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Coccidioidomycosis

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Overview
Fungal infection that occurs primarily as a respiratory tract infection, although generalized dissemination may occur
Also known as valley fever or San Joaquin Valley fever
Overview-Pathophysiology
After spores are inhaled, cell activation and cytokine formation stimulate inflammatory cells and facilitate killing of the organism, initially infecting the lungs.
In the lungs, the spores change from barrel-shaped spores to spheres and enlarge, eventually changing into individual endospores that are released into the tissues and initiate an inflammatory response.
Normal immune response helps to control the infection.
However, Immunosuppression may delay resolution of the infection.
The incubation period is 1 to 4 weeks after exposure.
Overview-Causes
Inhalation of spores from cultures of infected persons
Inhaled spores of Coccidioides immitis found in the soil
Overview-Incidence
Disseminated illness is more common in dark-skinned males, pregnant females, and patients receiving an immunosuppressant.
Coccidioidomycosis is endemic to the southwestern United States, especially between the San Joaquin Valley in California and southwestern Texas; it's also found in Mexico, Guatemala, Honduras, Venezuela, Colombia, Argentina, and Paraguay.
This disease generally affects Filipino Americans, Hispanic Americans, Native Americans, and Blacks because of population distribution and an occupational link (common in migrant farm laborers).
Overview-Complications
Meningitis
Bronchiectasis
Osteomyelitis
Hepatosplenomegaly
Liver failure
Pulmonary scarring
Septic arthritis
Assessment-History
Possibly asymptomatic
Living or traveling to an endemic area
Dry cough
Pleuritic chest pain
Sore throat
Chills
Malaise
Headache
Joint pain
Night sweats
Weight loss
Assessment-Physical Findings
Fever
Itchy maculopapular rash
Hemoptysis
Local swelling and redness in involved sites (with musculoskeletal involvement)
Pleural friction rub
Wheezing
Crackles
Decreased breath sounds; dullness on percussion; increased tactile and vocal fremitus
Hepatomegaly and splenomegaly with disseminated disease
Diagnostic Test Results-Laboratory
Complement fixation for immunoglobulin G antibodies.
Positive serum precipitins (immunoglobulins) may be seen.
C. immitis spores may be detected through immunodiffusion testing of sputum, pus from lesions, and tissue biopsy.
Presence of antibodies in pleural and joint fluid and a rising serum or body fluid antibody titer (indicate dissemination) may be present.
White blood cell count may be increased.
Eosinophil count may be increased.
Erythrocyte sedimentation rate may be increased.
Diagnostic Test Results-Imaging
Chest X-ray shows bilateral diffuse infiltrates, nodules, mediastinal or hilar adenopathy, or pleural effusion.
Chest computed tomography reveals abnormalities such as multiple nodules, interlobar septal thickening, and consolidation.
Diagnostic Test Results-Other
Biopsy of the affected tissue (lung or skin lesion) reveals evidence of a fungus.
Treatment-General
Symptomatic measures
Humidification of environment
Treatment-Activity
Bed rest
Treatment-Medications
I.V. fluids
Amphotericin B for severe and rapidly progressive disease
Ketoconazole, fluconazole, or itraconazole for nondisseminated disease
Analgesics, such as nonsteroidal anti-inflammatory drugs (NSAIDs) for pleuritic chest pain
Antitussives for cough
Treatment-Surgery
Reserved for chronic pulmonary coccidioidal infection with complications
Excision or drainage of lesions
Lobectomy for severe pulmonary lesions
Nursing Considerations-Nursing Diagnoses
Acute pain
Impaired gas exchange
Impaired skin integrity
Ineffective airway clearance
Ineffective breathing pattern
Risk for decreased cardiac perfusion
Risk for ineffective cerebral tissue perfusion
Nursing Considerations-Expected Outcomes
verbalize a decrease in pain
maintain adequate ventilation
exhibit improvement in rash and lesions
maintain a patent airway
maintain effective breathing pattern
exhibit signs and symptoms of adequate cardiac tissue perfusion
maintain adequate cerebral tissue perfusion.
Nursing Considerations-Nursing Interventions
Employ standard precautions.
Encourage bed rest.
Cluster nursing activities to minimize energy expenditure and oxygen demand. Encourage the use of energy conservation measures.
Administer oxygen as ordered based on oxygen saturation levels via pulse oximetry.
Auscultate lung sounds for changes.
Encourage coughing, deep breathing, and incentive spirometry to promote lung expansion. Elevate the head of the bed or encourage the patient to sit up to allow for maximum chest expansion and to ease the work of breathing.
Maintain a patent airway.
Provide cool mist humidification and other respiratory care measures to relieve cough.
Administer prescribed medications, such as NSAIDs for pain, antitussives for cough, and antifungal agents.
If ketoconazole is ordered, avoid administration of histamine-2 blockers, which decrease the absorption of ketoconazole.
Encourage adequate fluid intake. Offer frequent sips of fluids. Check skin turgor and inspect mucous membranes for moisture.
Obtain specimens for laboratory testing, such as sputum for cultures and blood for complete blood count.
Provide skin care measures as indicated.
Nursing Considerations-Monitoring
Fluid balance status
Intake and output
Vital signs
Sputum color, consistency, and amount
Oxygen saturation level
Cardiopulmonary status
Breath sounds
Level of orientation
Nursing Considerations-Associated Nursing Procedures
Blood pressure assessment
Humidifier therapy, bedside
IV bag preparation
IV bolus injection
IV catheter insertion
Intake and output assessment
Neurologic assessment
Oxygen administration
Pulse assessment
Pulse oximetry
Respiration assessment
Sputum collection by expectoration
Temperature assessment
Venipuncture
Patient Teaching-General
disorder, diagnosis, underlying cause, and treatment, including medication therapy
prescribed medications, such as antifungal agents, including drugs, dosages, schedule of administration, and duration of therapy, possibly ranging from 3 to 6 months
possible adverse reactions associated with medication therapy and signs and symptoms that need to be reported to a practitioner
that most cases are self-limiting and resolve in a few months but that relapse of extrapulmonary or disseminated disease is common
proper hand-washing technique and prevention measures to reduce the risk for exposure, especially for patients involved in working with soil (digging, construction)
appropriate skin care measures
importance of continued follow-up to ensure eradication of the infection.