Coccidioidomycosis in transplant recipients: A primer for clinicians in nonendemic areas

Purpose of review: Coccidioidomycosis is a fungal infection caused by Coccidioides spp., a fungus endemic to the southwestern USA. Immunocompromised patients with coccidioidomycosis often present with atypical manifestations. We provide clinical, diagnostic, and management approaches for clinicians in nonendemic areas who might encounter coccidioidomycosis in transplant recipients. Recent findings: With preemptive screening, heightened awareness, and targeted prophylaxis, the incidence of coccidioidomycosis in transplant recipients has decreased to 1-3% in endemic areas. Dissemination and mortality continues to be clinically significant (about 30%). Serological findings are often unreliable in transplant recipients, necessitating invasive procedures for a tissue or microbiological diagnosis. Management recommendations are similar to those for immunocompetent hosts, except that transplant patients may require more prolonged therapy and secondary prophylaxis to prevent reactivation. The exact risk of donor-derived coccidioidomycosis is unknown. Routine antifungal prophylaxis is not currently recommended for transplant recipients visiting or relocating to endemic areas. Summary: Transplant recipients who travel to or reside part-time or full-time in endemic areas are at risk for both primary and reactivated coccidioidomycosis. Clinicians in nonendemic areas should be aware that early diagnosis followed by prompt antifungal therapy could be lifesaving. Prophylactic strategies can prevent reactivation in select circumstances.