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Coccidioidomycosis in Infants

March 24 2016

Due to its rarity in infants, the diagnosis and treatment of Coccidioidomycosis is based largely on data on adults and older children. A retrospective study (Lee et al) of patients under 12 months old with Coccidioidomycosis, admitted to a Children’s Hospital in Madera, California investigated the epidemiology, clinical manifestations, treatment and outcomes of infants hospitalised with this illness. Coccidioidomycosis is highly infectious and endemic to southwestern states of America including Arizona and the Central Valley of California. It is acquired from the inhalation of the fungal arthospores in soil. The inhaled spores provoke an acute inflammatory response and the development of granulomas. Typical symptoms include fever, diaphoresis, anorexia, malaise, arthralgia, cough, sputum production and chest pain, though 60 % of individuals affected are asymptomatic (see here for more details).

Diagnosing Coccidioidomycosis in infants is difficult, due in part to their immature immune system.  In this study diagnosis was confirmed by serology, culture or histopathology. In adults and older children, the serum coccidioidal complement fixation test (CF) may show persistently high titres in severe and disseminated disease. However, infants may have a negative titre, potentially leading to misdiagnosis (2/13 patients were seronegative) Signs and symptoms may be indistinguishable from bacterial or viral illnesses, and this, in combination with negative titres may lead to extensive pulmonary and disseminated disease (5/13 infants). The most common presenting symptoms in infants were cough, fever and dyspnea. Treatment recommendations for Coccidioidomycosis are varied and it is debatable whether treatment in an uncomplicated primary infection can reduce illness duration and the risk of complication. Fluconazole or itraconazole is recommended in 3-6 month olds with severe primary infection. Amphotericin B is recommended as an alternative if lesions are progressing or are in critical locations (2012 report). In this study, all patients received antifungal therapy, with fluconazole as the initial agent and Amphotericin B for patients who presented with significant lung disease or disseminated infection.  Voriconazole and caspofungin were used in combination if patients responded poorly to fluconazole or Amphotericin B, despite limited literature on this treatment option.

The average length of treatment in this cohort was 4 years, much longer than the recommended length of treatment (6 months to 1 year). This suggests a greater severity of disease amongst young infants.

The study highlights the need to monitor Coccidioidomycosis in infants, especially in endemic areas, and Coccidioidomycosis should be considered as a differential diagnosis in infants particularly for those infants with persistent pulmonary symptoms who are not responding to conventional treatment.

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