Coccidioidomycosis- An Overview

Coccidioidomycosis is a fungal infection that affects the lungs and sometimes other parts of the body. It is also known as valley fever, desert rheumatism, or San Joaquin Valley fever. It is caused by two species of fungi, Coccidioides immitis and Coccidioides posadasii, that live in the soil of arid regions of the Western Hemisphere, such as southwestern United States, Mexico, Central America, and parts of South America .

People can get coccidioidomycosis by inhaling the spores of the fungi, which are released into the air when the soil is disturbed by wind, construction, farming, or other activities . The spores can travel long distances and cause outbreaks in areas where the fungi are not endemic. Most people who are exposed to the spores do not develop any symptoms or have a mild illness that goes away on its own . However, some people may develop a more severe or chronic infection that can affect the lungs, skin, bones, joints, nervous system, or other organs .

Coccidioidomycosis is more common and more severe in people who have weakened immune systems, such as those with HIV/AIDS, organ transplant recipients, cancer patients, or those taking immunosuppressive drugs . It is also more likely to affect certain ethnic groups, such as African Americans, Filipinos, Native Americans, Hispanics, and Asians . Pregnant women and elderly people are also at higher risk of complications from coccidioidomycosis .

The diagnosis of coccidioidomycosis is based on clinical signs and symptoms, history of exposure to endemic areas, and laboratory tests that can detect the fungi or antibodies against them in blood, sputum, cerebrospinal fluid, or tissue samples . The treatment of coccidioidomycosis depends on the severity and location of the infection. Mild cases may not require any specific treatment, while severe or disseminated cases may need antifungal drugs such as fluconazole, itraconazole, or amphotericin B . Some cases may also require surgery to remove infected tissue or drain abscesses .

The prevention and control of coccidioidomycosis are challenging because there is no vaccine available and the fungi are widespread in the environment . However, some measures that can reduce the risk of exposure include avoiding activities that generate dust in endemic areas, wearing protective masks and clothing when working with soil or animals in endemic areas, and educating travelers and health care workers about the signs and symptoms of coccidioidomycosis. Early diagnosis and treatment can also improve the outcomes and prevent complications from coccidioidomycosis.

Coccidioidomycosis is a fungal infection caused by two species of dimorphic fungi: Coccidioides immitis and Coccidioides posadasii . These fungi belong to the genus Coccidioides, which has no known sexual stage and reproduces asexually by forming spores.

The two species of Coccidioides are phenotypically identical and can only be distinguished by molecular methods. They are endemic to certain regions of the southwestern United States, Mexico, Central America, and South America, where they live in the soil and can become airborne when the soil is disturbed . People can get infected by inhaling the spores, which are called arthroconidia.

Once inside the lungs, the arthroconidia undergo a morphological change and develop into spherules, which are large (20 to 80 micrometers in diameter), thick-walled, and filled with hundreds of small endospores (2 to 4 micrometers in diameter) . The spherules eventually rupture and release the endospores, which can either form new spherules or disseminate to other tissues and organs through the bloodstream or lymphatic system . The spherules and endospores are the parasitic forms of the fungus and are responsible for causing disease.

The disease caused by Coccidioides can range from asymptomatic or mild respiratory infection to severe or disseminated infection involving various organs, such as skin, bones, joints, and meninges . The severity of the disease depends on several factors, such as the number of spores inhaled, the immune status of the host, and the genetic susceptibility of the host. Certain groups of people are at higher risk of developing severe or disseminated disease, such as pregnant women, elderly people, people with immunosuppressive conditions or medications, and people of African or Filipino descent .

Coccidioidomycosis is also known as valley fever, San Joaquin fever, or desert rheumatism . It is one of the most common fungal infections in the United States, with an estimated 150,000 cases occurring annually. However, many cases are undiagnosed or misdiagnosed due to nonspecific symptoms or lack of awareness among clinicians and patients . Therefore, it is important to recognize the causative agents and the epidemiology of coccidioidomycosis for timely diagnosis and treatment.

Coccidioidomycosis is a fungal infection caused by inhaling the spores of Coccidioides immitis or Coccidioides posadasii, which are dimorphic fungi that grow as mycelia in the soil and as spherules in the tissues . The spores, also called arthroconidia, are released into the air when the soil is disturbed by wind, farming, construction, or other activities . The spores can travel long distances and infect people who live in or visit endemic areas, such as the southwestern United States, Mexico, Central America, and parts of South America .

The pathogenesis of coccidioidomycosis involves the following steps:

• Inhalation: The spores are small (2-5 micrometers) and can reach the alveoli of the lungs, where they encounter macrophages and other immune cells .
• Transformation: The spores undergo a morphological change from a filamentous form to a spherical form, called a spherule, which has a thick wall and contains hundreds of endospores . This transformation is triggered by the increase in temperature and carbon dioxide concentration in the host tissues.
• Replication: The spherules grow in size (20-80 micrometers) and eventually rupture, releasing the endospores into the surrounding tissue . The endospores can then form new spherules and repeat the cycle of replication and rupture.
• Dissemination: The endospores can also spread through the bloodstream or lymphatic system to other organs, such as the skin, bones, joints, central nervous system, or meninges . This can result in extrapulmonary or disseminated coccidioidomycosis, which is more severe and potentially fatal .
• Immune response: The host immune system mounts a cellular and humoral response to the fungal infection, involving macrophages, neutrophils, eosinophils, T cells, B cells, and antibodies . The immune response can cause inflammation, granuloma formation, tissue damage, and hypersensitivity reactions . The immune response also determines the clinical outcome of the infection, as some people can clear the infection spontaneously or remain asymptomatic, while others develop chronic or progressive disease .

The pathogenesis of coccidioidomycosis is influenced by several factors, such as:

• Host factors: The susceptibility and severity of coccidioidomycosis vary among different hosts depending on their genetic background, immune status, age, sex, race, pregnancy status, and comorbidities . For example, immunocompromised individuals (such as those with HIV/AIDS, organ transplantation, diabetes mellitus, or autoimmune diseases) are more likely to develop disseminated disease than immunocompetent individuals . Similarly, pregnant women are more prone to severe disease than non-pregnant women . African Americans and Filipinos have higher rates of dissemination than Caucasians or Hispanics .
• Fungal factors: The virulence and pathogenicity of Coccidioides species depend on their ability to adhere to host cells, transform from spores to spherules, evade or modulate host immune responses, produce antigens that elicit protective or harmful immune reactions, and disseminate to distant sites . For example, C. immitis has estrogen-binding proteins that may enhance its growth in pregnant women or men with high estrogen levels. Coccidioides species also produce two antigens: coccidioidin (extracted from mycelial cultures) and spherulin (produced from broth cultures), which can induce delayed-type hypersensitivity or antibody-mediated immunity respectively.
• Environmental factors: The distribution and transmission of Coccidioides species are influenced by climatic conditions that affect the growth and survival of the fungi in the soil, such as temperature, rainfall, humidity, and soil pH. The spore concentration in the air can also vary depending on the season, wind speed, and human activities that disturb the soil. For example, dust storms, earthquakes, or construction projects can increase the risk of exposure and infection.

Coccidioidomycosis is an infection caused by inhaling the spores of the fungus Coccidioides, which lives in the soil in certain regions of the world, such as the southwestern United States, Mexico, and Central and South America. The risk of getting coccidioidomycosis depends on several factors, such as:

• Geographical location: People who live in or travel to areas where Coccidioides is endemic are at risk of exposure to the fungus. The highest incidence of coccidioidomycosis is reported in Arizona, California, New Mexico, and Texas. Other countries where coccidioidomycosis has been reported include Mexico, Guatemala, Honduras, El Salvador, Nicaragua, Costa Rica, Panama, Colombia, Venezuela, Brazil, Paraguay, Argentina, and Bolivia.
• Environmental conditions: The fungus grows best in hot and dry climates, and its spores can become airborne when the soil is disturbed by wind, dust storms, construction, farming, or other activities. The risk of infection is higher during certain seasons or weather events that increase dust exposure.
• Occupational or recreational activities: People who work or engage in outdoor activities that involve soil disruption or inhalation of dust are at higher risk of coccidioidomycosis. These include farmers, construction workers, archaeologists, military personnel, hunters, hikers, campers, and bikers.
• Immunological status: People who have weakened immune systems are at higher risk of developing severe or disseminated coccidioidomycosis. These include people who have HIV/AIDS, organ transplant recipients, people who take immunosuppressive drugs (such as corticosteroids or TNF-inhibitors), people who have autoimmune diseases (such as rheumatoid arthritis or lupus), people who have diabetes mellitus, and people who have cancer or are undergoing chemotherapy or radiation therapy.
• Demographic factors: Certain groups of people are more likely to develop severe or disseminated coccidioidomycosis than others. These include people who are African American or Filipino, pregnant women (especially during the third trimester), and men (especially older men). The reasons for these differences are not fully understood but may involve genetic factors that affect the immune response to the fungus.

Virulence factors are molecules or traits that enable pathogens to cause disease in their hosts. Coccidioides spp. have several virulence factors that allow them to survive and proliferate in the human body. Some of these factors are:

• Adherence: The arthroconidia, which are the infectious spores of Coccidioides spp., have a bar-shaped morphology and a thin cell wall that enable them to attach to epithelial cells and tissues in the respiratory tract. The arthroconidia are also lightweight and loosely chained, which makes them easily airborne and inhalable by humans .
• Specialization and remodeling: The arthroconidia undergo a dramatic transformation when they enter the host cells, shedding their outer layer and forming spherules. The spherules are spherical structures that divide internally by forming septa, creating compartments that contain numerous endospores. The endospores are small, thick-walled cells that can survive inside phagocytes and cause inflammation. When the spherules mature, they rupture and release the endospores into the surrounding tissues, where they can germinate and form new spherules .
• Antigenic variation: Coccidioides spp. produce two antigens that elicit different immune responses from the host: coccidioidin and spherulin. Coccidioidin is extracted from the mycelial form of the fungus and stimulates a delayed-type hypersensitivity reaction in skin tests. Spherulin is derived from the spherule form of the fungus and induces a humoral antibody response. Both antigens can modulate the host`s cell-mediated immunity and contribute to the pathogenesis of coccidioidomycosis .
• Ammonia production: Coccidioides spp. secrete urease, an enzyme that hydrolyzes urea into ammonia and carbon dioxide. Urea is abundant in the host`s tissues and fluids, especially in urine and sweat. Ammonia production by Coccidioides spp. can increase the pH of the local microenvironment, creating a favorable condition for fungal growth and survival. Ammonia can also damage the host`s cells and tissues by disrupting their membrane integrity and metabolic functions .

Coccidioidomycosis can cause a wide range of clinical manifestations, depending on the host`s immune status, the fungal load, and the duration of infection. Most cases are asymptomatic or mild, but some can be severe or even fatal.

The most common clinical features of coccidioidomycosis are:

• Flu-like symptoms: Fever, chills, headache, muscle aches, and fatigue. These usually occur within 1 to 3 weeks after exposure to the fungal spores and last for a few days to weeks .
• Respiratory symptoms: Cough, chest pain, shortness of breath, and difficulty breathing. These are caused by the inflammation and damage of the lungs by the fungal spherules and endospores. Some patients may develop pneumonia, nodules, cavities, or pleural effusions .
• Skin symptoms: A red rash that is painful and can blister. This is more common in women and may be associated with erythema nodosum or erythema multiforme. These are hypersensitivity reactions to the fungal antigens that occur on the legs, arms, or trunk .

Some of the major clinical manifestations of coccidioidomycosis include:

• Acute and chronic inflammation: This is associated with the production of neutrophils and eosinophils in response to endospore exposure in the alveolar sacs and the lung tissues. This leads to granuloma formation, fibrosis, and necrosis.
• Progressive pulmonary coccidioidomycosis: This is a chronic form of infection that involves the multiplication and enlargement of nodules or cavities in the lungs. This can cause hemoptysis, bronchopleural fistula, or respiratory failure .
• Disseminated coccidioidomycosis: This is a rare but life-threatening complication that occurs when the fungus spreads through the bloodstream to other organs such as the skin, bones, joints, liver, spleen, kidneys, adrenal glands, or central nervous system. This can cause abscesses, ulcers, osteomyelitis, arthritis, meningitis, or encephalitis .

The diagnosis of coccidioidomycosis is based on clinical features, epidemiological history, laboratory tests, and imaging studies. The treatment depends on the severity and extent of infection and may include antifungal drugs or surgery . The prevention and control of coccidioidomycosis involve avoiding exposure to dust in endemic areas and monitoring high-risk groups for early detection and treatment .

Coccidioidomycosis is a fungal infection caused by Coccidioides species, which are endemic in certain regions of the southwestern United States, Mexico, and Central and South America. The diagnosis of coccidioidomycosis can be challenging because the symptoms are often nonspecific and can mimic other respiratory illnesses. Therefore, a combination of clinical, laboratory, and radiological findings is usually required to confirm the diagnosis.

Clinical diagnosis of coccidioidomycosis

The clinical diagnosis of coccidioidomycosis depends on the patient`s history of exposure, symptoms, physical examination, and risk factors for severe or disseminated disease. The most common symptom of coccidioidomycosis is a flu-like illness with fever, cough, chest pain, headache, and fatigue. Some patients may also develop a rash, joint pain, or erythema nodosum (red, tender lumps on the lower legs). However, some patients may have no symptoms at all or only mild symptoms that resolve spontaneously.

The physical examination may reveal signs of pneumonia, such as crackles or wheezes in the lungs, or signs of extrapulmonary involvement, such as meningitis, osteomyelitis, or skin lesions. However, the physical examination may also be normal or nonspecific.

The clinical diagnosis of coccidioidomycosis should be considered in patients who have compatible symptoms and who live in or have traveled to endemic areas within the past year. The diagnosis should also be considered in patients who have risk factors for severe or disseminated disease, such as immunosuppression, pregnancy, diabetes mellitus, chronic lung disease, or certain racial/ethnic groups (African Americans, Native Americans, Filipinos).

Laboratory diagnosis of coccidioidomycosis

The laboratory diagnosis of coccidioidomycosis can be done by several methods:

• Microscopic examination: This method involves examining sputum, pleural fluid, cerebrospinal fluid (CSF), lesion exudates, or biopsy specimens under a microscope to look for the characteristic spherules of Coccidioides. Spherules are thick-walled structures that contain numerous endospores inside. They are usually 20 to 80 micrometers in diameter and can be seen with KOH wet mount or calcofluor stains. However, this method may have low sensitivity and specificity and may require multiple samples to detect the fungus.

• Culture: This method involves growing Coccidioides from body fluids or tissues in specialized media. Culture is considered the gold standard for the diagnosis of coccidioidomycosis because it can identify the species and strain of the fungus. However, culture may take several days to weeks to yield positive results and requires biosafety precautions because the arthroconidia (infective spores) are highly infectious by inhalation.

• Serology: This method involves detecting antibodies or antigens against Coccidioides in blood or CSF samples. Serology is the most common and widely available method for the diagnosis of coccidioidomycosis because it is relatively fast and easy to perform. However, serology may have limitations such as cross-reactivity with other fungi, false-negative results in early or severe infections, false-positive results in past infections or exposure to environmental antigens, and variability in test performance and interpretation.

  • Antibody detection: There are several types of antibody tests that can be used to diagnose coccidioidomycosis:

    • Enzyme immunoassays (EIA): These tests detect IgM and IgG antibodies against Coccidioides antigens in serum or CSF samples. EIA tests are sensitive and specific for acute infections but may not differentiate between active and past infections.

    • Immunodiffusion (ID): These tests detect IgM and IgG antibodies against Coccidioides antigens in serum samples. ID tests are less sensitive than EIA tests but more specific for active infections.

    • Complement fixation (CF): These tests detect IgG antibodies against Coccidioides antigens in serum or CSF samples. CF tests are less sensitive than EIA or ID tests but more useful for estimating the severity and prognosis of the infection. High titers (>1:16) indicate severe or disseminated disease while low titers (<1:4) indicate mild or resolving disease.

  • Antigen detection: There are two types of antigen tests that can be used to diagnose coccidioidomycosis:

    • EIA: These tests detect Coccidioides antigens in serum or urine samples. EIA tests are sensitive and specific for severe or disseminated disease but may not detect mild or localized disease.

    • Lateral flow assay (LFA): These tests detect Coccidioides antigens in serum, urine, or CSF samples. LFA tests are rapid and easy to perform but may have lower sensitivity and specificity than EIA tests.

• Molecular diagnosis: This method involves detecting Coccidioides DNA or RNA in body fluids or tissues by polymerase chain reaction (PCR) or other nucleic acid amplification techniques. Molecular diagnosis is a promising method for the diagnosis of coccidioidomycosis because it is fast, sensitive, and specific. However, molecular diagnosis is not widely available and may have limitations such as false-negative results due to low fungal load, false-positive results due to contamination, and lack of standardization and validation.

Radiological diagnosis of coccidioidomycosis

The radiological diagnosis of coccidioidomycosis can be done by imaging tests such as chest X-ray or computed tomography (CT) scan of the lungs. These tests can help identify the pulmonary manifestations of coccidioidomycosis, such as:

• Unilateral or bilateral infiltrates
• Lobar consolidation
• Nodular infiltrate
• Cavitation
• Hilar or mediastinal lymphadenopathy

However, these findings are not specific for coccidioidomycosis and may resemble other causes of pneumonia or lung disease. Therefore, radiological diagnosis should be correlated with clinical and laboratory findings to confirm the diagnosis of coccidioidomycosis.

Coccidioidomycosis is a fungal infection caused by inhalation of spores of the genus Coccidioides, which are endemic in certain regions of the United States, Mexico, Central and South America. The infection can range from asymptomatic to severe and disseminated, affecting various organs and systems. The treatment of coccidioidomycosis depends on the severity, duration, and location of the infection, as well as the patient`s immune status and comorbidities.

Antifungal medications

The mainstay of treatment for coccidioidomycosis is antifungal medication, which can be administered orally or intravenously. The most commonly used antifungals are azoles (such as fluconazole, itraconazole, voriconazole, and posaconazole) and amphotericin B (either deoxycholate or lipid formulations). The choice of antifungal depends on several factors, such as the availability, cost, efficacy, toxicity, drug interactions, and patient preference.

According to the Infectious Diseases Society of America (IDSA) guidelines, the following recommendations can be made for the treatment of different forms of coccidioidomycosis:

• For mild to moderate pulmonary coccidioidomycosis, antifungal therapy is not routinely indicated, unless the symptoms persist for more than 8 weeks or are severe enough to interfere with daily activities. In such cases, fluconazole (400 mg/day) or itraconazole (200 mg twice daily) are preferred for at least 3 to 6 months.
• For severe pulmonary coccidioidomycosis, such as acute pneumonia with hypoxemia, respiratory failure, or diffuse miliary disease, antifungal therapy is indicated. Amphotericin B (0.5 to 0.7 mg/kg/day intravenously) is preferred for initial therapy until clinical improvement, followed by fluconazole (400 to 800 mg/day) or itraconazole (200 mg twice daily) for at least 12 months.
• For chronic pulmonary coccidioidomycosis, such as persistent or progressive pulmonary nodules, cavities, or fibrosis, antifungal therapy is indicated. Fluconazole (400 to 800 mg/day) or itraconazole (200 mg twice daily) are preferred for at least 12 months. Surgical resection of pulmonary lesions may be considered in selected cases.
• For disseminated coccidioidomycosis, such as extrapulmonary involvement of the skin, bones, joints, or other organs, antifungal therapy is indicated. Fluconazole (400 to 800 mg/day) or itraconazole (200 mg twice daily) are preferred for at least 12 months. Amphotericin B (0.5 to 0.7 mg/kg/day intravenously) may be added for initial therapy in severe or life-threatening cases. Surgical drainage or debridement of infected sites may be required in some cases.
• For coccidioidal meningitis, antifungal therapy is indicated and should be continued lifelong unless otherwise advised by an expert. Fluconazole (400 to 1200 mg/day) is preferred for initial and maintenance therapy. Intrathecal amphotericin B may be considered as an adjunctive therapy in refractory cases.

Supportive care

In addition to antifungal therapy, patients with coccidioidomycosis may require supportive care to manage their symptoms and complications. This may include:

• Rest and hydration
• Analgesics and anti-inflammatory drugs for pain and fever
• Corticosteroids for severe inflammatory reactions or hypersensitivity syndromes
• Oxygen therapy for hypoxemia
• Mechanical ventilation for respiratory failure
• Blood transfusion for anemia
• Fluid and electrolyte replacement for dehydration
• Nutritional support for weight loss

Prevention and control

There is no vaccine or prophylaxis available for coccidioidomycosis. The best way to prevent infection is to avoid exposure to dust that may contain Coccidioides spores, especially in endemic areas. Some preventive measures include:

• Wearing a mask or respirator when working or traveling in dusty environments
• Wetting the soil before digging or disturbing it
• Avoiding outdoor activities during dust storms or windy days
• Keeping doors and windows closed during dust storms
• Using air filters or humidifiers indoors
• Educating travelers and residents about the risk and symptoms of coccidioidomycosis
• Reporting cases and outbreaks to public health authorities

Coccidioidomycosis is a fungal infection caused by inhaling the spores of Coccidioides, a soil-dwelling fungus that lives in certain areas of the southwestern United States, Mexico, and Central and South America. The infection can cause mild to severe respiratory symptoms, and in some cases, it can spread to other parts of the body and cause serious complications. Therefore, preventing and controlling coccidioidomycosis is important for public health and individual well-being.

Primary Prevention

Primary prevention aims to reduce the exposure to Coccidioides spores in the environment and to protect the people who are at higher risk of developing severe or disseminated disease. Some of the strategies for primary prevention are:

• Avoiding activities that generate dust, such as digging, gardening, or construction, especially in windy or dry conditions, in areas where Coccidioides is endemic.
• Wearing a properly fitted N95 respirator mask when working or traveling in dusty settings, such as farms, mines, or construction sites, in endemic areas.
• Wetting the soil before disturbing it to reduce dust formation.
• Planting grass or crops, paving roads and airfields, and using oil sprays to reduce dust in endemic areas.
• Educating travelers and residents about the symptoms and risks of coccidioidomycosis and advising them to seek medical attention if they develop respiratory illness after visiting endemic areas.
• Screening people who are at higher risk of severe or disseminated disease, such as those with weakened immune systems, pregnant women, people with diabetes, or people who are Black or Filipino, for coccidioidal antibodies before they travel or move to endemic areas. If they test positive, they should be counseled about the possibility of reactivation or relapse of coccidioidomycosis and the need for close monitoring and prompt treatment if they develop symptoms.
• Vaccinating people who are at higher risk of severe or disseminated disease with a safe and effective vaccine against Coccidioides. However, such a vaccine is not yet available for human use.

Secondary Prevention

Secondary prevention aims to diagnose and treat coccidioidomycosis early and prevent its complications and transmission. Some of the strategies for secondary prevention are:

• Performing laboratory tests, such as microscopic examination, culture, histology, serology, antigen detection, or molecular methods, to confirm the diagnosis of coccidioidomycosis in patients with compatible clinical features and exposure history.
• Treating mild to moderate pulmonary coccidioidomycosis with oral antifungal drugs, such as fluconazole or itraconazole, for 3 to 6 months or until symptoms resolve and serologic titers decline.
• Treating severe or disseminated coccidioidomycosis with intravenous amphotericin B followed by oral azoles for at least 12 months or until clinical and serologic improvement is achieved.
• Treating meningeal coccidioidomycosis with lifelong oral fluconazole or intrathecal amphotericin B to prevent relapse and neurological deterioration.
• Monitoring patients with coccidioidomycosis for signs of worsening disease or complications, such as pulmonary cavitation, hemoptysis, osteomyelitis, skin lesions, or meningitis, and adjusting treatment accordingly.
• Reporting cases of coccidioidomycosis to local health authorities to facilitate epidemiological surveillance and outbreak investigation.
• Isolating patients with coccidioidal wound infections or draining lesions to prevent direct contact transmission to other people or animals. However, respiratory isolation is not necessary as coccidioidomycosis is not contagious through airborne route.

Tertiary Prevention

Tertiary prevention aims to reduce the disability and mortality associated with coccidioidomycosis and improve the quality of life of patients. Some of the strategies for tertiary prevention are:

• Providing supportive care for patients with coccidioidomycosis, such as pain management, nutritional support, hydration, oxygen therapy, or mechanical ventilation as needed.
• Performing surgical interventions for patients with coccidioidal complications that require removal of infected tissue or organs, such as pulmonary resection for hemoptysis or cavity closure, debridement for osteomyelitis or skin ulcers, or shunt placement for hydrocephalus due to meningitis.
• Providing rehabilitation services for patients with coccidioidal sequelae that impair their physical or mental functioning, such as physiotherapy for joint stiffness or weakness, occupational therapy for daily living skills, speech therapy for cognitive impairment or dysphagia, or psychological counseling for depression or anxiety.
• Educating patients and their families about the chronic and relapsing nature of coccidioidomycosis and the need for regular follow-up and adherence to treatment.
• Empowering patients and their families to participate in their own care and decision making and to seek social and emotional support from their community or peer groups.

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