What are the symptoms and treatment options for valley fever?

Valley Fever (Coccidioidomycosis): Symptoms and Treatment

Valley fever typically presents as a self-limited respiratory illness 1-3 weeks after exposure, with most immunocompetent patients requiring only supportive care and monitoring rather than antifungal treatment. 1

Clinical Symptoms

Primary Symptom Presentation

The most common symptoms include:

• Fever, fatigue, chills, and myalgia are the most frequently reported constitutional symptoms 1
• Respiratory symptoms manifest as pneumonia with cough and chest pain 1
• Severe, debilitating headaches are common and may be retroorbital with photophobia, sometimes misdiagnosed as migraines or dental issues 1

Disease Course and Timeline

• Symptoms typically appear 1-3 weeks after inhalation of fungal spores from contaminated soil 1, 2
• Fever typically lasts a median of 10 days in untreated patients and usually resolves within 72 hours of appropriate treatment 1
• Systemic symptoms improve first, followed by respiratory symptoms, with fatigue often being the most persistent symptom 1
• Most infections (60%) are asymptomatic, while approximately one-third develop pulmonary illness 2

Classic Triad ("Desert Rheumatism")

• Fever, erythema nodosum, and arthralgia often accompanied by respiratory problems 3

Treatment Approach

When NOT to Treat

For immunocompetent patients with mild to moderate symptoms, antifungal therapy is generally not required as most infections are self-limited and resolve spontaneously 4, 1, 5

• Patient education about disease course and when to seek further medical attention is essential for all patients 4, 5
• Avoid unnecessary antifungal treatment in immunocompetent patients with mild disease, as this can lead to adverse effects without clinical benefit 4, 5

Indications for Antifungal Treatment

Antifungal therapy should be initiated for:

• Severe primary pulmonary disease with significant symptoms 4, 5
• Patients with risk factors for dissemination (cellular immunodeficiencies, transplant recipients, HIV, pregnancy, African Americans, Filipinos) 1, 2
• Disseminated disease to extrapulmonary sites 1

First-Line Antifungal Treatment

Fluconazole is the standard first-line drug of choice for most cases requiring treatment 4, 5, 3, 6:

• 400 mg daily for mild-moderate disease 4, 5
• 800 mg daily for severe disease 4, 5
• Treatment may continue for 3-12 months, although lifetime treatment is indicated for coccidioidal meningitis 6

Alternative Antifungal Options

• Itraconazole (200 mg twice daily) may be more effective for skeletal infections 4, 5
• Liposomal amphotericin B is recommended for:
  • Critically ill patients 4, 5
  • Rapidly progressive disease 4, 5
  • Patients who fail to respond to azole therapy 4, 5

Surgical Considerations

Surgical intervention should be considered for persistent symptomatic cavities that have been present for more than 2 years or when symptoms recur after stopping antifungal treatment 4, 5

Monitoring and Follow-Up

• Regular medical follow-up is essential for all patients with valley fever 1
• Laboratory studies and chest radiographs should be monitored periodically to assess disease resolution 1
• Erythrocyte sedimentation rate is often elevated and can be used to monitor improvement 1
• In patients treated with antifungals, complement fixation titers should be followed for at least two years 6

Common Pitfalls to Avoid

• Misdiagnosis as bacterial pneumonia or other respiratory infections due to similar presentation 1
• Failure to consider valley fever in patients with compatible symptoms who have lived in or traveled to endemic regions (southwestern US, parts of Mexico, Central and South America) 1, 2
• Treatment should never be delayed while awaiting laboratory confirmation if clinical suspicion is high in high-risk patients 5
• Obtaining a travel history is recommended when evaluating patients with community-acquired pneumonia, as valley fever accounts for 17-29% of cases in endemic areas 6