The Infectious Diseases Society of America has updated its clinical practice guidelines for the diagnosis and management of coccidioidomycosis, otherwise known as San Joaquin Valley fever.
The new recommendations update prior IDSA guidance published in 2005, and include treatment suggestions for pregnant women, immunosuppressed patients and those who may otherwise be at increased risk of severe coccidioidal illness. In addition, the new guidance includes advice for primary care providers who could mistake the fungal infection for another form of pneumonia.
“Valley fever is underdiagnosed in part because past guidelines were directed to the specialists, whereas most of these patients initially see their primary care physicians, many of whom aren’t aware just how common this infection is,” John N. Galgiani, MD, professor at the University of Arizona College of Medicine and director of the Valley Fever Center for Excellence, Tucson, said in a press release. “About a third of cases of pneumonia in Arizona are caused by valley fever. Doctors need to ask patients with pneumonia about their travel history and if they’ve recently traveled to endemic areas, and need to consider valley fever.
John N. Galgiani
A multidisciplinary panel of 16 experts reviewed the available literature on coccidioidomycosis. They weighted these data — which they noted were often limited to uncontrolled observations — using the previously established GRADE system of evaluation, and submitted the final recommendations to the International Society for Heart and Lung Transplantation, IDSA’s Standards and Practice Guidelines Committee and its Board of Directors for review and approval.
Major features of the guidance include a summary of coccidioidal infection’s various presentations, as well as a rundown of strategies to diagnose the fungal infection. Many patients who are not at risk of severe infection may not require medication and should only be monitored over the course of 2 years; however, antifungal therapies may be required for more severe cases and could be required for the remainder of the patient’s life.
The new guidance also details various treatment and pretreatment recommendations for at-risk populations, such as those with HIV or other immunocompromising conditions. Of note, pregnant women in their second or third trimester should now be treated with fluconazole as opposed to amphotericin B, which requires tri-weekly IV administration and is toxic to the mother.
“It’s an equal opportunity bug, and everyone who is exposed has the same chance of getting infected,” Galgiani said. “These patients feel horrible, they can’t get out of bed or go to work, and often they are sick for weeks or months. Many worry they have cancer or another disease, so getting correctly diagnosed puts a name to the illness and dispels that fear.” – by Dave Muoio
Disclosure: Galgiani reports receipt of research grants from Valley Fever Solutions. Please see the full guidance for a complete list of relevant financial disclosures.