New perspectives on coccidioidomycosis

Coccidioidomycosis is a growing problem in the endemic regions of Arizona and California. The reasons for its increase are unclear, but may relate to an influx of nonsusceptible individuals into the endemic regions, construction and dust, and climate. Most cases of coccidioidal infection are completely asymptomatic, but approximately 40% present as a pulmonary process that may be difficult to distinguish from a bacterial community-acquired pneumonia. This has led to underdiagnosis of coccidioidomycosis and inappropriate antibacterial therapy. Serology has been the mainstay of diagnosis, but its sensitivity has not been established. A commercial enzyme immunoassay appears more sensitive than the traditional tube precipitin and complement fixation tests and the immunodiffusion assays, but concern about specificity lingers. Newer tests, including detection of coccidioidal antigenuria and genomic assays, offer promise of greater sensitivity, specificity, and rapidity. The treatment of coccidioidomycosis has most recently depended on oral triazole therapy. However, a recent study suggests that, at least for those with primary pulmonary disease, antifungal therapy may lead to subsequent complications once this therapy is discontinued compared with those who receive no therapy at all.