Diagnosis, treatment, and outcomes of coccidioidomycosis in allogeneic stem cell transplantation

Background: Allogeneic hematopoietic stem cell transplant (allo-HSCT) recipients have multiple risk factors for coccidioidomycosis, and previous reports of coccidioidomycosis in this patient population describe severe infections with poor outcomes. Methods: We performed a retrospective chart review of allo-HSCT recipients with active coccidioidomycosis to characterize the utility of diagnostic tests for coccidioidomycosis and to determine treatment outcomes. Results: Eleven of 426 (2.6%) allo-HSCT recipients experienced active coccidioidomycosis after transplantation. Of these 11 patients, 1 (9%) had extrapulmonary infection, 9 (82%) patients were hospitalized, and 5 (45%) died. Culture or histology was positive in 33% (3/9) of the patients tested. Most (64% [7/11]) had at least 1 positive serologic test result, and the enzyme immunoassay immunoglobulin G test was positive most often (overall 55% [6/11]). Chest radiographs and chest computed tomography scans showed miliary or multifocal nodular infiltrates or consolidations, consistent with coccidioidomycosis, in 80% (8/10) and 100% (9/9), respectively, of patients tested throughout the course of active illness. Rapid polymerase chain reaction testing was positive in 71% (5/7) of the patients tested. Peripheral eosinophilia was present in 18% (2/11) of patients. Conclusion: Coccidioidomycosis is associated with high morbidity and mortality in allo-HSCT recipients in an area endemic for Coccidioides. Diagnosis of this infection can be difficult and often requires multiple and frequently invasive tests. Antifungal prophylaxis should be considered for patients at highest risk.