed.\nWelsh O, Vera-Cabrera L, Rendon A, Gonzalez G, Bonifaz A. Coccidioidomycosis. Clin Dermatol. 2012 Nov-Dec. 30(6):573-91. [Medline].\nSchwartz RA, Lamberts RJ. Isolated nodular cutaneous coccidioidomycosis. The initial manifestation of disseminated disease. J Am Acad Dermatol. 1981 Jan. 4(1):38-46. [Medline].\nCanteros CE, Vélez H A, Toranzo AI, Suárez-Alvarez R, Tobón O Á, Del Pilar Jimenez A M, et al. Molecular identification of Coccidioides immitis in formalin-fixed, paraffin-embedded (FFPE) tissues from a Colombian patient. Med Mycol. 2015 Apr 23. [Medline].\nLiang G, Shen Y, Lv G, Zheng H, Mei H, Zheng X, et al. Coccidioidomycosis: Imported and possible domestic cases in China: A case report and review, 1958-2017. Mycoses. 2018 Jan 31. [Medline].\nMolina-Morant D, Sánchez-Montalvá A, Salvador F, Sao-Avilés A, Molina I. Imported endemic mycoses in Spain: Evolution of hospitalized cases, clinical characteristics and correlation with migratory movements, 1997-2014. PLoS Negl Trop Dis. 2018 Feb. 12 (2):e0006245. [Medline].\nWilson L, Ting J, Lin H, Shah R, MacLean M, Peterson MW, et al. The Rise of Valley Fever: Prevalence and Cost Burden of Coccidioidomycosis Infection in California. Int J Environ Res Public Health. 2019 Mar 28. 16 (7):[Medline].\nColson AJ, Vredenburgh L, Guevara RE, Rangel NP, Kloock CT, Lauer A. Large-Scale Land Development, Fugitive Dust, and Increased Coccidioidomycosis Incidence in the Antelope Valley of California, 1999-2014. Mycopathologia. 2017 Jan 13. [Medline].\nKaffenberger BH, Shetlar D, Norton SA, Rosenbach M. The effect of climate change on skin disease in North America. J Am Acad Dermatol. 2017 Jan. 76 (1):140-147. [Medline].\nMease L. Pulmonary and extrapulmonary coccidioidomycosis, active component, U.S. Armed Forces, 1999-2011. MSMR. 2012 Dec. 19(12):2-4. [Medline].\nSmith JA, Riddell J 4th, Kauffman CA. Cutaneous Manifestations of Endemic Mycoses. Curr Infect Dis Rep. 2013 Aug 6. [Medline].\nNicas M. A point-source outbreak of Coccidioidomycosis among a highway construction crew. J Occup Environ Hyg. 2018 Jan. 15 (1):57-62. [Medline].\nBenedict K, Park BJ. Invasive fungal infections after natural disasters. Emerg Infect Dis. 2014 Mar. 20(3):349-55. [Medline]. [Full Text].\nMedoza N, Noel P, Blair JE. Diagnosis, treatment, and outcomes of coccidioidomycosis in allogeneic stem cell transplantation. Transpl Infect Dis. 2015 Feb 14. [Medline].\nJehangir W, Tadepalli GS, Sen S, Regevik N, Sen P. Coccidioidomycosis and Blastomycosis: Endemic Mycotic Co-Infections in the HIV Patient. J Clin Med Res. 2015 Mar. 7(3):196-8. [Medline]. [Full Text].\nWheeler C, Lucas KD, Mohle-Boetani JC. Rates and risk factors for Coccidioidomycosis among prison inmates, California, USA, 2011. Emerg Infect Dis. 2015 Jan. 21(1):70-5. [Medline]. [Full Text].\nGarza-Chapa JI, Martínez-Cabriales SA, Ocampo-Garza J, Gómez-Flores M, Ocampo-Candiani J, Welsh O. Cold subcutaneous abscesses as the first manifestation of disseminated coccidioidomycosis in an immunocompromised host. Australas J Dermatol. 2016 May. 57 (2):e49-52. [Medline].\nSingh G, Patel T, Hu S. Disseminated cutaneous coccidioidomycosis in a liver transplant patient. JAAD Case Rep. 2015 Jul. 1 (4):225-6. [Medline].\nBuot G, Bachmeyer C, Haettich-Pialoux B, Bélangé G, Thiébaut JB, Dupont B, et al. [Coccidioidomycosis revealed by specific cutaneous lesions occurring after placement of a ventricular cardiac shunt for chronic meningitis]. Presse Med. 2008 Jun. 37(6 Pt 1):970-4. [Medline].\nCarpenter JB, Feldman JS, Leyva WH, DiCaudo DJ. Clinical and pathologic characteristics of disseminated cutaneous coccidioidomycosis. J Am Acad Dermatol. 2010 May. 62(5):831-7. [Medline].\nFoerter J, Sundell J, Vroman P. PET/CT: First-Line Exam To Assess Disease Extent of Disseminated Coccidioidomycosis. J Nucl Med Technol. 2016 Apr 21. [Medline].\nBrewer AC, Huber JT, Girardo ME, Kosiorek HE, Burns MW, Stewart TD, et al. Cutaneous effects associated with fluconazole in patients treated for coccidioidomycosis. Int J Dermatol. 2019 Feb. 58 (2):250-253. [Medline].\nRobert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Professor of Pediatrics, Professor of Medicine, Rutgers New Jersey Medical School\nRobert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, New York Academy of Medicine, Royal College of Physicians of Edinburgh, Sigma Xi\nLinas Riauba, MD Assistant Professor of Clinical Medicine, Department of Medicine, Section of Infectious Disease, University Hospital, University of Medicine and Dentistry of New Jersey, New Jersey Medical School\nLinas Riauba, MD is a member of the following medical societies: American Medical Association, Infectious Diseases Society of America\nDavid F Butler, MD Former Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic\nDavid F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Society for MOHS Surgery, Association of Military Dermatologists, Phi Beta Kappa\nVan Perry, MD Assistant Professor, Department of Medicine, Division of Dermatology, University of Texas School of Medicine at San Antonio\nVan Perry, MD is a member of the following medical societies: American Academy of Dermatology\nDirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine\nDirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology\nJanet Fairley, MD Professor and Head, Department of Dermatology, University of Iowa, Roy J and Lucille A Carver College of Medicine\nJanet Fairley, MD is a member of the following medical societies: American Academy of Dermatology, American Federation for Medical Research, Society for Investigative Dermatology\nencoded search term (Dermatologic Manifestations of Coccidioidomycosis) and Dermatologic Manifestations of Coccidioidomycosis\nFungal Infections in Preterm Infants\nNoncandidal Fungal Infections of the Mouth\nManagement of Oral Infection\nManagement of Erythematous Oral Lesions\nCutaneous Manifestations of HIV\nPathology of Pulmonary Infectious Granulomas\nSGLT2 Inhibitors for Diabetes Safe, Effective in Older Adults\nFungal Alterations in Inflammatory Bowel Diseases\nChoosing Wisely: 5 Recommendations on Testing to Avoid in Pediatric Hematology\nHair Disorders: Finding the Root of the Problem\nAccording to Infectious Disease Physicians\nFlu Rates Rising, Pediatric Deaths Double Compared to 2018: CDC\nFlu Can Be Catastrophic in Older Patients: 5 Things to Know\nAlice in Wonderland Syndrome: What Can It Reveal?\nFecal Transplant Transmits Fatal Drug-Resistant E coli Infection\nTwo Drugs Better Than One for Severe Influenza\nDiseases & Conditions Noncandidal Fungal Infections of the Mouth\nDiseases & Conditions Fungal Infections in Preterm Infants\n2010 ambisome-amphotericin-b-liposomal-999576 Drugs\nDrugs amphotericin B liposomal\n2010 abelcet-amphoterin-b-phospholipid-complex-999575 Drugs\nDrugs amphotericin B phospholipid complex"