Coccidioidomycosis

Wanke, B.

Serviço de Micolngia, Instituto de Pesquisus Clinicas Evandro Chagas IPEC/Fiocruz, Rio de Janeiro

Coccidioidomycosis is a systemic mycosis caused by the dimorphic fungus Coccidioidex hnmiiis, affecting humans and a wide variety of animals. It is endemic in many countries of the American continent, characteristically restricted to semiarid or desert-like regions ranging from 40° N to 40° S. The highest prevalence of the infection occurs in the Southwestern states of USA and the Northern Mexican states. Endemic foci are also known in Central and South America. Although the first two Brazilian human cases were reported in 1978 and 1979, only in 1998 Brazil was included in the map of geographical distribution of Coccidioidomycosis [5], after the first reports of small outbreaks that occurred in the states of Piaui and Ceará [6.8.9].

In 1999 Wanke et al. recorded a total of 14 cases coming from 4 different Brazilian states [8]. Since then, several more cases were diagnosed, but only three of them, fatal cases, have been published [1,3,7]. Until December 2004 a total of 79 cases have been diagnosed in patients coming from the states of Piaui (66), Ceará (6). Maranhao (5) and Bahia (2). More recently Moreira et al. (2005) reported three additional cases from Ceará, including a fatal case [4]. While the first Brazilian cases had the diagnosis based only on histopathologic findings, the more recent cases have been diagnosed on the basis of mycological exams (direct microscopy and culture), serology (immunodiffusion tests) and histopathology. The predominance of cases diagnosed in the state of Piaui probably reflects a collaborative multidisciplinary study group integrating doctors and technicians of the Federal University in Piaui (UFPI) and the Oswaldo Cruz Foundation (FIOCRUZ) in Rio de Janeiro, relying on a good laboratory support for the mycological diagnosis.

The analysis of epidemiological and clinical data of the Coccidioidomycosis cases in Brazil reveals that: (i) most cases were young adult male without any evidence of immunodeficiency; (ii) all cases presented with pulmonary involvement and only recently cases with dissemination to CNS, bone, joints and skin were diagnosed; (iii) the overall lethality rate of > 10% (9/82) is very high; (iv) the most prevalent (about 90%) risk activity is hunting armadillos (mainly Dasypitx novemcinctus) and digging them out of their burrows; (v) almost all cases occurred in events that involve one or more individuals at risk activity in more than 36 different counties of four Brazilian states: Piaui 28, Cearâ 6, Maranhào 3 and Bahia 2.

So far, the mycosis has been diagnosed in humans, dogs and armadillos, and C hnmitis has been isolated from soil samples collected in and around armadillo burrows in the state of Piaui [2,8,9]. However, the semi-arid NE region of Brazil also encompasses large areas of the states of Sergipe, Alagoas, Pemambuco, Parafba and Rio Grande do Norte with similar climatic conditions as observed in Piauí.

In conclusion, we are convinced that coccidioidomycosis is actually underdiagnosed in Brazil and that the endemic area is expected to be larger than the cases point now.

References

1. J. Pneumol. 27: 275-278, 2001; 2. Mycopathologia 149: 57-61, 2000; 3. Rev. Soc. Bras. Med. Trop. 35(Supl. I): 191, 2002; 4. Rev. Soc. Bras. Med. Trop. 38(Supl.I): 168-169, 2005; 5. Medical Mycology. In: Topley & Wilson's, Microbiology and Microbial Infections, 9th ed., p. 357-371, 1998; 6. J. Mycol. Méd. 7: 37-39, 1997; 7. J. Pneumol. 29: 45-48, 2003; 8. Rev. Soc. Bras. Med. Trop. 27(Supl.IV): 375-378, 1994; 9. Mycopathologia 148: 57-67, 1999.

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