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Table of Contents:
Taxonomy Information
  1. Species:
    1. Coccidioides immitis (Website 1):
      1. Common Name: Coccidioides immitis
      2. GenBank Taxonomy No.: 5501
      3. Description: Coccidioidomycosis was originally described by Alehandro Posadas (and later confirmed by Robert Wernicke) from a soldier, Domingo Ezcurra, who acquired this infection in the Argentine pampas (1892). Posadas and Wernicke recognized the presence of an organism, likened to a protozoan of the order Coccidia. Formal description of C. immitis was performed by Rixford and Gilchrist from a case observed in California (1896). However, the parasite was then still thought to be a protozoan. The correct taxonomic status of C. immitis as an ascomycete fungus was demonstrated by Ophuls and Moffit (1900) by culture on artificial of the fungal mycelia using arthrospores isolated from laboratory infections of guinea pigs. The etiological relationship between C. immitis and coccidioidomycosis was also demonstrated by showing that arthroconidia cause infection in several types of laboratory animal. The lack of any known meiosporic state in vitro or in vivo hampered further classification until work by Sigler and Carmichael (1976) recognized the similarity between the asexual spores (arthroconidia) of C. immitis and those (aleurioconidia) found in the mitosporic genus Malbranchea Sacc., placing C. immitis in the order Onygenaceae. This relationship was confirmed by molecular phylogenetic methods (1996), and Uncinocarpus reesii Sigler and Orr was shown to be the sister group to C. immitis(Fisher et al., 2002).
      4. Variant(s):
Lifecycle Information
    1. Stage Information:
      1. Mold(Kirkland and Fierer, 1996):
        • Shape: Colony Morphology: At first, it is moist, glabrous, and grayish, but the colony rapidly develops abundant, floccose, aerial mycelium that soon covers the slant. The mycelium is initially white, but usually becomes tan to brown with age.
        • Description: Conidiation begins within a few days after the initiation of growth. The conidia usually appear first on side branches of the vegetative hyphae. The hyphae themselves are thin and septate, but the side branches are almost twice as thick and have numerous septations(Rippon, 1988).
      2. Arthroconidia(Kirkland and Fierer, 1996):
        • Size: 2.5 to 4um by 3 to 6um
        • Shape: Barrel shaped
        • Description: Thick-walled arthroconidia are then produced, alternating with thin-walled empty cells (disjunctors). The arthroconidia are barrel-shaped 2.5 to 4um by 3 to 6um in size, and are released by fragmentation of the mycelium. They retain portions of the walls of the disjunctor cells as ornaments on the walls of either end. This characteristic is often helpful in distinguishing the species. As the culture ages, the vegetative hyphae also fragment into arthronconidia. No other type of conidia formation is seen in culture of this fungus(Rippon, 1988).
      3. Spherule(Kirkland and Fierer, 1996):
        • Size: 30 to 60um in diameter
        • Shape: Round
        • Description: They become more rounded as they transform into spherules. At maturity, these are 30 to 60 um in diameter. The wall is thick (to 2um) and quite prominent. The cytoplasm is eosinophilic and contains many nuclei. As the spherules near maturity, endospore production begins by a process called ?progressive cleavage.?(Rippon, 1988).
      4. Endospore(Kirkland and Fierer, 1996):
        • Size: 2 to 5um in diameter
        • Shape: Round
        • Description: Secondary cleavage lines are formed, which divide the contents of the spherule into uninucleate endospores that are 2 to 5um in diameter. At maturation, the spherule wall breaks and the endospores are released(Rippon, 1988).
    2. Progression Information:
      1. Arthroconidia release:
        • From Stage: Mold
        • To Stage: Arthroconidia
        • Description: As the mycelial strands mature, barrel-shaped arthroconidia form, which disarticulate, become airborne, and are returned to the soil or inhaled(Stevens, 1995).
      2. Spherule formation:
        • From Stage: Arthroconidia
        • To Stage: Spherule
        • Description: Following inhalation, the arthroconidium develops into a spherule, within a few hours or days(Rippon, 1988).
      3. Endosporulation:
        • From Stage: Spherule
        • To Stage: Endospore
        • Description: As the spherules near maturity, endospore production begins by a process called ?progressive cleavage.? Furrows form and divide the protoplasm into multinucleate masses called ?protospores.? Often there is a central vacuole in the spherule. Secondary cleavage lines are formed, which divide the contents of the spherule into uninucleate endospores that are 2 to 5um in diameter. At maturation, the spherule wall breaks and the endospores are released. The surviving spores gradually evolve into spherules, and the process is repeated(Rippon, 1988).
    3. Picture(s):
    4. Description: Coccidioidomycosis is caused by Coccidioides immitis, a dimorphic fungus that grows as a mold in the soil. The mold forms arthroconidia within the hypha, a type of conidia formation known as enteroarthric development. C. immitis is the only species within the primary pathogenic fungi that has this type of conidia development. Alternate conidia undergo autolysis, leaving empty spaces between viable arthroconidia. The arthroconidia are released into the atmosphere when the wind ruptures the hypha. C. immitis infects humans and animals almost exclusively by the respiratory route. Once inhaled, the arthroconidia cluster in the lungs and undergo a dramatic morphologic change. The round cells, which develop into spherules, undergo repeated internal divisions until they are filled with hundreds to thousands of offspring, termed endospores. This process occurs over 48 to 72 hours. When the spherule ruptures, each released endospore has the capacity to develop into a mature spherule(Kirkland and Fierer, 1996). We conclude that biparental sex is a regular part of the C. immitis life cycle, at least in our study population. This study is, to our knowledge, the first to find molecular evidence for recombination in a fungus for which no sexual stage has yet been described. These results motivate a directed search for mating and meiosis, as the ability to cross isolates would greatly facilitate genetic studies of this human pathogen(Burt et al., 1996).
Genome Summary
  1. Genome of Coccidioides immitis RS(Coccidioides Sequencing Project Website)
    1. Description: The Coccidioides immitis sequence project is part of the Broad Institute's Fungal Genome Initiative. Its goal is to release a 10X genome sequence coverage for Coccidioides immitis, strain RS. Genomic DNA for C. immitis was contributed by Theo Kirkland and Suganya Viriyakosol at University of California San Diego, School of Medicine, Department of Pathology. Broad Institute produced whole genome shotgun sequence from 4kb and 10kb plasmids and 40kb Fosmids. The resulting 10X assembly was made public April 2004. Data releases: July 2004 - Release 1 consists of a 10X whole-genome shotgun assembly generated at the Broad Institute, available for download and BLAST searches. Release 2 will provide the results of automated genome annotation(Coccidioides Sequencing Project Website).
    2. 10X whole-genome shotgun assembly
      1. GenBank Accession Number: CH379576,CH379577,CH379578,CH379579,CH379580,CH379581,CH379582,CH379583,CH379584,CH379585,CH379586
      2. Size: 29 Mb(Coccidioides Sequencing Project Website-FAQ).
      3. Description: ADDITIONAL DATA: 10X sequencing coverage of the genome; 215 contigs longer than 2 Kb; 20 supercontigs; 133.8 Kb average contig length (range 2.0 - 794.5 Kb); 1.4 Mb average supercontig length (range 3.0 Kb - 7.9 Mb); 28.8 Mb total length of combined contigs (28,777,468 bp); Average base lies in a contig of length 251.8 Kb; Average base lies within a supercontig of length 3.9 Mb;(Coccidioides Sequencing Project Website).
Biosafety Information
  1. Biosafety information for Coccidioides immitis
    1. Level: 2 and 3 -- Biosafety Level 2 practices and facilities are recommended for handling and processing clinical specimens, identifying isolates, and processing animal tissues. Animal Biosafety Level 2 practices and facilities are recommended for experimental animal studies when the route of challenge is parenteral. Biosafety Level 3 practices and facilities are recommended for propagating and manipulating sporulating cultures already identified as C. immitis and for processing soil or other environmental materials known or likely to contain infectious arthroconidia(US Dept. Health and Human Services, 1999).
    2. Applicable: BIOSAFETY LEVEL 2 is similar to Biosafety Level 1 and is suitable for work involving agents of moderate potential hazard to personnel and the environment. It differs from BSL-1 in that (1) laboratory personnel have specific training in handling pathogenic agents and are directed by competent scientists; (2) access to the laboratory is limited when work is being conducted; (3) extreme precautions are taken with contaminated sharp items; and (4) certain procedures in which infectious aerosols or splashes may be created are conducted in biological safety cabinets or other physical containment equipment. BIOSAFETY LEVEL 3 is applicable to clinical, diagnostic, teaching, research, or production facilities in which work is done with indigenous or exotic agents which may cause serious or potentially lethal disease as a result of exposure by the inhalation route. Laboratory personnel have specific training in handling pathogenic and potentially lethal agents, and are supervised by competent scientists who are experienced in working with these agents. All procedures involving the manipulation of infectious materials are conducted within biological safety cabinets or other physical containment devices, or by personnel wearing appropriate personal protective clothing and equipment. The laboratory has special engineering and design features(US Dept. Health and Human Services, 1999).
    3. Precautions: Eating, drinking, smoking, handling contact lenses, and applying cosmetics are not permitted in the laboratory. All cultures, stocks, and other regulated wastes are decontaminated before disposal by an approved decontamination method, such as autoclaving. Laboratory personnel receive the appropriate immunizations or tests for the agents handled or potentially present in the laboratory (e.g., hepatitis B vaccine or TB skin testing), and periodic testing as recommended for the agent being handled. A high degree of precaution must always be taken with any contaminated sharp items, including needles and syringes, slides, pipettes, capillary tubes , and scalpels. All open manipulations involving infectious materials areconducted in biological safety cabinets or other physical containment devices within the containment module. Spills and accidents that result in overt or potential exposures to infectious materials are immediately reported to the laboratory director. Appropriate medical evaluation, surveillance, and treatment are provided and written records are maintained(US Dept. Health and Human Services, 1999).
    4. Disposal: Spills of infectious materials are decontaminated, contained and cleaned up by appropriate professional staff, or others properly trained and equipped to work with concentrated infectious material. Spill procedures are developed and posted. Contaminated equipment must be decontaminated before removal from the facility for repair or maintenance or packaging for transport, in accordance with applicable local, state, or federal regulations(US Dept. Health and Human Services, 1999).
Culturing Information
  1. Culture methods for pathogenic mold :
    1. Description: The fungus grows on almost all routine laboratory media with or without antibiotics. Because of the hazards inherent in culture work, the use of Petri dishes is not advised without special precautions. Material to be examined can be spread on slants or bottles of Saubouraud?s agar and incubated at room temperature. Growth usually occurs by the third to fourth day, and conidiation by the tenth to 14th day. If subcultures are to be done, they should be made in a gloved isolation hood. When the culture is ready for examination, formaldehyde may be poured over the slants(Rippon, 1988).
    2. Medium: Almost any routine media(Rippon, 1988).
    3. Optimal Temperature: 22C or 72F(Rippon, 1988).
    4. Note: Morphology: At first, it is moist, glabrous, and grayish, but the colony rapidly develops abundant, floccose, aerial mycelium that soon covers the slant. The mycelium is initially white, but usually becomes tan to brown with age(Rippon, 1988).
  2. Culture Methods for endosporulating spherule :
    1. Description: Spherules are most easily produced in liquid modified Converse medium (MCM) with CO2 added at 37C, or better yet at 40C. Some spherule formation can be seen in agar slants 40C using a variety of media, however. The MCMA of Brosbe is probably the best medium for initiation and propagation of the spherule stage of C. immitis(Rippon, 1988).
    2. Medium: Modified Converse Medium(Rippon, 1988).
    3. Optimal Temperature: 37C(Rippon, 1988).
    4. Upper Temperature: 40C(Rippon, 1988).
    5. Note: Morphology: Numerous soil fungi have similar morphology at 25C, only C. immitis converts to the endosporulating spherule at 37 to 40C in culture or in experimentally infected animals(Rippon, 1988).
Epidemiology Information:
  1. Outbreak Locations:
    1. Coccidioidomycosis is endemic in California. In an 11-year period from the beginning of 1980 to the end of 1990, an average of approximately 400-500 cases per year were reported to the California State Department of Health Services (CSDHS). In 1990, 441 cases were reported. However, a striking increase in the number of cases was noted in 1991, 1992, and 1993, particularly in the southern San Joaquin Valley counties of Kern and Tulare. In 1992, striking increases were noted in other counties as well. In California there were 1,200 and 4,541 new cases in 1991 and 1992, respectively, that were reported to the CSDHS. The usual rate (5%-7%) of metapulmonary dissemination was noted in these outbreaks, and cases resembling acute adult respiratory distress syndrome that had been noted infrequently in previous outbreaks were conspicuous among the 1991 and 1992 cases. Factors thought to contribute to the extraordinary increases in coccidioidomycosis were a drought of 5 to 6 years' duration; abundant rain in March 1991 and February-March 1992; construction of new buildings; and arrival of new, susceptible individuals to the areas of endemicity(Pappagianis, 1994).
    2. Early in the morning on December 20, 1977, high-velocity winds centered around Arvin, a town in the southern extreme of the San Joaquin Valley near Bakersfield, in Kern County, California, bore aloft soil containing arthroconidia of Coccidioides immitis. Dispersion of this soil by peculiar wind conditions resulted in an epidemic of coccidioidomycosis in an area encompassing approximately 87,00 square km, an area larger than the stated of Maine. We report the morbidity, mortality and cost of the epidemic in Sacramento County, an area of 2792 square km at the northern limit of the San Joaquin Valley, which is normally an area of low endemicity for coccidioidomycosis. The State of California Department of Health Services recorded approximately 550 cases of coccidioidomycosis in the first 16 weeks of 1978, as compared with a maximum of 175 for this period in any of the previous 10 years. The steep rise in cases from the fourth to the 18th weeks of 1978 reflects cases reported after the dust storm. The rate of rise resumed a slope similar to that in previous years at approximately the 18th week. Sacramento County reported 139 cases that probably resulted from exposure to the dust, in contrast to the zero to six cases reported per year over the previous 20 years. One hundred and fifteen of these 139 cases met our criteria for dust-storm-related coccidioidomycosis. Six of the 115 persons who acquired acute coccidioidomycosis as a result of infection with C. immitis during the dust storm have died(Flynn et al., 1979).
    3. On January 17, 1994, at 4:30am (Pacific standard time), a magnitude 6.7 earthquake occurred in the Northridge/Reseda area in Los Angeles County, California. The main shock and aftershocks resulted in 72 fatalities and assessed damage costs estimated at $23.8 billion. Ventura County, a coastal county northeast of Los Angeles County, has not been recognized as an area where coccidioidomycosis is highly endemic. Fewer than 60 cases were reported annually in 1992 and 1993, with peak reporting occurring in the late fall and winter months. However, in the first 5 weeks following the earthquake, 20 coccidioidomycosis cases were reported to the Ventura County Health Department, which was more than expected for that time period. Persons who reported being physically in a dust cloud generated by landslides following the earthquake or aftershocks were 3 times more likely to be diagnosed with acute coccidioidomycosis than those persons who did not report being physically in a dust cloud. Risk increased with reported duration of exposure to a dust cloud(Schneideret al., 1997).
    4. In July 1996 the Washington State Department of Health (Seattle) was notified that at least 15 persons from a church group, including many adolescents, had developed an unidentified, rash-associated, flulike illness. One of these cases was eventually recognized as coccidioidomycosis. The group had recently returned from a 6-day stay at an orphanage <15 miles south of Tecate, Mexico, a town in the Sonoran Desert adjacent to the United States?Mexico border. To determine the extent of the outbreak and risk factors for disease, we conducted an investigation(Cairns et al., 2000). One hundred twenty-six church group members participated in the trip to Tecate, which occurred from 8 to 13 July 1996. Of 100 members (79%) who were contacted, 59 (47% of 126) completed questionnaires, underwent skin tests, and had the results read(Cairns et al., 2000). Twenty-seven (46%) of the 59 church group members had a positive skin test. Serological testing for 21 of these members was positive for C. immitis(Cairns et al., 2000). Of the 21 members who met the case definition, 20 (95%) were adolescents aged 14?18 years (median, 16 years; range, 14?43 years), and 18 (86%) were female. Four patients (19%) had negative skin tests(Cairns et al., 2000).
    5. On December 4, 2001, CDC was notified by the United Kingdom (UK) Public Health Laboratory Service (PHLS) of a UK resident aged 72 years who had culture-confirmed coccidioidomycosis (i.e., Valley fever) diagnosed in early December. During October 8?12, the patient had attended the world championship of model airplane flying in Lost Hills, California, located in Kern County in the Central Valley of California, an area where coccidioidomycosis is highly endemic. The patient had influenza-like symptoms on approximately October 25, 1 week after returning from Lost Hills. CDC, in collaboration with UK PHLS and the California Department of Health Services, is conducting an investigation(MMWR, 2001b).
    6. Dinosaur National Monument (DNM) encompasses 320 square miles in northeastern Utah and northwestern Colorado; 397,800 persons visited DNM in 2000. On June 18, 2001, under the direction of National Park Service (NPS) archeologists, six student volunteers and two leaders began work at an archeologic site in DNM. Work included laying stone steps, building a retaining wall, and sifting dirt for artifacts. Peak dust exposure occurred on June 19, the day most sifting occurred. Workers did not wear protective facemasks. During June 29?July 3, all eight team members and two NPS archeologists who had worked at the site sought medical care at a local hospital emergency department for respiratory and systemic symptoms. All 10 persons had diffuse pulmonary infiltrates on chest radiographs; eight were hospitalized with pneumonia of unknown etiology. Pending investigation, NPS closed the work site to all visitors and staff, and the TriCounty Health Department alerted the public. On July 2, the TriCounty Health Department, the Utah Department of Health, and CDC initiated an investigation to identify the risk factors, cause, and extent of the outbreak(MMWR, 2001a). Results of blood cultures from the hospitalized persons were negative for bacterial pathogens. Initial serologic tests were negative for antibodies to Francisella tularensis, Yersinia pestis, Mycoplasma species, Histoplasma capsulatum, and C. immitis. On further analysis, using serum specimens concentrated 3?5 fold in an assay that detects IgM antibodies (immunodiffusion tube precipitin), nine of the 10 acute serum specimens from patients contained IgM antibodies to C. immitis, confirming the diagnosis of acute coccidioidomycosis. All hospitalized patients were treated with fluconazole. The average length of hospital stay was 1.5 days(MMWR, 2001a).
    7. From 10 September to 27 October 2001, a group of 23 Navy SEALs from San Diego and Honolulu participated in a military training exercise near Coalinga, California, which is located 60 miles southwest of Fresno, in a C. immitis?endemic area within the San Joaquin Valley. During the 6-week training period, the men camped in tents on sandy soil, drove in open military vehicles, ran on poorly vegetated land, and occasionally dugholes to conceal themselves. During these activities, all men reported extensive dust exposure and none used protective measures, such as facemasks(Crum et al., 2002). Ten (45%) of 22 men had serologic evidence of a recent C. immitis infection. Complement fixation (CF) titers in case subjects ranged from <1:2 to 1:16. The sole Hispanic man in this training group developed coccidioidomycosis with a CF titer of 1:16. Of the 10 men with serologic evidence of recent infection, all reported symptoms consistent with a C. immitis infection. No one reported joint swelling, bone pain, or a rash consistent with erythema nodosum or erythema multiforme. The onset of symptoms in 8 of the 10 case subjects occurred during the last week of September or the first week of October, approximately 2?3 weeks after their arrival at the Coalinga training site. Two case subjects reported symptoms beginning during the first 2 weeks of November. Symptoms persisted for 2?63 days (median, 19 days), and 3 patients reported missing 1?3 work days(Crum et al., 2002).
    8. Early in the human immunodeficiency virus (HIV) epidemic, coccidioidomycosis was recognized as an opportunistic infection that caused significant morbidity and mortality among HIV-infected persons living in areas of endemicity. Recently, analysis of surveillance data from Arizona during 1990?1995 documented a substantial increase in the incidence of coccidioidomycosis. This increase in incidence disproportionately affected residents aged >65 years and HIV-infected persons. During the same period, the prevalence of AIDS in Arizona increased by at least 79%. Analysis of hospital discharge data from 1993 revealed that 98 HIV-infected persons were hospitalized with coccidioidomycosis in Arizona, constituting 10% of all HIV-related hospitalizations. One-third of these HIV-infected persons died, compared with 15% of HIV-infected persons hospitalized for other reasons. The majority of coccidioidomycosis cases in Arizona, as well as cases of HIV infection, are reported from 2 southern counties: Maricopa (population 2,611,327) and Pima (population 767,873). By January 1995, approximately 4000 HIV-infected persons were living in both counties. Previous studies suggest that up to 27% of HIV-infected persons in southern Arizona may develop symptomatic coccidioidomycosis each year and that between 5% and 10% develop disseminated disease. Before this study, the only identified risk factors for developing symptomatic coccidioidomycosis in these persons were a diagnosis of AIDS and a CD4 lymphocyte count <250 cells/mL(Woods et al., 2000).
    9. The 1991 Piau? outbreak of coccidioidomycosisinvolved three individuals. On August 31, 1991 a 38 year old Brazilian man, his 11 year old son; and a 24 year old cousin, all life time residents of the community of Oeiras in the state of Piau?, went into the nearby hills to hunt for nine-banded armadillos (Dasypus novemcinctus) accompanied by eight hunting dogs. Their search was successful for they had dug one out of its burrow and had it as the piece de resistance of the family?s dinner. In digging out their prey, the three hunters and their eight dogs inevitably were exposed to aerosols of dust. Nine days later, on September 9, 1991, all three humans became ill with symptoms that included fever, weakness, myalgia, cough (at first without sputum, later with sputum) and dyspnea. At the same time all of the dogs also became ill. Three of them died in a few days. At that time the men were hospitalized in Oeiras?s local hospital. Their x-rays showed pneumonia. After the second week, the 11 year old boy got better and recovered spontaneously from his acute illness. The two adults, however, continued to have severe pneumonia with bilateral infiltrates. Accordingly,they were transferred to the Infectious Disease Hospital in Teresina, the capital of Piau?, about 161 kms to the north. As ofDecember 1999 all the three patients were healthy and active(Wanke et al., 1999).
    10. On Dec. 26, 1966, 2 families consisting of 10 persons went on an outing near Beeville, Texas. Family A (father, mother, 8-year-old boy, 6-year-old boy, and a 4-year-old boy) were residents of Beeville. Family B (father, mother, 18-year-old boy, 14-year-old boy, and 7-year-old girl) were residents of Perry, Oklahoma. The group, all in good health prior to that time, visited and excavation area used for road-grading materials. The adults engaged in target practice, later removing the spent bullets from the walls of the excavation. The children, during the course of play, retrieved the family dog, which had become entrapped in a rodent burrow in the excavation area. Within 5 to 10 days of the outing, 9 of the 10 persons developed a flu like illness, including fever, headache, malaise, myalgia, cough, chest pain, anorexia, and vomiting. In addition, several patients had erythema nodosum and erythema multiforme. Signs and symptoms were self-limited in all persons except the index case, persisting from 1 to 3 weeks. On the fifth day following exposure, the family dog developed an illness characterized by respiratory distress, anorexia, and lethargy. He died on the third day of illness. Eight soil samples were obtained from the excavation area (7 random samples and 1 from the rodent burrow in which the dog had been entrapped). Of these, only the sample from the rodent burrow was positive for C immitis(Teel et al., 1970).
  2. Transmission Information:
    1. From: Coccidioides immitis, Soil , To: Humans (Homo sapiens), Coccidioides immitis
      Mechanism: ENVIRONMENTAL: Infection by Coccidioides results after inhalation of dust containing arthroconidia(Rippon, 1988).
    2. From: Humans (Homo sapiens), Coccidioides immitis , To: Humans (Homo sapiens), Coccidioides immitis
      Mechanism: LAB ACCIDENTS: Numerous reports of laboratory-associated coccidioidomycosis are documented in the literature published prior to 1980. Although cutaneous infections from accidental inoculation are documented, most laboratory-associated infections are caused by inhalation of the infectious arthroconidia(Sewell, 1995).
    3. From: Humans (Homo sapiens), Coccidioides immitis , To: Humans (Homo sapiens), Coccidioides immitis
      Mechanism: VERTICAL: The placenta is thought to be impermeable to the coccidioidin spherule because of the large size (40 to 70 ?m) of the spherule. Moreover thrombotic and chronic granulomatous reactions in the placenta appear to wall off the infection from the villous circulation. In a comprehensive review by Spark of neonatal onset of coccidioidomycosis, no cases of neonatal coccidioidal disease resulting from transplacental spread or vertically acquired infection were identified. Conversely placental involvement was not identified in 12 reported cases of neonatal onset and death. Our second patient is the first reported case (to our knowledge) linking maternal disseminated disease, placentitis and neonatal onset of infection. This indicates that transplacental spread may occur rarely. The findings in the mother's placenta substantiate the usefulness of histopathology to establish a specific diagnosis. Whether vertical infection by C. immitis could have been prevented by cesarean section is unknown(Linsangan and Ross, 1999). Neonatal coccidioidomycosis, although rare, has been reported. Aspiration of infectious vaginal secretions during birth appears to be the major mode of transmission. Transplacental infection has been thought not to occur because extensive coccidioidal placentitis is found without transmission of disease to the fetus. We report a case of neonatal coccidioidomycosis in an infant delivered by cesarean section. There was no labor and fetal membranes were intact at birth, indicating intrauterine acquisition of Coccidioides(Charlton et al., 1999).
    4. From: Humans (Homo sapiens), Coccidioides immitis , To: Humans (Homo sapiens), Coccidioides immitis
      Mechanism: TRANSPLANTATION: A North Carolinian developed fatal coccidioidomycosis immediately after bilateral lung transplantation. The donor had previously traveled to Mexico, and the recipient had no travel history to an area where Coccidioides immitis is endemic. Immunosuppresive therapy of the transplant recipient likely reactivated latent Coccidioides infection in the donor lungs, leading to posttransplant coccidioidomycosis(Miller et al., 2004).
    5. From: Equus caballus, Coccidioides immitis , To: Humans (Homo sapiens), Coccidioides immitis (Kohn et al., 1992)
      Mechanism: INHALATION OF ENDOSPORES: A 33-year-old white veterinary resident was referred to the University of California Davis Medical Center because of fever, skin rash, and loss of 10 lb in 12 days. As a resident in large animal medicine, the patient primarily took care of sick horses. As of 13 days before he became ill, he autopsied a 5-year-old quarter horse mare subsequently discovered to have disseminated coccidioidomycosis. As the patient gave no history of recent travel through, or activity in, a region endemic for coccidioidomycosis, it is probable that he was infected when he autopsied the horse. Although inhalation of Coccidioidal arthroconidia is the usual mode of infection, an autopsy source of arthroconidia was not found. Exposure of the patient to spherules - endospores of C. immitis was indubitable. Transdermal infection is implausible because the patient had no preexisting skin lesions, was not wounded at autopsy, and never developed the chancriform lesions characteristic of this route of infection. Infection by inhalation is supported by the certainty of generation of infected aerosols during dissection that discovered abscesses, especially, while bandsawing through a patellar abscess(Kohn et al., 1992).
  3. Environmental Reservoir:
    1. Soil:
      1. Description: The fungus proliferates readily on almost any type of sterile soil at the extremes of naturally occurring pH and temperature(Rippon, 1988).
      2. Survival: Growth is more luxuriant on rich soil than on poor. However, survival of the organism in soil with normal bacterial and fungal flora is greatly decreased. It appears that C. immitis is ill fitted to survive in competition with other soil microorganisms and indeed is inhibited by some. Egeberg et al. found that, in the soils particularly favored by C. immitis, the most important inhibitory organisms were Bacillus subtilis and Penicillium janthinellum. These species proliferate during the rainy season, but as the temperature increases and evaporation increases salinity of the soil, their growth is inhibited. B. subtilis is sensitive to high salt concentration, and P. janthinellum to a temperature of 100F. C. immitis is very tolerant of a wide range of salt concentrations and almost uniquely tolerant to boron-containing salts. Growth also occurs up to a temperature of 130F. Both spherules and arthroconidia survive for long periods under adverse conditions, although the arthroconidia survive extreme conditions much longer. It appears, then, that the factors that delineate the ecologic areas inhabited by C. immitis are dependent upon the tolerance of the fungus to adverse soil composition and high temperatures, which are inhibitory to competing organisms(Rippon, 1988).
  4. Intentional Releases:
    1. Intentional Release Information:
      1. Description: C. immitis could be used as a weapon of bioterror or biowarfare with aerosol delivery. Its use for this purpose would, however, present a number of obstacles and its effect would be uncertain and most probably limited(Deresinski, 2003).
      2. Delivery Mechanism: C. immitis conforms to some of the suggest characteristics of an ideal biological weapon, including ease of procurement, simplicity and low cost of production, ease of dissemination (at least on a small scale), and possibly, the potential to overwhelm a medical system by a large number of casualties. However, the difficulties in weaponization, as well as in control and dissemination of an airborne pathogen, are many and are not easily overcome. These include the need for production of nonclumping particles of appropriate size that are stable during aerosolization, and uniform distribution of an adequate number of arthroconidia. Furthermore, the lack of a safe and effective vaccine, although leaving a targeted population without an immunologic means of prophylaxis, also leaves the individuals producing the weapon and disseminating it without access to this means of protection. In the absence of a vaccine, however, it may be possible for the perpetrators to protect themselves by taking antifungal agents for prophylaxis. Line source contamination, as by an aircraft, is said to be the most effective means of delivery of a biological warfare agent, but this method is highly susceptible to meterologic conditions. Thus, changes in barometric pressure, rain, and wind are among the many factors that will affect dispersal of an airborne agent. Optimal conditions include a pressure inversion, no wind, and limited ultraviolet radiation. In consequence, as with other agents spread by aerosol, a small attack would be relatively easy to accomplish, but a large-scale attack would be much more difficult because of the problems of dispersal within and limited to the targeted area(Deresinski, 2003).
      3. Containment: Because human-to-human or animal-to-human aerosol transmission does not occur, quarantine is of no value. Exposed individuals could be given a drug such as fluconazole while still in the incubation period. There is, however, no data showing the effectiveness of such an approach. In most instances, coccidioidomycosis is a treatable infection. The vast majority of cases of symptomatic infection resolve without treatment, although it is possible that chemotherapy may shorten the duration of illness. If soil were to become persistently contaminated, the risk to individuals working in the area could be diminished by keeping dust levels to a minimum and the wearing of masks capable of preventing entry of arthroconidia. Decontamination of small areas of soil has been suggested. C. immitis is susceptible to 1% sodium hypochlorite, phenolics, glutaraldehyde, 1-chlor-2-nitropropane, and formaldehyde; its susceptibility to 70% ethanol is said to be questionable. Formaldehyde has been used to decontaminate sites at which epidemiologics of histoplasmosis have occurred. The toxicity of formaldehyde for humans, however, makes its use problematic. Iodophors, phenols, formaldehyde, and hypochlorite have been used to decontaminate laboratory surfaces. The most profound effect of an attack using C. immitis is likely to be psychologic. Immediate efforts to accurately and honestly inform the population of their risk would be the most critical part of any response to an attack using this organism(Deresinski, 2003).
Diagnostic Tests Information
  1. Organism Detection Test:
    1. Fluorescent Microscopy :
      1. Time to Perform: unknown
      2. Description: FA methods have been used for the detection of both C. immitis in infected tissue and antibody in human sera. Histologic staining was accomplished by preparing antisera in rabbits injected with viable or nonviable arthroconidia of C. immitis. The globulin fraction was separated from the sera and conjugated with fluorescein isothiocyanate. With this conjugate, endospores and the contents of spherules fluoresced but the walls of spherules in infected tissues did not, perhaps because antibody was already present on the surface of spherules in vivo. However, the walls of spherules produced in vitro did react with the fluorescein-labeled antibody. This reagent provided a sensitive histologic method for the detection of C. immitis in tissue and exudates. Its specificity was enhanced by prior adsorption with yeast cells of Histoplasma capsulatum or by diluting antibody globulin induced by injection of rabbits with viable (but not with killed) C. immitis arthroconidia. The one-step FA inhibition test was used to detect the presence of coccidioidal antibody in human sera. Smears of endospores prepared from the cut surface of infected mouse lungs were exposed to a mixture (A) of fluorescein-labeled rabbit antibody plus unlabeled unknown serum. The intensity of staining was compared with that of endospores exposed to a mixture (B) of fluorescein-labeled globulin and normal serum (the negative control). In A, coccidioidal antibody in the patient serum inhibited the uptake of the fluorescent tag by endospores. The FA inhibition test showed a 93% correlation with CF-positive sera and was positive with sera from some cases of coccidioidomycosis that were negative by CF as well as some that were reactive only by TP(Pappagianis and Zimmer, 1990).
  2. Immunoassay Test:
    1. TP test :
      1. Time to Perform: 1-to-2-days
      2. Description: The TP test is carried out by adding 0.2 ml of serum to 0.2 ml of coccidioidin solution. Antigen compared with a reference lot of antigen should be of such a concentration that undiluted and 1:10 dilutions of antigen will react with known TP-positive sera. Smith et al. originally included 1:40 and 1:100 dilutions of antigens to cover the "zone of equivalence" usually expected in a quantitative precipitin test, but these are not required. As a control, the patient's serum is added to culture medium similar to that in which coccidioidin was produced. The tubes are then shaken vigorously and placed in the 35C incubator. The test has incorrectly been described as one in which antigen is overlaid on the serum. The tubes are incubated for 24 h and then examined for presence of a translucent gelatinous button of precipitate by flicking the tube sharply to dislodge the button from the bottom of the tube. If no reaction is noted, the tubes are incubated again and read daily for the next 3 days. In 85 to 90% of instances, the TP test will show a precipitate in 24 h; only rarely will a reaction not be evident within 48 h. Although various dilutions of antigen have been used, the TP test has not been clearly standardized as a quantitative test. Presence or absence of TP reactivity is significant. The TP test is no longer recommended because of the greater sensitivity of the IDTP(Pappagianis and Zimmer, 1990).
      3. Antigen:
      4. Antibody:
    2. ID double diffusion test (Ouchterlony test) (Pappagianis and Zimmer, 1990):
      1. Time to Perform: 1-to-2-days
      2. Description: In 1958, the double diffusion (Ouchterlony test) was shown to yield a band of precipitate when coccidioidin was diffused through agar toward serum from a patient with coccidioidomycosis. Subsequently, multiple bands of precipitation were obtained when various fractions derived from coccidioidin were tested against sera from patients with coccidioidomycosis. Huppert and Bailey developed the ID so that it could be used to detect antibody that correlated with CF (the IDCF) and TP (the IDTP). They used culture filtrate antigen solution (FAS or F) for the IDCF test and toluene lysate antigen solution (LAS or L) for the IDTP test, but in reality either of these antigen solutions can detect both kinds of antibody. The antigen solutions were concentrated, washed by ultrafiltration, and titrated to obtain the optimal dilution for serologic tests. However, Huppert et al. indicated that ultrafiltration removed most of the TP antigen. Based on the earlier observations of Smith et al. that the TP antigen is heat stable, Huppert and Bailey heated the toluene or lysate antigen to 60C for 30 min to inactivate CF (or IDCF) antigen. Their ID tests were carried out in 50-mm plastic petri dishes containing 5 ml of agar. Seven wells, 4.5 mm in diameter, were cut in the agar in a hexagonal pattern with one well in the center. The wall to wall distance between wells was 5 mm. The volume required per well was 40 to 50 RI. Other methods such as that of Kaufman and colleagues permit the testing of smaller volumes of many specimens in a single 90-mm petri dish. The serum (or other body fluid) is placed in the appropriate well and allowed to prediffuse at room temperature for 2 h, followed by addition of the appropriate antigen dilution. This prediffusion may be unnecessary for the detection of the IDCF reaction but appears essential in order to have the IDTP reaction, which is dependent on slowly diffusing IgM, occur approximately midway between serum and antigen wells. In our experience with concentrated specimens, 85 to 90% of reactions detectable by ID are apparent in 24 h, most of the remainder becoming detectable within 48 h. Only infrequently does a reaction appear with longer incubation. Nevertheless, we recommend that final readings be made at 96 h. The substrate for ID tests can be agar, agarose, or gellan gum, a polysaccharide produced by a Pseudomonas species. We have used the last agent for over 3 years (approximately 20,000 specimens tested) and have found it a satisfactory substitute for agar or agarose when testing human and animal sera. (Rabbit serum, however, may not show the same reactions in gellan gum that it does in agar.)(Pappagianis and Zimmer, 1990).
      3. Antigen:
      4. Antibody:
    3. LA test :
      1. Time to Perform: 1-to-2-days
      2. Description: For the LA test, latex particles are coated with coccidioidal antigen obtained by toluene autolysis of mycelial C. immitis or from culture filtrates. Originally, polystyrene latex particles 0.15 to 0.35 um in diameter were used, but in more recent preparations 0.8-gm particles are used. The antigen solution is heated at 60C to inactivate the antigenic components) reactive with complement. The commercial distributors also have recommended that the serum to be tested be heated at 56C for 30 min to inactivate complement. Agglutination is read after 4 min. The LA test is more sensitive than TP, but it has yielded at least 6% false-positive reactions. Results of LA tests reported to us from several different laboratories indicate that, in general use, the rate of false-positives is higher. Because of this, a confirmatory test(s), preferably ID, must follow any positive LA. Very high rates of false-positive LA occur with CSF or with sera that have been diluted whether obtained from patients with coccidioidomycosis or not. Because of this, the attempted application of LA as a quantitative test is likely to provide spurious information. While the LA test is designated as a test to detect antibody (IgM) corresponding to that detectable by TP, our experience shows that some LA-positive reactions are reported with sera that are positive by IDCF (IgG) but not for IgM. The LA test has been useful in diagnosis of coccidioidomycosis in the dog(Pappagianis and Zimmer, 1990).
      3. False Positive: 6% -- The LA test is more sensitive than TP, but it has yielded at least 6% false-positive reactions(Pappagianis and Zimmer, 1990).
      4. Antigen:
      5. Antibody:
    4. CF test :
      1. Time to Perform: unknown
      2. Description: To develop a standardized procedure that could be universally adopted, comparisons of different complement-fixation (CF) methods were carried out. The Smith CF macromethod, using overnight binding of complement at 4 to 5C, gave more reproducible results than the LBCF procedure (also using complement binding at 5C) in either its macro- or microdilution version. In the LBCF, the last tube or well showing 30% or less hemolysis is considered positive. The micro-LBCF requires approximately one-tenth the volume of serum, CSF, or other fluid required by the Kolmer or macro-LBCF, and it has been widely adopted. No direct comparison between the micro-LBCF and the original method of Smith et al. has been reported; however, binding at 4C provides higher titers than 2-h binding at 37C. In some instances, positive results are obtained after overnight test incubation at 4C but not at 37C after 2 h. As ordinarily described, the LBCF titration may begin with a 1:8 dilution of serum. Therefore, sera that are positive but only with titers of 2 or 4 would appear negative at the 1:8 dilution. Such low titers may be encountered in early coccidioidal disease, limited dissemination, pulmonary residua, or late disease when the titer has declined. The LBCF should begin with a 1:2 dilution if the IDCF is positive. Because CF titers of 2 to 8 may represent antibody reacting with another, cross-reactive antigen, the presence of coccidioidal CF antibody should be verified in the initial specimen by the more specific ID test(Pappagianis and Zimmer, 1990).
      3. Antibody:
    5. IDCF test :
      1. Time to Perform: unknown
      2. Description: The evolution and use of the ID test have beendescribed above. In 1962, Schubert and Hampson showed that CF-positive sera reacted in an ID test with coccidioidin as antigen. Huppert and Bailey set forth appropriate conditions for the performance of the IDCF, which detected antibody corresponding to that detected by CF. The test relied on selection of the appropriate dilution of antigen, known to be heat labile, for the detection of IDCF. The dilution of antigen chosen, after 2-h prediffusion, yields a precipitate with antibody approximately midway between the wells. The IDCF test can be carried out without prediffusion of the serum. The higher the concentration of antibody, the closer to the antigen well will be the antigen-antibody precipitate. The location of the precipitate can even provide a rough estimate of how many dilutions of serum may be needed to obtain the endpoint titer in the CF test. While many coccidioidal sera yield a positive IDCF result without prior concentration, some specimens, e.g., from well-focalized pulmonary nodules or cavities, will not show IDCF reaction unless concentrated first. A control CF-positive human serum is used in each test(Pappagianis and Zimmer, 1990).
      3. Antigen:
      4. Antibody:
    6. QID test :
      1. Time to Perform: 2-to-7-days
      2. Description: The QID test for IDCF antibody is carried out by diffusing various dilutions of serum against a fixed concentration of antigen previously determined to have appropriatereactivity. Several workers have studied the QID. By refilling the antigen and serum wells 24 and 48h after the original filling and taking a final reading at 72 h, Wieden et al. found that agreement between QID and CF titers (?1 two-fold dilution) was 84.7%. The QID was tested with consecutive sera from the same patients. Although it tended to yield slightly lower titers than the CF test performed by 2-h binding of complement at 37C, over time the changes in titer were comparable. Others found similar agreement between CF and QID tests: 80% , 87%, and 82%. The QID testrequires fewer reagents and smaller volumes than the CF test. The manipulations are simpler, but no automation has been used and the results are delayed (final reading after 48 to 72 h). The QID test is practical for the laboratory that carries out few serologic determinations, but for large numbers of specimens the CF test is more practical. QID is needed when serum is anticomplementary and will not yield a readable titer by CF (frequent with canine sera) and for those unusual sera that do not show fixation of complement but yield a titer by QID(Pappagianis and Zimmer, 1990).
    7. Counterimmunoelectrophoresis :
      1. Time to Perform: 1-hour-to-1-day
      2. Description: CIE has been used for both qualitative and quantitative antibody determination. With coccidioidin as antigen, both IDTP and IDCF antibodies were detected in sera of dogs with coccidioidomycosis. All canine sera that were positive by CF (titers, 2 to 128) were positive by CIE. Human sera and CSF were tested by CIE, using spherulin; the CIE provided 100% correlation with ID and 98% correlation with CF results. The mean titer by CIE was 1 serial dilution lower than that obtained by CF. The nature of the antigens used in two other studies is uncertain as one referred to a "toluene extract of culture filtrates" (82) and the other referred to "spherule coccidioidin". The former study found that 100% of sera with CF titers of >16were positive by CIE, but at lower CF titers CIE was proportionately less sensitive, detecting only 64% when the titer was 2. As Kozub et al. pointed out, the sensitivity of the CIE would probably be improved by appropriate selection of reagents. However, if the sensitivity does not exceed that of ID, the advantage of more rapid results by CIE (1 to 2 h) may be of particular importance only in the infrequent cases of rapidly progressing coccidioidomycosis(Pappagianis and Zimmer, 1990).
    8. Radioimmunoassay :
      1. Time to Perform: unknown
      2. Description: A solid-phase RIA method was tested by Catanzaro and Flatauer as a means of detecting antibody in human sera. RIA values correlated well with the clinical status of patients with pulmonary coccidioidomycosis (type of pulmonary disease not given) and with the CF titer in disseminated infections(Pappagianis and Zimmer, 1990).
    9. ELISA :
      1. Time to Perform: unknown
      2. Description: Several groups of workers have studied detectionof coccidioidal antibody by ELISA. A consistent shortcoming, found in about 10% of sera tested, is the inability to distinguish clearly between patient (positive) and control (negative) sera, as determined by conventional tests. Thus far, the closest correlation has been obtained between IDTP and ELISA. In a study of 792 sera, Leonard and Talbot reported an 89% agreement between ELISA and the TP test but 100% agreement between IDTP and ELISA, using anti-human globulin as the secondary antibody. In a separate study, Talbot et al. found that a large number of patients had CSF antibodies detectable by ELISA but not by CF. None of these patients ever developed coccidioidal meningitis, indicating that the greater sensitivity of the ELISA makes it unreliable for the detection of meningitis. This finding resembles that noted earlier for IDCF tests with concentrated CSF. The IDCF was overly sensitive because it detected IgG antibody in the CSF of patients with nonmeningitic coccidioidomycosis. Cole et al. tested antibody response to an isolated immunoreactive spherule wall antigen. Using anti-IgM in the ELISA they found overlapping optical density values between sera from patients and controls. When anti-IgG was the detecting antibody, there was clear differentiation between CF-positive and -negative sera; however, there was no correlation between CF titers and ELISA values, as noted also by Lindsay et al. We recently studied various coccidioidin, spherule-endospore, and synthetic (3-O-methylmannose-based) antigens in the conduct of coccidioidal ELISA, using 400 sera. The use of 20% normal goat serum as an ELISA diluent rather than traditional phosphate-buffered saline with Tween 20 provided a better distinction between IDTP-positive and -negative sera and a 97% correlation between ELISA and IDTP in serum when anti-IgM was used. Levels of anticoccidioidal IgG did not correlate with CF activity regardless of ELISA reagents(Pappagianis and Zimmer, 1990).
    10. Cloned epitope specific to Complement-Fixing Antibody :
      1. Time to Perform: unknown
      2. Description: This investigation is the first to show that the C. immitis CF/chitinase protein contains a domain that is specific for anti-Coccidioides CF antibody. This domain, comprised of amino acid residues 20 through 310, detected antibody in 21 (95%) of 22 serum samples from coccidioidomycosis patients and was without reactivity with serum samples from 20 histoplasmosis patients, 15 patients with blastomycosis, and 14 normal subjects. Preincubation of reference IDCF antibody serum with peptide 20-310 ablated its reactivity in the IDCF assay, thereby confirming that the peptide contains the CF reactive epitope. Antibody reactivity to peptide 20-310 is predominantly of the IgG1 isotype and is directed against a heatlabile peptide epitope(Yang et al., 1997).
      3. False Positive: 0%(Yang et al., 1997).
      4. False Negative: 5%(Yang et al., 1997).
      5. Antigen:
      6. Antibody:
  3. Nucleic Acid Detection Test: