Pulmonary coccidioidomycosis, also known colloquially as valley fever, refers to lung involvement of the dimorphic fungus Coccidioides spp., mainly Coccidioides immitis and Coccidioides posadasi.
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Epidemiology
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.
Clinical features
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 hematogenously to bones, joints, and the central nervous system (see CNS coccidioidomycosis) 2.
Pathology
The overall pathology of coccidioidomycosis is discussed elsewhere (see coccidioidomycosis and Figure 1).
Radiographic features
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.
Complications
residual pulmonary nodules or coccidioidomycomas 3
chronic coccidioidal cavities, which can themselves also complicate with mycetoma, abscess formation, or bronchopleural fistula 3
persistent coccidioidal pneumonia, which itself may progress to chronic fibrocavitary pneumonia 3
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