Can Coccidiomycosis cause lymphadenopathy (lymph node enlargement) in the neck and when does it typically resolve?

Cervical Lymphadenopathy in Coccidioidomycosis

Yes, coccidioidomycosis can cause cervical (neck) lymphadenopathy, and in uncomplicated primary infections, it typically resolves spontaneously within 1-2 years without treatment, though patients with disseminated disease require prolonged antifungal therapy. 1

Clinical Presentation of Lymphadenopathy

• Cervical lymphadenopathy is a recognized manifestation of coccidioidomycosis, occurring as part of both primary pulmonary infection and disseminated disease 1, 2
• In primary pulmonary coccidioidomycosis, prominent or persistent hilar adenopathy is considered an indicator of severe infection, and cervical lymphadenopathy can occur as regional spread 1
• Disseminated coccidioidomycosis frequently involves lymph nodes, with documented cases showing submandibular and cervical lymphadenopathy containing Coccidioides spherules on biopsy 2, 3, 4

Natural History and Resolution Timeline

• For uncomplicated primary infections: At least 95% of patients resolve spontaneously without antifungal therapy, with management requiring repeated patient encounters every 3-6 months for up to 1-2 years to document resolution 1
• For disseminated disease with lymph node involvement: Spontaneous resolution does not occur, and prolonged antifungal therapy ranging from many months to years is required, with some patients needing lifelong suppressive therapy 1

When Lymphadenopathy Indicates Need for Treatment

You should initiate antifungal therapy if any of the following are present:

• Evidence of disseminated disease (lymph node biopsy showing spherules, multiple organ involvement) 2, 3, 4
• Concurrent immunosuppression (HIV infection, organ transplant, high-dose corticosteroids) 1
• Persistent symptoms beyond 2-3 months with prominent lymphadenopathy 1
• Complement fixation antibody titers ≥1:16 1
• Weight loss >10%, intense night sweats persisting >3 weeks, or inability to work 1
• African, Filipino, Asian, Hispanic, or Native American ancestry (higher dissemination risk) 1

Treatment Approach

For disseminated disease with cervical lymphadenopathy:

• Initiate fluconazole 400-800 mg daily or itraconazole 200 mg twice daily for subacute presentations 1
• Use amphotericin B 0.5-1.5 mg/kg/day IV for rapidly progressive or severe infections, then transition to oral azoles 1
• Continue treatment for at least 1 year minimum, with many patients requiring lifelong suppressive therapy 1
• Monitor with serial complement fixation titers and clinical assessments every 3-6 months 1

For uncomplicated primary infection with mild lymphadenopathy:

• Observation with periodic reassessment every 3-6 months for up to 2 years is appropriate if no risk factors for complications are present 1
• Document resolution radiographically and clinically, or identify complications early 1

Critical Diagnostic Pitfall

• A case report documented a patient who received only 4 weeks of fluconazole for primary pulmonary coccidioidomycosis with cervical lymphadenopathy, which was grossly insufficient 2
• This inadequate treatment led to progression to disseminated disease with septic shock, ARDS, and multi-organ involvement requiring weeks of IV amphotericin B 2
• The key lesson: If lymph node involvement is documented (especially by biopsy showing spherules), this represents disseminated disease requiring prolonged therapy, not a brief 4-week course 2, 3, 4

Distinguishing from Tuberculosis

• In adults, over 90% of mycobacterial cervical adenitis is caused by M. tuberculosis, making this a critical differential diagnosis 5
• Coccidioidomycosis lymphadenitis can mimic tuberculosis clinically, particularly in non-endemic areas 3, 4
• Definitive diagnosis requires excisional biopsy with fungal stains (demonstrating spherules with endospores), fungal culture, and coccidioidal serology 6, 3, 4