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July/August 2016
Updated IDSA Guideline on Valley Fever Published in CID
Every year, an estimated 150,000 people are infected with coccidioidomycosis, originally nicknamed San Joaquin Valley fever, and about 160 die, note updated guidelines by IDSA on Valley fever, published in Clinical Infectious Diseases. Valley fever is endemic in desert regions ranging from western Texas, Arizona and northern Mexico to the central San Joaquin Valley in California, as well as an area in south central Washington State. Some areas in Central and South America harbor the fungi as well. 
The fungi that cause the infection – Coccidioides immitis and Coccidioides posadasii – live in desert soil. The fungal spores become airborne when wind blows the dust around, are easily inhaled and settle deep in the lungs, causing pneumonia. 
The updated guidelines are now much more geared towards primary care clinicians who typically are the first to see and treat patients with pneumonia, but who may overlook valley fever as a potential cause of the illness and prescribe unnecessary tests and therapy. 
While 60 percent of people with valley fever have a mild infection with few or no symptoms, others may have fever, fatigue, cough, headache, chest pain, skin rash and joint aches. In extreme cases it can cause severe pneumonia, holes in the lungs (cavities), lung nodules, skin sores and meningitis. Pregnant women and people who are immunosuppressed (those with HIV, who had an organ transplant or are taking medication for rheumatologic disease) or have diabetes have a very high risk of complications. 
Fifty to 80 percent of people infected don’t require medication. Their immune systems eventually will rid their bodies of the infection and they will become immune. However, patients may benefit from physical therapy and should be seen by a health care provider regularly for two years to ensure their symptoms aren’t worsening, the guidelines say. 
Those who do need therapy should be treated with an anti-fungal medication such as fluconazole. The medication does not cure the infection, but suppresses symptoms. The guidelines note that some patients with more serious illness, including coccidioidal meningitis, will need to remain on antifungal therapy for life. 
The updated guidelines recommend treatment with fluconazole for women with complications from valley fever who are in their second or third trimester of pregnancy. That is a change from the previous guidelines (published in 2005), which recommended pregnant women be treated with amphotericin B, which does not harm the fetus but is highly toxic for the mother and requires intravenous treatment three times a week. Fluconazole is not toxic to the mother, can be taken orally and, while not recommended during the first trimester, appears safe during the second and third trimester, the guidelines note. 
The guidelines note valley fever can be diagnosed with simple blood tests called enzyme-linked immunosorbent assays (EIA), which test for antibodies to the fungus. Because it may take weeks or months for an EIA to show a positive result, taking a culture of the fungus from the sputum is another option. The guidelines panel includes infectious disease, pulmonary, critical care and rheumatology specialists, as well as thoracic surgeons and neurosurgeons. 
In addition to lead author, John N. Galgiani, MD, FIDSA; the guidelines panel includes Neil M. Ampel, MD; FIDSA; Janis E. Blair, MD, FIDSA; Antonino Catanzaro, MD; Francesca Geertsma, MD; Susan E. Hoover, MD, PhD; Royce H. Johnson, MD, FIDSA; Shimon Kusne, MD;Jeffrey Lisse, MD;Joel D. MacDonald, MD; Shari L. Meyerson, MD; Patricia B. Raksin, MD; John Siever, MD; David A. Stevens, MD, FIDSA; Rebecca Sunenshine, MD and Nicholas Theodore, MD.

As with other IDSA guidelines, the coccidioidomycosis guidelines will be available in a smartphone format and a pocket-sized quick-reference edition. 

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