Coccidioides fungemia in six patients, with a review of the literature.

To identify demographics, clinical manifestations, and outcomes of patients with Coccidioides fungemia, we searched our institutional medical records to identify patients with Coccidioides fungemia treated between 1998 and 2008 and conducted a comprehensive search of the medical literature to identify previously reported cases. Coccidioides fungemia is an uncommon manifestation of coccidioidomycosis, a fungal infection caused by Coccidioides sp. endemic to the southwestern United States. Six Coccidioides fungemia patients were treated at our institution during the 10-year period. All 6 had underlying comorbid disease; three were receiving immunosuppressants. Three patients survived longer than 2 years. The literature review identified 107 patients, bringing the total cohort to 113 (mean age, 42 years). Forty-three patients (38%) had infection with the human immunodeficiency virus, 20 (18%) were receiving corticosteroids, 11 (10%) had solid organ transplants, and 5 (4%) were pregnant. Sites of extrapulmonary dissemination were reported for 97 (86%); the most common sites were liver (26/97 [27%]), spleen (21/97 [22%]), and meninges/central nervous system (17/97 [18%]). No patient showed evidence of endocarditis. At least 1 serologic test was positive in 45 (87%) of 52 patients for whom results were available. Overall mortality at 30 days was 62% (70/113; mean survival, 11.4 days). Survival was significantly worse in immunocompromised versus immunocompetent patients (22/72 [31%] vs. 19/36 [53%], respectively; P = .04). Lack of antifungal therapy predicted poor survival (8/38 [21%] vs. 32/65 [49%], respectively; P = .004). Coccidioides fungemia is an uncommon manifestation of fulminant, disseminated coccidioidomycosis. Survival is poorest in immunocompromised patients or those not receiving antifungal therapy.