Fungal Infections

Residual Pulmonary Sequelae

• Valley fever can cause residual lung damage in 5-10% of infections, typically presenting as nodules or thin-walled cavities that may persist even after successful treatment, with certain patient characteristics (extensive pulmonary involvement, concurrent diabetes, elderly or frail patients with comorbidities, and persons of African or Filipino ancestry) at higher risk 1
• Most patients with residual nodules or cavities will be protected from second primary infections, although radiographic abnormalities may take months to years to completely resolve, and some may never completely disappear 1

Treatment and Clinical Course

• The recommended diagnostic approach for Valley fever is serologic testing with IgM and IgG antibodies against coccidioidal antigens, followed by observation without antifungal therapy for most patients with mild symptoms, as recommended by the Infectious Diseases Society of America 2
• Patients with significantly debilitating illness, extensive pulmonary involvement, concurrent diabetes, frail patients due to age or comorbidities, patients of African or Filipino ancestry, or any evidence of disseminated disease are at higher risk and require closer monitoring, with first-line therapy being fluconazole 400 mg orally daily for 3-6 months, or alternative therapy being itraconazole 200 mg twice daily 2
• Severe disease may require amphotericin B, and special situations such as bone/joint involvement or meningeal involvement may require extended or lifelong antifungal therapy, with prolonged azole therapy (6-12 months) and surgical intervention considered for persistent symptomatic cavities 2
• All patients should be monitored for 2 years after diagnosis with clinical evaluation every 3-6 months, repeat serologic testing if symptoms worsen or persist, and chest imaging to document resolution in treated patients, as recommended by the Infectious Diseases Society of America, with clinical assessment every 1-3 months, serologic testing to monitor response, and monitoring for medication side effects being essential for patient management 2
• Failure to recognize risk factors for dissemination, such as race/ethnicity and immunocompromised status, and overlooking drug interactions with azole antifungals can lead to inadequate treatment, poor outcomes, and adverse effects, emphasizing the importance of adequate follow-up and monitoring for complications or dissemination 2, 3