“The Fungus Among Us”
Hello Kern River Valley! It is I, Alex Ledesma your friendly neighborhood nurse at KVHD. I wanted to share some information with you regarding an important health issue that we see here in our beloved valley. I was able to find a great resource of information on the University of Arizona’s website: College of Medicine Tucson Valley Fever Center for Excellence. I found their frequently asked question area extremely helpful. If you would like to get more information please visit their website at https://vfce.arizona.edu/valley-fever-people/faqs. I hope you find the following information helpful.
What is Valley Fever?
Valley Fever (medical name coccidioidomycosis or “cocci” for short) is an infection in the lungs caused by the fungus coccidioides spp., which grows in soils in areas of low rainfall, high summer temperatures and moderate winter temperatures, such as: throughout Arizona, the San Joaquin and Central Valleys of California, southern parts of Nevada, New Mexico and western Texas, east-central Utah, south-eastern Washington, and the semiarid and arid soils of Central and South America.
How does one become infected with Valley Fever?
Valley Fever is acquired by inhaling one or more airborne spores of the fungus coccidioides spp. The spores are carried in dust particles from the soil by the wind when the desert soil is disturbed.
What are spherules?
Spherules are the form that the fungus takes in tissue. In nature, the fungus grows in soil and appears in the mycelial form similar to bread mold. Portions of the hair-like mycelia break off into arthroconidia (“spores”) and become airborne when the soil is disturbed. The arthroconidia are extremely small and light and may be carried many miles by the wind. Fifteen trillion of the arthroconidia would fit into a cubic inch. There has been documentation of a severe dust storm occurring in Bakersfield, California, an endemic area, blowing as far north as San Francisco where it is not normally found, and causing an epidemic in the Bay area.
Does Asthma/COPD increase the chances of contacting Valley Fever?
No. The risk of contracting Valley Fever is no greater for a person with Asthma/Chronic Obstructive Pulmonary Disease than anyone else. You must inhale the spores from the fungus in order to become ill.
Is Valley Fever contagious?
NO! Valley Fever is contracted only by the inhalation of the fungal spores. Valley Fever is NOT spread from human to human, or animal to animal, or animal to human or human to animal. The spores change form in tissues of the body and are not contagious in tissue form.
Is Valley Fever contagious from an open lesion?
No. The tissue phase of the fungus coccidioides spp. is a spherule. The infectious phase is when the “spores” are inhaled from the air.
How do I prevent getting Valley Fever?
There is no prevention or vaccine at this time. Avoiding activities associated with dust and airborne dirt of native desert soil is recommended, but it is not a certain means of prevention, as the dust may or may not contain coccidioides spores. Some occupations recommend wearing masks. Use common sense and stay out of the blowing dust.
Who gets Valley Fever?
Anyone who lives, visits, or travels through the areas where the fungus grows in the soil (these areas are called endemic) may acquire Valley Fever. People working in certain occupations such as construction, excavation, agricultural work, archaeological digging, or pursuing activities like biking or driving ATVs which disturb soil in endemic areas, may have an increased risk of exposure and disease. Earthquakes that have occurred in endemic areas of California have also resulted in increased cases of Valley Fever. Various domestic animals such as dogs, cats, and horses as well as wild animals are also susceptible.
Is there a seasonal variation in the spread of Valley Fever?
Yes. Although blowing dust may carry the infectious spores of cocci anytime throughout the year, there are times which we call peak seasons for cocci. These vary with the seasons of the year and appear to be related to the amount of rainfall. In Arizona, the peak seasons occur from June through August and from October through November. In California, the summer months of June through August have the most cases reported.
What is the incubation period for Valley Fever?
Symptoms usually develop within 7-28 days after exposure.
What are the symptoms of Valley Fever?
Most people (60%) have no symptoms or only very mild flu-like symptoms and do not see a doctor. When symptoms are present, the most common are fatigue, cough, fever, profuse sweating at night, loss of appetite, chest pain, generalized muscle and joint aches particularly of the ankles and knees. There may also be a rash that resembles measles or hives but develops more often as tender red bumps on the shins or forearms.
What is Valley Fever Skin rash like?
Valley Fever can cause rashes that look several different ways. A common presentation is as painful or tender, slightly elevated red nodules or bumps, which may change color to bluish to brown and often occur on the legs, but may occur on the chest, arms and back. Another common form of rash is a red raised rash which may have blisters or somewhat pointed pimple-like bumps. It’s important to note that other diseases may also cause rashes that look the same. The names of the rashes are Erythema Nodosum (the most common) and Erythema Multiform.
What are lung nodules and do they go away?
Lung nodules are the result of pneumonia caused by Valley Fever. Nodules are small residual patches of infection that generally appear as single lesions, typically one to one and one-half inches in diameter. Patients who have no symptoms as well as patients who do have symptoms may develop nodules. Approximately 5-7% of patients with cocci pneumonia will form sharply circumscribed singular nodules. If it is documented that the nodule is caused by Valley Fever, no other treatment is required. However, because the nodule may appear to be cancer, a biopsy or removal may be necessary. Nodules caused by cocci may remain a life-time.
The doctor says I have a cavity. Do I need surgery?
Cavities occur in about 5% of patients with pulmonary cocci. The typical cocci cavity is thin-walled and solitary. Coccidioidal cavities are commonly asymptomatic (do not cause symptoms) and about 50% will disappear within 2 years of their occurrence. A cavity may persist for years with minor changes. About one-third of the patients with cavities may experience hemoptysis (coughing blood). The hemoptysis is often recurrent but generally not life-threatening. If rupture of the cavity is a large possibility, surgical removal may be necessary.
How long will I be sick?
The length of illness depends on the severity of the infection. Most cases have no symptoms, others may take months to even more than a year to resolve. Persons frequently complain of fatigue and joint aches lasting months. The chronic forms of Valley Fever may last years, with a waxing and waning course.
Is there a cure for Valley Fever?
No. Researchers within our center and in the U.S. are working on the development of a prophylactic vaccine. We are also in the early phases of testing a drug that shows promise of a cure in the future.
What is the chronic form of Valley Fever?
Patients with this manifestation present with chronic systemic symptoms such as low grade Fever, weight loss, cough, chest pain and coughing blood. These symptoms are often slowly progressive and resemble tuberculosis when coupled with x-ray findings.
How is Valley Fever diagnosed?
Diagnosis is obtained by use of a specific blood test (called a coccidioidal or cocci serology) which measures the level or titer of antibodies to the fungus. A positive titer is usually measured or reported in dilutions of the patient’s serum that continue to react to the fungal antigen. Titers are reported as 1:2, 1:4, etc. In early disease, the cocci serology must be repeated in 2-4 weeks if negative because the antibody level is too low to be detected. Culture of sputum, tissue, biopsies, or body fluids or histopathologic (microscopic) evidence from the same sources are diagnostic. The doctor also uses the x-ray as a means of following the progress of the disease.
Can Valley Fever be misdiagnosed?
Yes. Depending upon the symptoms, it may be confused with cancer, tuberculosis, chronic obstructive pulmonary disease, chronic fatigue syndrome and others. However, if the specific blood test to measure antibodies against the fungus is performed along with chest x-rays, travel history through the Southwest, and when appropriate skin test results are performed and considered, a diagnosis is made. The isolation in laboratory culture of the causative fungus from sputum, tissue or body fluids is diagnostic as is the presence of the diagnostic spherules as seen in histopathology.
What kinds of doctors know most about Valley Fever?
Infectious Disease specialists can treat patients with a diagnosed case of Valley Fever. In endemic areas, Pulmonary specialists and most primary care and family practitioners should be versed in the diagnosis and treatment of this disease. However, physicians in other parts of the country treat patients with Valley Fever much less frequently and, therefore, may not consider it as a diagnosis. Be sure to tell your physician that you have been in the endemic area and request to be tested for Valley Fever.
Which antifungal medications are used to treat Valley Fever?
The “azole” family of antifungal drugs are frequently used. These are oral preparations of ketoconazole, itraconazole and fluconazole. Each have various side-effects and may be expensive. The azoles do not kill the fungus but they control it. Amphotericin B is an antifungal medication that is used in serious and fulminant infections. It may be administered intravenously or intrathecally (injecting the medication directly into the fluid surrounding the brain).
Will antibiotics help a Valley Fever infection?
No. Coccidioidal pneumonia is not treated with routine antibiotics (such as penicillin, cephalosporin, and erythromycin) because it is caused by a fungus and “regular” pneumonia is caused by bacteria. There are antifungal medications that may be used to treat Valley Fever.
What are the side effects of the medications used to treat Valley Fever?
The most common side effects of ketoconazole are nausea and vomiting, gynecomastia (enlargement of male breasts) and decreased libido. The most common side effects of itraconazole and fluconazole are nausea, headache, skin rash, vomiting, abdominal pain and diarrhea. Side effects resulting from treatment with the azoles usually resolve with the discontinuation of the drug. Amphotericin B may have several side effects, most of which may occur during administration and then pass. Newer forms of Amphotericin B have been developed to ease symptoms during administration. Amphotericin B may affect the kidneys and requires close monitoring. Additional side effects with all antifungal medications may occur. Consult with your doctor, pharmacist and/or package insert for further details.
What is the length of treatment for Valley Fever?
The length of treatment depends on the severity of symptoms and disease and complications of the disease. Some patients take antifungal medication for a few months; others need life time therapy.
Why won’t my doctor prescribe any medication when I feel really sick?
Before the availability of antifungal medications, at least 95% of patients with pulmonary Valley Fever got better without any treatment. Studies have not been completed yet to determine if drug therapy hastens the resolution of immediate symptoms or prevents subsequent complications. The physician usually monitors the progress of the patient by chest x-rays, following the cocci serology (blood test) titer and the severity and duration of symptoms. This may require frequent visits to the doctor. If weight loss and night sweats continue, infiltrates in the lungs enlarge, and the inability to work persists, antifungal medication usually is considered.
What does dissemination mean?
Dissemination is the spread of the fungal infection from the lungs to other parts of the body. The most common sites of dissemination in Valley Fever are skin, bones, joints and brain meninges. Cocci meningitis is the most lethal.
Who is at risk of dissemination?
While there are no racial or gender differences in susceptibility or who contracts the primary infection, there are differences in risk of dissemination. Men have a higher rate of dissemination than women. African Americans and Filipinos have several times higher rate of dissemination. Others at increased risk of disseminated disease are those with immune system deficiencies such as organ transplants, Hodgkin’s disease patients, pregnant women in their third trimester, patients on chronic corticosteroid therapy or chemotherapy, cancer patients and HIV/AIDS patients.
What does immunocompromised mean? How does this affect a Valley Fever infection?
A person is immunocompromised when his or her immune system (the body’s defense against disease) is not intact. This may be the result of diabetes, chronic use of corticosteroids, cancer, chemotherapy, HIV/AIDS, organ transplantation, pregnancy or even aging. Usually the body is able to fight the fungus and recover without medication. If the immune system is compromised, it is unable to control the infection and allows the infection to spread from the lungs to other organs. The spread of infection from the lungs to other parts of the body is called dissemination.
For patients who are immunocompromised (have AIDS, Diabetes, Chronic Renal Disease, Cancer, etc.) is it safe to travel to an endemic area?
The risk is probably no greater than for anyone else. However, the longer you remain in an endemic area, the greater the chance of exposure: In Arizona, it is estimated that the average risk of annual infection of the resident population is 3%. That means each year only 3% of the susceptible population will contract Valley Fever. If you are particularly concerned about getting Valley Fever, try to avoid activities associated with dust and airborne dirt of native desert soil. Stay indoors during dust storms.
Are pregnant women more at risk of getting disseminated Valley Fever?
Women in their third trimester of pregnancy are at a high risk of developing disseminated Valley Fever due to normal hormonal changes that cause a decrease in function of the immune system. However, most pregnant women with Valley Fever do fine. If you are pregnant and think you have Valley Fever, you should visit your physician.
When a baby is born to a pregnant woman infected with Valley Fever, will the baby have it?
Valley Fever is rare in newborn babies. Most babies who get Valley Fever probably acquire it during or shortly after birth, through inhaling fungal spores from the environment.
Does the fungus lay dormant in the body?
In many cases the fungus does remain in the body. If the person’s immune system is greatly immunocompromised, a reactivation of the disease may occur. This has been found to occur in many patients with AIDS and disseminated Valley Fever.
I had Valley Fever in the past. Can I get it again?
Usually a life-time immunity is acquired from an infection which means you don’t get it again. However, occasionally, changes in the person’s immune system brought about by other diseases or treatments which lower or suppress the immune system can allow a reactivation or re-infection. (The University of Arizona Health Sciences)
Again, I hope this article finds you all in good health. If you have any further questions, please contact you primary care provider. If you have a life threatening emergency, call 911 and see us here at your KVHD ER.
Alex Ledesma RN