, 19 tweets, 16 min read
My Authors
Read all threads
Growing up in Tucson and going to med school @UAZMedTucson, I thought I knew a lot about #coccidioidomycosis. Definitely not!

Here we discuss history, epidemiology, ecology, some cool facts about #Cocci, and reasons why #fluconazole may not be the best drug for Cocci.
In 1892 in Argentina, Alejandro Posadas wrote the first report of a pt w/ disseminated cutaneous cocci

Shortly after, a laborer in San Joaquin valley also had skin lesions

Skin biopsies of both pts revealed protozoa-like orgs, similar to Coccidia

Here are images of the first patient diagnosed with #Cocci, Domingo Escurra, by Alejandro Posadas


Gilchrist, Rixford & Stiles named the org after its morphologic & clinical features:
🍄Coccidioides (“resembling Coccidia”) immitis (“not mild”)

It is interesting that all 3 US dimorphics (Histo, Blasto, Cocci) were initially mistaken as protozoa

Charles Smith had amazing observations about Cocci:
1⃣Incubation period 1-3 weeks
2⃣People rarely got re-infected
3⃣No transmission from person-person
4⃣Occurred in summer and fall- other months were more wet & farmers didn't work in winter & spring

The genus consists of 2 species: immitis and posadasii

Natural reservoir of #Cocci is in soil of SW US, Mexico, Central, and South America

In the US, most cases are found in AZ and CA

Animal reservoir has not been identified


Why do we see more cases in drier seasons?

When there is moisture, cocci grows as mold with hyphae

When the soil dries, cells➡️arthroconidia, break off & release

If the early Summer is filled with rains➡️lower incidence of Cocci in later summer

We know that fungus don't like to grow in really hot temperatures, how come Cocci is endemic in SW US?

1⃣theory: Soil is sterilized by high temps, but Cocci survives by growing deep into soil. Then, when it rains, Cocci can grow back to soil surface

Here comes the inevitable...

Over the years, temperature will increase, precipitation patterns will change

By 2100-
🌎Cocci endemic area will double
🍁17 states will be affected
🌲# of cases will increase by 50%

60% of patients are asymptomatic

Most recover without dissemination or sequelae

Those that do can develop CNS, skin, MSK, and other complications

Did you know...

In endemic areas, 20-30% of CAP can be secondary to Cocci...that's wild!!

What do we do about primary pulmonary cocci?

2016 @IDSAInfo guidelines recommend therapy for:
- dissemination
- debilitating illness
- frail 2/2 age or comorbidities
- immunosuppressed
- African/Filipino decent
- extensive pulmonary involvement

Similar to #crypto, should we do LPs on pts with newly diagnosed Cocci?

2016 @IDSAInfo guidelines- do LP in patients w/:
🍏unusual, worsening, or persistent HA
🍐unexplained N/V
🍊new focal neuro deficit after CNS imaging

#Fluc is recommended in guidelines

But is it the best drug?

There is1⃣comparative trial- Fluc vs Itra
#Itra was better for bone/joint disease, and may have been better overall!


It is interesting that IDSA first line for #Histo & #Blasto is ITRA.
Just wait for it...

A 2017 in-vitro study noted increased fluconazole MIC for 37% of isolates, raising concerns for therapy in serious infections!


A retrospective review of 35 patients who initially received fluconazole, looked at treatment of refractory cases with #Vori and #Posa

🎻21 changed to #Vori -> 67% improved

🪕 16 changed to #Posa -> 75% improved

Here is a nice table of the available antifungals with the benefits, weaknesses, and adverse effects

There are novel therapies coming (just to name a few):
#nikkomycin Z
#rezafungin (@DxRxEdu)

🌛60% asympt, others have CAP
🌜95% recover w/o sequelae
⭐️Infxn results in lifelong immunity
🌟⬆️Temp & change in precipitation will expand endemic regions
💫Fluconazole may not be the best
✨Other triazoles may be better
☄️We need prospective & randomized studies!
Missing some Tweet in this thread? You can try to force a refresh.

Enjoying this thread?

Keep Current with Saman Nematollahi

Profile picture

Stay in touch and get notified when new unrolls are available from this author!

Read all threads

This Thread may be Removed Anytime!

Twitter may remove this content at anytime, convert it as a PDF, save and print for later use!

Try unrolling a thread yourself!

how to unroll video

1) Follow Thread Reader App on Twitter so you can easily mention us!

2) Go to a Twitter thread (series of Tweets by the same owner) and mention us with a keyword "unroll" @threadreaderapp unroll

You can practice here first or read more on our help page!

Follow Us on Twitter!

Did Thread Reader help you today?

Support us! We are indie developers!

This site is made by just three indie developers on a laptop doing marketing, support and development! Read more about the story.

Become a Premium Member ($3.00/month or $30.00/year) and get exclusive features!

Become Premium

Too expensive? Make a small donation by buying us coffee ($5) or help with server cost ($10)

Donate via Paypal Become our Patreon

Thank you for your support!