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Coccidioidomycosis during Pregnancy
Coccidioidomycosis during Pregnancy* An Analysis of Ten Cases Among 47,120 Pregnancies Elizabeth E. Wack, M.D.; Neil M. Ampel, M.D.; John N. Galgiani, M.D.; and Danetta A. Bronnimann, M.D., F.C.C.P.
Previous studies have suggested that coccidioidomycosis during pregnancy is a devastating illness associated with high maternal mortality However, this concept recently has been challenged. We examined the incidence of coccidioidomycosis during pregnancy in Tuscon, Arizona, an area endemic for this infection. After reviewing the records of three separate health care facilities, we found ten cases of coccidioidomycosis among 47,120 pregnancies. Nine of the ten women had no underlying disease. Seven were diagnosed with coccidioidomycosis during either the first or second trimester, . Illness resolved in all seven. Three other
patients were diagnosed during the first ten days postpartum. While infection was self-limited in one woman, two others developed severe disseminated coccidioidomycosis associated with meningitis. Despite this, there were no maternal deaths. Of eight deliveries, all were uncomplicated and produced healthy infants. In summary, diagnosing coccidioidomycosis during pregnancy is rare. Although we observed no maternal death, our experience suggests that women who develop coccidioidomycosis late in pregnancy are at risk for developing severe disseminated infection.
COCcidiOidomYCOSiS is a fungal infection caused by the soil saprophyte Coccidioides immitis. In endemic areas of the southwestern United States, the average annual incidence of symptomatic infection among young adults is 0.4 percent of the susceptible (skin-test negative) population. 1 In most patients, infection is asymptomatic and detected only by skin-test conversion. Severe disease is unusual, and dissemination of infection beyond the lungs occurs in less than 1 percent of those infected. Coccidioidal infection during pregnancy has been described as devastating. 2-13 It has been estimated that pregnant women with symptomatic infections have at least a 10 percent risk of dissemination and, if this occurs, a 90 percent mortality: 5 However, much of this information is based on experience from previous decades, and recently it has been suggested that these estimates may no longer be accurate. 14 Because of this, we decided to examine the current pattern of coccidioidal infection during pregnancy in Tucson, Arizona, an area endemic for coccidioidomycosis.
University of Arizona Medical Center (UMC)
METHODS
We sought to identify cases of coccidioidomycosis during pregnancyin three health care facilities in Tucson, Arizona. Methods of case detection differed for each center. *From the Medical Service, Veterans Administrations .Medical Center, the Department of Internal Medicine, Section of Infectious Diseases, and the Respiratory Sciences Division, University of Arizona College of Medicine, Tucson. Manuscript received No.vember 9; revision accepted. January 25. Reprint requests: Dr. Ampel, Medical Service (111), VA Medical Center; Tucson 85723 376
This institution acts as both a primary care and a referral medical center. We obtained the medical records from January 1979 through December 1985 of all women aged 15 through 45 years seen at UMC who had (1) a reactive tube precipitin or complement fixation serology or (2) a positive culture for C. immitis from any site, or (3) a discharge diagnosis of coccidioidomycosis. We reviewed all records of those who met these criteria and were coincidentally pregnant. Tucson Medical Center (TMC)
At this community hospital, where the majority of deliveries in Tucson are performed, we used a computerized diagnosis recordkeeping system to locate the medical records from January 1979 through December 1985 of all women aged 15 through 45 years with the discharge diagnosis of coccidioidomycosis and pregnancy. These records were reviewed. University ofArizona Student Health Center (UASHC)
The UASHC is an outpatient facility providing care to approximately 30,000 college students. Students with pregnancies, once diagnosed, are referred to local private physicians for further care. With computer-generated diagnosis lists of coccidioidomycosis and pregnancy cases of coccidioidal infection occurring during pregnancy from June 1980 through June 1986 were located and the records reviewed. RESULTS
At UMC there were 11,971 deliveries and five cases of coccidioidomycosis complicating pregnancy during the time of this study: At TM C there were three cases of coccidioidomycosis among 34,427 deliveries. At UASHC, we found two cases of coccidioidomycosis during 722 pregnancies. Overall, these ten cases of Coccidioidomycosis during Pregnancy (Wackat al)
coccidioidomycosis constitute 0.02 percent of the 47,120 pregnancies surveyed. The clinical details of the ten cases of coccidioidomycosis during pregnancy are given in Table 1. The mean age of the women was 26 years, with a range from 16 to 38. Five of the women were white, and one each was black, Hispanic, or American Indian. In two instances, the race was not recorded. One of the women suffered from poorly controlled juvenile onset diabetes mellitus. All the others were healthy Seven of the women had coccidioidomycosis diagnosed during the first two trimesters: three during the first trimester, three during the second, and one three
months prior to pregnancy: All seven women recovered from their infections and are currently asymptomatic. Twowere treated with ketoeonazole during their acute illness. Two women developed fulminant coccidioidomycosis in the postpartum period. Both had symptoms consistent with a respiratory infection during the third trimester. Within ten days after delivery; both developed disseminated coccidioidal infection, with diffuse nodular infiltrates on the chest radiograph, and meningitis. Intravenous and intrathecal amphotericin B was given and both patients continue, more than four years later, to be treated for chronic coccidioidal
Table I-Summary ofFindings in Ten Patients with Coccidioidomycosis Diagnosed in Association with Pregnancy Patient No.
Agel Race
Underlying Disease
Type of Infection
Trimester and Date of Diagnosis
Serum Serology*
Skin Testt
1
16/B
JODM
Primary pneumonia; subsequent nodule
1st (Feb 1980)
TPCF-
POS
2
211W
None
Asymptomatic cavity
2nd (Jan 1979)
TPCF+:j:
NEG
3
28/W
None
Disseminated (cutaneous)
2nd (May 1983)
TPCF-
POS
4
38/W
None
Primary pneumonia
TPCF+
POS
5
34/H
None
Primary pneumonia
TPCF+:j:
NEG
6
33/W
None
Primary pneumonia
3mo before pregnancy (May 1985) 7d postpartum (Dec 1984) 2nd (July 1983)
ND
POS
7
26/W
None
Disseminated§
4d postpartum (Sept 1980)
TPCF 1:128
NEG
8
25/1
None
Disseminated§
10 d postpartum (Sept 1979)
TPCF 1:32
NEG
9
18/ND
None
Primary pneumonia
TP1st (March 1982) CF-
POS
10
24/ND
None
Primary pneumonia
1st (Sept 1985)
POS
ND
Treatment
Outcome
None
Nodule resolved; delivered healthy infant Cavity resected 11 mo Infection resolved; postpartum delivered healthy infant Ketoconazole Infection resolved; postpartum delivered healthy infant None Infection resolved; delivered healthy infant None
Infection resolved; delivered healthy infant Ketoconazole Infection resolved; from 2nd trimester delivered healthy to 2 wk postpartum infant Coccidioidal Amphotericin BII meningitis; delivered healthy infant Coccidoidal Amphotericin BII meningitis; delivered healthy infant None Infection resolved; elective abortion not related to infection None Infection resolved; elective abortion not related to infection
*The signs "+" and "- " indicate whether antibody was present or not. A number after "CF" indicates the titer. t"PQS" or "NEG" in this column indicates whether the patient had a positive or negative delayed dermal hypersensitivity reaction to coccidioidin. :j:Serum undiluted. §Symptoms of primary coccidioidal pneumonia during the third trimester with dissemination occurring immediately postpartum. Chest radiograph revealed a miliary pattern, and coccidioidal meningitis was diagnosed. [Intrathecal and intravenous amphotericin B given. unknown or not done, JODM = juvenile onset Abbreviations: B = black, W = white, H = Hispanic, I = American Indian, ND diabetes mellitus, TP = tube precipitin antibody; CF = complement fixing antibody CHEST I 94 I 2 I AUGUST; 1988
377
meningitis. A- third woman developed pulmonary coccidioidomycosis one week postpartum and recovered with p.o complication. Eight patients continued their pregnancies and delivered healthy full-term infants. Two patients chose to terminate their pregnancies; this decision was not related to their coccidioidal infection. DISCUSSION
Previous studies have emphasized the high mortality associated with coccidioidal infection during pregnancy 3,4,7,8,10-12 Purtilo, 6 on reviewing cases of fatal mycotic infection in 17 pregnant and 27 nonpregnant women from the files of the Armed Forces Institute of Pathology found coccidioidomycosis was the only mycotic infection that led to the death of pregnant women who were not immunosuppressed. Vaughn and Ramirez" reviewed 28 cases of coccidioidomycosis during pregnancy in Kern county for the period 1946 through 1949 and estimated the incidence of infection at approximately one in 1,000 pregnancies. There were nine deaths among the 28 cases. Smale and Waechter, 4 in reviewing the same endemic area for the years 1959 through 1967, found nine more deaths and concluded that disseminated coccidioidomycosis was the leading cause of maternal death during that time period. In two other reviews from armed services hospitals in nonendemic areas during the 1950s, five cases among 39,124 deliveries were identified, two of which resulted in maternal death. 7,8 In our study in Tucson, we found coccidioidomycosis during pregnancy to be rare, with only ten cases among over 47,000 pregnancies in an endemic area. The prevalence may be even lower when one considers that in four of our cases (numbers 1, 6, 9, and io in Table 1), the diagnosis of coccidioidomycosis was only presumptive and was based on a compatible clinical course in association with a positive coccidioidal skin test. In addition, we found no fatalities associated with coccidioidomycosis during pregnancy Even in the most fulminant cases occurring during the postpartum period, the two patients were alive severalyears later. Several factors may account for these findings when com-pared to previous studies, First, we may have failed to locate cases because of restrictions due to our search methods. However, since our methods were directed predominantly at hospitalized patients, it is likely that any cases missed were among those who wereminimally symptomatic. It is also possible that improvement in medical care, particularly the introduction of antifungal therapy; played a role in reducing the mortality in our patients. We cannot assess this in our study: Further, it is not clear that the populations in our study and in earlier studies are comparable. They may have differed in age, racial background, and in risk of exposure to C immitis. Finally; those in 378
earlier studies may have been at increased risk for maternal mortality because of reasons other than coccidioidomycosis. The latter half of pregnancy and the peripartum period have been stressed as particularly vulnerable periods for coccidioidal infection and subsequent dissemination. 3,4,7,&,10-~2 Both women in our study who developed fulminant, disseminated coccidioidomycosis did so immediately postpartum after presumably acquiring pulmonary coccidioidomycosis during the third trimester. These cases demonstrate the increased risk of fulminant infection associated with the immediate postpartum period and are similar to previous experiences with tuberculosis." (Einstein HE, personal communication). The role of antifungal therapy for coccidioidomycosis during pregnancy remains undefined. Amphotericin B was, first used to treat disseminated coccidioidomycosis in pregnant women in the mid-1950s. In one series from 1950 through 1967, 4 four of the nine patients treated with amphotericin B survived, although there was significant renal toxicity: Hadsall" and Harris? each added one case to the literature: both cases had favorable outcomes. Aggressive intervention at 32 weeks of gestation and careful monitoring for toxicity allowed a favorable outcome in the most recent case reported in 1980. 13 In our series, amphotericin B administered intrathecally and intravenously immediately postpartum appeared to be lifesaving in two cases. Ketoconazole was also used in one case with severe second trimester coccidioidalpneumonia, which subsequently resolved. The utility of ketoconazole in the treatment of coccidioidomycosis during pregnancy will require further study ACKNOWLEDGMENTS: The writers thank Michael Yozwiak and Linda Minnich for their kind assistance. This work was presented in part at the American Society for Microbiology meetings, Atlanta, Georgia, March 1-5, 1987. REFERENCES
1 Kerrick SS, Lundergan LL, Galgiani IN. Coccidioidomycosis at a university health service. Am Rev Respir Dis 1985; 131:100102 2 SJ11ale LE, Birsner JW Maternal deaths from coccidioidomycosis. JAMA 1949; 140:1152-54 3 Vaughan JE, Ramirez H. Coccidioidomycosis as a complication of pregnancy Calif Med 1951; 74:121-25 4 Smale LE, Waechter KG. Dissemination of coccidioidomycosis in pregnancy Am J Obstet Gynecol1970; 107:356-61 5 Pappagianis D. Epidemiology of coccidioidomycosis. In: Coccidioidomycosis, Stevens D, ed. New York: Plenum 1980; 63-85. 6 Purtilc DT. Opportunistic mycotic infections in pregnant women. Am J Obstet Gynecol 1975; 122:607-10 7 Harrison HN. Fatal maternal coccidioidomycosis: a case report and review of sixteen cases from the literature. Am J Obstet Gynecol1958~ 75:813-20 8 Baker RL. Pregnancy complicated by coccidioidomycosis: report of two cases. Am J Obstet Gynecol1955; 70:1033-38 9 Hadsall FJ, Acquarelli MJ. Disseminated coccidioidomycosis Coccidioidomycosis during Pregnancy (Wackat a/)
presenting as facial granulomas in pregnancy: a report of two cases and a review of the literature. Laryngoscope 1973; 83:5158 10 Harris RE. Coccidioidomycosis complicating pregnancy: report of 3 cases and review of the literature. Obstet Gynecol 1966; 28:401-405 11 Mongan ES. Acute disseminated coccidioidomycosis. Am J Med 1958; 24:820-22 12 Van Bergen WS, Fleury FJ, Cheatle EL. Fatal maternal dissem-
inated coccidioidomycosis in a nonendemic area. Am J Obstet Gynecol1976; 124:661-63 13 McCoy MJ, Ellenberg JF, Killam AE Coccidioidomycosis complicating pregnancy Am J Obstet Gynecol1980; 137:739-40. 14 Catanzaro A. Pulmonary mycosis in pregnant women. Chest 1984; 86:145-185 15 Weinburg ED. Pregnancy-associated depression of cell-mediated immunity Rev Infect Dis 1984; 6:814-31
Plan to Attend 54th Annual Scientific Assembly Anaheim October 3-7, 1988
CHEST / 94 / 2 / AUGUS-r, 1988
379
Previous studies have suggested that coccidioidomycosis during pregnancy is a devastating illness associated with high maternal mortality However, this concept recently has been challenged. We examined the incidence of coccidioidomycosis during pregnancy in Tuscon, Arizona, an area endemic for this infection. After reviewing the records of three separate health care facilities, we found ten cases of coccidioidomycosis among 47,120 pregnancies. Nine of the ten women had no underlying disease. Seven were diagnosed with coccidioidomycosis during either the first or second trimester, . Illness resolved in all seven. Three other
patients were diagnosed during the first ten days postpartum. While infection was self-limited in one woman, two others developed severe disseminated coccidioidomycosis associated with meningitis. Despite this, there were no maternal deaths. Of eight deliveries, all were uncomplicated and produced healthy infants. In summary, diagnosing coccidioidomycosis during pregnancy is rare. Although we observed no maternal death, our experience suggests that women who develop coccidioidomycosis late in pregnancy are at risk for developing severe disseminated infection.
COCcidiOidomYCOSiS is a fungal infection caused by the soil saprophyte Coccidioides immitis. In endemic areas of the southwestern United States, the average annual incidence of symptomatic infection among young adults is 0.4 percent of the susceptible (skin-test negative) population. 1 In most patients, infection is asymptomatic and detected only by skin-test conversion. Severe disease is unusual, and dissemination of infection beyond the lungs occurs in less than 1 percent of those infected. Coccidioidal infection during pregnancy has been described as devastating. 2-13 It has been estimated that pregnant women with symptomatic infections have at least a 10 percent risk of dissemination and, if this occurs, a 90 percent mortality: 5 However, much of this information is based on experience from previous decades, and recently it has been suggested that these estimates may no longer be accurate. 14 Because of this, we decided to examine the current pattern of coccidioidal infection during pregnancy in Tucson, Arizona, an area endemic for coccidioidomycosis.
University of Arizona Medical Center (UMC)
METHODS
We sought to identify cases of coccidioidomycosis during pregnancyin three health care facilities in Tucson, Arizona. Methods of case detection differed for each center. *From the Medical Service, Veterans Administrations .Medical Center, the Department of Internal Medicine, Section of Infectious Diseases, and the Respiratory Sciences Division, University of Arizona College of Medicine, Tucson. Manuscript received No.vember 9; revision accepted. January 25. Reprint requests: Dr. Ampel, Medical Service (111), VA Medical Center; Tucson 85723 376
This institution acts as both a primary care and a referral medical center. We obtained the medical records from January 1979 through December 1985 of all women aged 15 through 45 years seen at UMC who had (1) a reactive tube precipitin or complement fixation serology or (2) a positive culture for C. immitis from any site, or (3) a discharge diagnosis of coccidioidomycosis. We reviewed all records of those who met these criteria and were coincidentally pregnant. Tucson Medical Center (TMC)
At this community hospital, where the majority of deliveries in Tucson are performed, we used a computerized diagnosis recordkeeping system to locate the medical records from January 1979 through December 1985 of all women aged 15 through 45 years with the discharge diagnosis of coccidioidomycosis and pregnancy. These records were reviewed. University ofArizona Student Health Center (UASHC)
The UASHC is an outpatient facility providing care to approximately 30,000 college students. Students with pregnancies, once diagnosed, are referred to local private physicians for further care. With computer-generated diagnosis lists of coccidioidomycosis and pregnancy cases of coccidioidal infection occurring during pregnancy from June 1980 through June 1986 were located and the records reviewed. RESULTS
At UMC there were 11,971 deliveries and five cases of coccidioidomycosis complicating pregnancy during the time of this study: At TM C there were three cases of coccidioidomycosis among 34,427 deliveries. At UASHC, we found two cases of coccidioidomycosis during 722 pregnancies. Overall, these ten cases of Coccidioidomycosis during Pregnancy (Wackat al)
coccidioidomycosis constitute 0.02 percent of the 47,120 pregnancies surveyed. The clinical details of the ten cases of coccidioidomycosis during pregnancy are given in Table 1. The mean age of the women was 26 years, with a range from 16 to 38. Five of the women were white, and one each was black, Hispanic, or American Indian. In two instances, the race was not recorded. One of the women suffered from poorly controlled juvenile onset diabetes mellitus. All the others were healthy Seven of the women had coccidioidomycosis diagnosed during the first two trimesters: three during the first trimester, three during the second, and one three
months prior to pregnancy: All seven women recovered from their infections and are currently asymptomatic. Twowere treated with ketoeonazole during their acute illness. Two women developed fulminant coccidioidomycosis in the postpartum period. Both had symptoms consistent with a respiratory infection during the third trimester. Within ten days after delivery; both developed disseminated coccidioidal infection, with diffuse nodular infiltrates on the chest radiograph, and meningitis. Intravenous and intrathecal amphotericin B was given and both patients continue, more than four years later, to be treated for chronic coccidioidal
Table I-Summary ofFindings in Ten Patients with Coccidioidomycosis Diagnosed in Association with Pregnancy Patient No.
Agel Race
Underlying Disease
Type of Infection
Trimester and Date of Diagnosis
Serum Serology*
Skin Testt
1
16/B
JODM
Primary pneumonia; subsequent nodule
1st (Feb 1980)
TPCF-
POS
2
211W
None
Asymptomatic cavity
2nd (Jan 1979)
TPCF+:j:
NEG
3
28/W
None
Disseminated (cutaneous)
2nd (May 1983)
TPCF-
POS
4
38/W
None
Primary pneumonia
TPCF+
POS
5
34/H
None
Primary pneumonia
TPCF+:j:
NEG
6
33/W
None
Primary pneumonia
3mo before pregnancy (May 1985) 7d postpartum (Dec 1984) 2nd (July 1983)
ND
POS
7
26/W
None
Disseminated§
4d postpartum (Sept 1980)
TPCF 1:128
NEG
8
25/1
None
Disseminated§
10 d postpartum (Sept 1979)
TPCF 1:32
NEG
9
18/ND
None
Primary pneumonia
TP1st (March 1982) CF-
POS
10
24/ND
None
Primary pneumonia
1st (Sept 1985)
POS
ND
Treatment
Outcome
None
Nodule resolved; delivered healthy infant Cavity resected 11 mo Infection resolved; postpartum delivered healthy infant Ketoconazole Infection resolved; postpartum delivered healthy infant None Infection resolved; delivered healthy infant None
Infection resolved; delivered healthy infant Ketoconazole Infection resolved; from 2nd trimester delivered healthy to 2 wk postpartum infant Coccidioidal Amphotericin BII meningitis; delivered healthy infant Coccidoidal Amphotericin BII meningitis; delivered healthy infant None Infection resolved; elective abortion not related to infection None Infection resolved; elective abortion not related to infection
*The signs "+" and "- " indicate whether antibody was present or not. A number after "CF" indicates the titer. t"PQS" or "NEG" in this column indicates whether the patient had a positive or negative delayed dermal hypersensitivity reaction to coccidioidin. :j:Serum undiluted. §Symptoms of primary coccidioidal pneumonia during the third trimester with dissemination occurring immediately postpartum. Chest radiograph revealed a miliary pattern, and coccidioidal meningitis was diagnosed. [Intrathecal and intravenous amphotericin B given. unknown or not done, JODM = juvenile onset Abbreviations: B = black, W = white, H = Hispanic, I = American Indian, ND diabetes mellitus, TP = tube precipitin antibody; CF = complement fixing antibody CHEST I 94 I 2 I AUGUST; 1988
377
meningitis. A- third woman developed pulmonary coccidioidomycosis one week postpartum and recovered with p.o complication. Eight patients continued their pregnancies and delivered healthy full-term infants. Two patients chose to terminate their pregnancies; this decision was not related to their coccidioidal infection. DISCUSSION
Previous studies have emphasized the high mortality associated with coccidioidal infection during pregnancy 3,4,7,8,10-12 Purtilo, 6 on reviewing cases of fatal mycotic infection in 17 pregnant and 27 nonpregnant women from the files of the Armed Forces Institute of Pathology found coccidioidomycosis was the only mycotic infection that led to the death of pregnant women who were not immunosuppressed. Vaughn and Ramirez" reviewed 28 cases of coccidioidomycosis during pregnancy in Kern county for the period 1946 through 1949 and estimated the incidence of infection at approximately one in 1,000 pregnancies. There were nine deaths among the 28 cases. Smale and Waechter, 4 in reviewing the same endemic area for the years 1959 through 1967, found nine more deaths and concluded that disseminated coccidioidomycosis was the leading cause of maternal death during that time period. In two other reviews from armed services hospitals in nonendemic areas during the 1950s, five cases among 39,124 deliveries were identified, two of which resulted in maternal death. 7,8 In our study in Tucson, we found coccidioidomycosis during pregnancy to be rare, with only ten cases among over 47,000 pregnancies in an endemic area. The prevalence may be even lower when one considers that in four of our cases (numbers 1, 6, 9, and io in Table 1), the diagnosis of coccidioidomycosis was only presumptive and was based on a compatible clinical course in association with a positive coccidioidal skin test. In addition, we found no fatalities associated with coccidioidomycosis during pregnancy Even in the most fulminant cases occurring during the postpartum period, the two patients were alive severalyears later. Several factors may account for these findings when com-pared to previous studies, First, we may have failed to locate cases because of restrictions due to our search methods. However, since our methods were directed predominantly at hospitalized patients, it is likely that any cases missed were among those who wereminimally symptomatic. It is also possible that improvement in medical care, particularly the introduction of antifungal therapy; played a role in reducing the mortality in our patients. We cannot assess this in our study: Further, it is not clear that the populations in our study and in earlier studies are comparable. They may have differed in age, racial background, and in risk of exposure to C immitis. Finally; those in 378
earlier studies may have been at increased risk for maternal mortality because of reasons other than coccidioidomycosis. The latter half of pregnancy and the peripartum period have been stressed as particularly vulnerable periods for coccidioidal infection and subsequent dissemination. 3,4,7,&,10-~2 Both women in our study who developed fulminant, disseminated coccidioidomycosis did so immediately postpartum after presumably acquiring pulmonary coccidioidomycosis during the third trimester. These cases demonstrate the increased risk of fulminant infection associated with the immediate postpartum period and are similar to previous experiences with tuberculosis." (Einstein HE, personal communication). The role of antifungal therapy for coccidioidomycosis during pregnancy remains undefined. Amphotericin B was, first used to treat disseminated coccidioidomycosis in pregnant women in the mid-1950s. In one series from 1950 through 1967, 4 four of the nine patients treated with amphotericin B survived, although there was significant renal toxicity: Hadsall" and Harris? each added one case to the literature: both cases had favorable outcomes. Aggressive intervention at 32 weeks of gestation and careful monitoring for toxicity allowed a favorable outcome in the most recent case reported in 1980. 13 In our series, amphotericin B administered intrathecally and intravenously immediately postpartum appeared to be lifesaving in two cases. Ketoconazole was also used in one case with severe second trimester coccidioidalpneumonia, which subsequently resolved. The utility of ketoconazole in the treatment of coccidioidomycosis during pregnancy will require further study ACKNOWLEDGMENTS: The writers thank Michael Yozwiak and Linda Minnich for their kind assistance. This work was presented in part at the American Society for Microbiology meetings, Atlanta, Georgia, March 1-5, 1987. REFERENCES
1 Kerrick SS, Lundergan LL, Galgiani IN. Coccidioidomycosis at a university health service. Am Rev Respir Dis 1985; 131:100102 2 SJ11ale LE, Birsner JW Maternal deaths from coccidioidomycosis. JAMA 1949; 140:1152-54 3 Vaughan JE, Ramirez H. Coccidioidomycosis as a complication of pregnancy Calif Med 1951; 74:121-25 4 Smale LE, Waechter KG. Dissemination of coccidioidomycosis in pregnancy Am J Obstet Gynecol1970; 107:356-61 5 Pappagianis D. Epidemiology of coccidioidomycosis. In: Coccidioidomycosis, Stevens D, ed. New York: Plenum 1980; 63-85. 6 Purtilc DT. Opportunistic mycotic infections in pregnant women. Am J Obstet Gynecol 1975; 122:607-10 7 Harrison HN. Fatal maternal coccidioidomycosis: a case report and review of sixteen cases from the literature. Am J Obstet Gynecol1958~ 75:813-20 8 Baker RL. Pregnancy complicated by coccidioidomycosis: report of two cases. Am J Obstet Gynecol1955; 70:1033-38 9 Hadsall FJ, Acquarelli MJ. Disseminated coccidioidomycosis Coccidioidomycosis during Pregnancy (Wackat a/)
presenting as facial granulomas in pregnancy: a report of two cases and a review of the literature. Laryngoscope 1973; 83:5158 10 Harris RE. Coccidioidomycosis complicating pregnancy: report of 3 cases and review of the literature. Obstet Gynecol 1966; 28:401-405 11 Mongan ES. Acute disseminated coccidioidomycosis. Am J Med 1958; 24:820-22 12 Van Bergen WS, Fleury FJ, Cheatle EL. Fatal maternal dissem-
inated coccidioidomycosis in a nonendemic area. Am J Obstet Gynecol1976; 124:661-63 13 McCoy MJ, Ellenberg JF, Killam AE Coccidioidomycosis complicating pregnancy Am J Obstet Gynecol1980; 137:739-40. 14 Catanzaro A. Pulmonary mycosis in pregnant women. Chest 1984; 86:145-185 15 Weinburg ED. Pregnancy-associated depression of cell-mediated immunity Rev Infect Dis 1984; 6:814-31
Plan to Attend 54th Annual Scientific Assembly Anaheim October 3-7, 1988
CHEST / 94 / 2 / AUGUS-r, 1988
379