Pediatric Coccidioidomycosis in CA: Delayed Diagnosis Increases Severity
ABSTRACT & COMMENTARY
By Dean L. Winslow, MD, FACP, FIDS, Chairman, Department of Medicine, Santa Clara Valley, Medical Center; Clinical Professor, Stanford University School of Medicine, Associate Editor of Infectious Disease Alert. Dr. Winslow is a consultant for Siemens Diagnostic.
Sources: McCarthy JM, et al. Pediatric coccidioidomycosis in central California: A retrospective case series. Clin Infect Dis 2013; 56: 1579-85.
A retrospective observational study of all children admitted to Children's Hospital of Central California (Madera, CA) with coccidioidomycosis (coccy) from January 2010 to September 2011 was conducted. Thirty-three children were hospitalized with coccy during this period and ranged in age from 6 months to 17 years. Clinical manifestations included pneumonia (n=28), pleural effusion (n=13), empyema (N=4), lung abscess (n=7), pericarditis (n=2), osteomyelitis (n=5), meningitis/cerebritis (n=2), and vocal cord infection (n=1). Mediastinitis with evidence of purulent/necrotic/abscessed nodes in the mediastinum was present in 7 (21%) and tended to occur in younger children (median age 3 years). Seven patients were admitted to the ICU, 10 required surgical intervention, and one patient died of meningitis. Children with mediastinitis required longer hospitalization (median 130 days) vs. median 43 days for children without mediastinitis. Patients with coccy CF titers ≥1:128 required longer hospitalization than those with titers #lt;1:128 (median 130 days vs. 43 days). Overall, 64% of children were Hispanic, 21% were non-Hispanic Caucasian, 9% were Asian, and 6% were African-American.
All patients were treated initially with intravenous liposomal amphotericin B or fluconazole with amphotericin preferentially used in those patients with more severe disease. Overall, 76% of patients responded to initial therapy. Eight patients (47%) failed to respond to initial amphotericin B therapy and had progressive disease. Various salvage therapy regimens were used, including liposomal amphotericin B+an azole in most cases, voriconazole+caspofungin in 2 patients, interferon gamma in 3 patients, and intrathecal amphoterician B in one patient. All patients except the one patient who died of meningitis were eventually discharged home on an oral azole.
This is an important retrospective study which highlights a number of interesting issues for diagnosis and management of coccy in children. Despite the prevalence of coccy throughout much of California, delayed diagnosis of coccy was common in these children and likely contributed to the severity of disease and prolonged hospitalizations observed in many of these patients. None of these children were known to be immunocompromised. The common presentation of mediastinitis with necrotic mediastinal lymph nodes (occasionally resulting in airway compression) was also of note.
Practicing the past 15 years in California has given me a real appreciation for the diverse clinical manifestations of patients with coccy, the problems associated with treatment, and management of complications associated with this disease. I am grateful every day for the wise counsel and expertise of my colleagues at our County hospital (especially David Stevens and Larry Mirels) in managing these patients and I would encourage all of us who care for coccy patients to make liberal use of the advice from experts like these. I am still haunted by the death of a 6-year-old child I cared for about 3 years ago on the Pediatric service at our hospital. This little boy died of complications of coccy meningitis (which included hydrocephalus requiring shunt placement and cerebral vasculitis requiring systemic corticosteroid therapy) despite aggressive treatment with intravenous liposomal amphotericin B, fluconazole, and intrathecal amphotericin B.
Optimal therapy of coccy is still vigorously debated. In this same issue of CID there was another interesting case series describing 9 pediatric patients with refractory coccy who responded to combination therapy with voriconazole and caspofungin.1 Clearly much work, including large multicenter randomized controlled trials, need to be done to develop more effective therapy of severe coccidioidomycosis in both adults and children.
1. Levy ER, et al. Treatment of pediatric refractory coccidioidomycosis with combination voriconazole and caspofungin: a retrospective case series. Clin Infect Dis 2013; 56: 1573-8.