Coccidioidomycosis physical examination
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: ; Vidit Bhargava, M.B.B.S [2]
Physical Findings
There are no pathognomic signs for Coccidioidomycosis, however numerous findings are observed depending on the organ system involved. Features suggestive of disseminated disease include: profuse sweating, dyspnea, high grade fever and weight loss. The various organ systems involved are.
Respiratory system
- Bronchial breathing.
- Rales & Ronchi
- Areas of consolidation with resultant dullness to percussion , and increased tactile and vocal fremitus.
- 5-10% cases may develop pulmonary nodules which may resolve spontaneously or may ulcerate and cause hemoptysis.
Skin manifestations
Erythema nodosum presenting as tender, erythematous nodules, about 1-2 cm in size are classic in endemic areas. Theses are more frequently found on the anterior surface of lower extremities but are also seen on upper extremities. Erythema multiforme occuring around the neck in necklace like pattern is also seen.
Ocular hypersensitivity is a frequent finding presenting as episcleritis, conjunctivitis, sclerities. Cutaneous hypersensitivity sometimes occur, and is suggestive of a trend towards resolution of symptoms, however needs to be differentiated from cutaneous involvement which is a bad prognostic sign. classical skin manifestation of coccidioidomycosis is a verrucous granuloma at the nasolabial fold, but other morphological appearances such as plaques and pustules are also found.
Meningitis
Meningitis associated with coccidioidomycosis is usually more chronic in onset then acute and is a result of disseminated infection. It is a serious condition and may result in death. Symptoms of meningitis are more common and obvious, while other symptoms such as focal deficits and cranial nerve palsies are much less common. Increased intracranial pressure is a common finding and is often symptomatic. Untreated disease is uniformly fatal.
Musculoskeletal manifestations
It can present with a monoarticular arthritis which may sometimes be migratory, knees are the most commonly affected joint. scleroic or lytic bone lesions are also seen but are not as common as in blastomycosis. Joint involvement resulting in synovitis is observed but aspiration of synovial fluid does not give specific findings. Osteomyelitis from hematogenous spread and from direct inoculation can lead to chronic infections, which may ulcerate to surface to cause draining fistulas. Paraspinal abscesses can occur from contiguous spread and may need surgical decompression to relieve cord compression.
Other organ systems
Almost all other organs can be involved as well but the chances are minimal. The total percent of cases with dissemination are close to 1%.In people with HIV and other immuno-compromised diseases septic shock and fungemia may occur.