Coccidioidomycosis

2022 Case Definition

CSTE Position Statement Number: 22-ID-07

Clinical Criteria

In the absence of a more likely diagnosis of an alternative fungal infection, such as histoplasmosis or blastomycosis, which have similar clinical presentation as coccidioidomycosis, and which can lead to serologic and antigenic false positives for coccidioidomycosis due to cross reactivity, patient must meet the following clinical criteria:

• Acute onset or worsening of at least two of the following signs or symptoms:
  • Cough
  • Fever or chills or night sweats
  • Shortness of breath
  • Chest or flank pain
  • Headache
  • Unintentional weight loss
  • Myalgia (muscle pain) Arthralgia (joint pain) or bone pain
  • Fatigue,

OR

• At least one of the following findings:
  • Abnormal lung findings on chest imaging (e.g., pulmonary infiltrates, nodule or cavitary lesions) or report of pneumonia
  • Single or multiple skin lesions
  • Bone or joint abnormality (e.g., osteomyelitis, pathologic fracture)
  • Meningitis, encephalitis, or focal brain lesion
  • Abscess, granuloma, or lesion in other body system
  • Erythema nodosum or erythema multiforme rash

Laboratory Criteria:

For the purposes of surveillance, laboratory evidence includes

Confirmatory laboratory evidence:

• Culture of Coccidioides spp. from a clinical specimen, OR
• Identification of Coccidioides spp. in the tissue or body fluid by histopathology, OR
• Identification of Coccidioides spp. in the tissue or body fluid by cytopathology, OR
• Detection of Coccidioides-specific nucleic acid in a clinical specimen using a validated molecular assay (e.g., PCR, DNA Probe), OR
• Detection of Coccidioides-specific proteins in a clinical specimen or isolate using a validated molecular assay (e.g., MALDI-TOF), OR
• Detection of coccidioidal antibodies in cerebrospinal fluid (CSF), OR
• Detection of coccidioidal antibodies in serum or other body fluids using any of the following diagnostic tests:
  • Immunodiffusion (may be abbreviated as ID, IMD, IMDF, IDTP, IDCF)
  • Complement fixation (CF) with a titer of >1:2
  • Tube precipitin
  • Detection of both IgM and IgG by enzyme immunoassay (may be abbreviated as EIA or ELISA).

Presumptive laboratory evidence:

• Detection of coccidioidal antibodies in serum or other body fluids using any of the following diagnostic tests:
  • Complement fixation (CF) with a titer of 1:2
  • Lateral flow assay (LFA)
  • Latex agglutination
  • Detection of either IgM or IgG by enzyme immunoassay (may be abbreviated as EIA or ELISA), OR
  • Detection of Coccidioides spp. antigen in serum, urine, CSF, or other body fluids.

Epidemiologic Linkage

Exposure to Coccidioides spp. endemic area. These exposures include work, residence, or travel in the two months prior to acute symptom onset or positive coccidioidal laboratory result if acute onset date is unknown.

High-incidence Jurisdictions

High-incidence jurisdictions are those that have had an average coccidioidomycosis incidence of ≥10 confirmed cases/100,000 population for a period of three consecutive years. Currently (as of July 2022), those jurisdictions are Arizona and California. While Low-incidence jurisdiction are those that have not had an average coccidioidomycosis incidence of ≥10 confirmed cases/100,000 population for a period of three consecutive years. Alabama will qualify for low incidence because in the last 3 years, the average case confirmed case/100,0000 population is less than 1.

Case Classifications

The CSTE recommends three case classifications

For Alabama, which is a low-incidence jurisdiction

Confirmed*:

• A case that meets confirmatory laboratory evidence AND either epidemiologic linkage OR clinical criteria, OR
• A case that meets presumptive laboratory evidence AND epidemiologic linkage AND clinical criteria.

Probable*:

• A case that meets confirmatory laboratory evidence and does NOT meet epidemiologic linkage criteria AND does NOT meet clinical criteria, OR
• A case that meets presumptive laboratory evidence AND either epidemiologic linkage OR clinical criteria.

Suspect*:

• A case that meets presumptive laboratory evidence and does NOT meet epidemiologic linkage criteria AND does NOT meet clinical criteria.

*Illness in a person with compelling evidence (e.g., culture, histopathology, seroconversion) of a different fungal infection, such as histoplasmosis or blastomycosis, should not be counted as a case of coccidioidomycosis without evidence of co-infection since other fungal infections can cause false positive (cross-reactive) Coccidioides spp. antigen and antibody test results. Thus, coccidioidomycosis cases should only be classified as such in the absence of a more likely diagnosis.

Criteria to distinguish a new case of this disease or condition from reports or notifications which should not be enumerated as a new case for surveillance

A new case is a case not known to be previously reported and counted in any public health jurisdiction in the United States.

There is no standardized system to check if a coccidioidomycosis case has been reported in another state; however, if it is known that a case was previously diagnosed or reported out-of-state, that case should not be counted or reported again.

Reactivation of coccidioidomycosis can occur, particularly among patients with previous coccidioidomycosis who are later treated with immunosuppressive medications. Potential cases of reactivation should not be counted or reported unless they are known to have not been previously diagnosed or reported.

Multiple cases of coccidioidomycosis for the same patient should only be reported if reactivation of a previous infection can be ruled out (i.e., patient was reinfected) by whole genome sequencing (i.e., sequencing data indicate infection from distinct Coccidioides spp. lineages/strains).

Date Posted: March 06,2023