Increasing Frequency and Severity of Pediatric Coccidioidomycosis

Source: Malhotra S, Adachi K, Kaur I, et al. Rising burden of severe pediatric coccidioidomycosis: a 25-year single-center study. J Pediatric Infect Dis Soc. 2026;15(4):piag019; doi: 10.1093/jpids/piag019.Investigators from the University of California Los Angeles (UCLA) conducted a retrospective study to evaluate trends in children treated at their center for coccidioidomycosis over a 25-year period and compare the clinical presentation, treatment, and outcomes of those with primary vs disseminated disease. Study participants were patients <18 years old with coccidioidomycosis who were evaluated at UCLA between 2000 and 2025. Study children were identified by ICD codes, positive culture for Coccidioides spp., or a positive serum Coccidioides complement fixation test. The medical records of the identified patients were reviewed to confirm eligibility and collect data on demographics, medical history, treatment, and outcomes. Children were classified as having primary coccidioidomycosis if they were asymptomatic or had localized pulmonary infection or with disseminated coccidioidomycosis if they had extra-pulmonary disease. The characteristics of patients with primary or disseminated disease were compared with a variety of statistical tests.Data were analyzed on 81 children with coccidioidomycosis. The mean age of study patients was 11.8 years, and 9% were immunocompromised. During the period 2000–2025, the number of children seen at UCLA with coccidioidomycosis increased, with large increases between 2018 and 2024. There were 58 (72%) children with primary coccidioidomycosis and 23 (28%) with disseminated disease. Those with primary disease were significantly older (mean age, 12.5 vs 10.2 years; P = 0.046) and more likely to present with cough (57% vs 26%; P = 0.012) and chest pain (40% vs 4%; P = 0.002) than children with disseminated coccidioidomycosis, while those with disseminated disease were more likely to present with central nervous system (CNS) symptoms (30% vs 10%; P = 0.026). There was no difference between groups in duration of symptoms prior to diagnosis (78 days for those with primary disease and 79 days for those with disseminated coccidioidomycosis). Children with disseminated disease were more likely than those with primary coccidioidomycosis to be hospitalized (87% vs 47%; P = 0.001) and had longer hospitalizations (P <0.0010). Overall, 71 (88%) children were treated with antifungal therapy, with 90% initially receiving fluconazole. Those with disseminated disease were more likely to require multiple medications than patients with primary coccidioidomycosis (83% vs 21%; P <0.001), including mold-active triazoles and amphotericin B. A total of 23 (28%) children required surgical intervention, including 17 (74%) of those with disseminated disease and 6 (26%) with primary disease (P <0.001). There were 3 deaths in study children: 2 from meningitis and 1 from pulmonary disease with acute respiratory distress syndrome.The authors conclude that the frequency of children presenting with coccidioidomycosis at their center increased over the 25-year study period.Dr Brady has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.The current authors report a substantial increase in the incidence of pediatric coccidioidomycosis in southern California over the past 25 years. Climate change and increasing swings between rainy and drought periods have led to this increase.1,2 The geographic area of endemicity also is expanding.1 Clinicians who see patients who have been to these areas need to be prepared to recognize the various presentations of coccidioidomycosis and plan an appropriate diagnostic evaluation.The first step is taking a thorough travel, occupational, and recreational history. Coccidioides spp. inhabit soil in arid regions. C. immitis is found in California’s San Joaquin Valley and Washington.3 C. posadasii’s endemic area includes the southern regions of Arizona, Utah, Nevada, New Mexico, western Texas, and regions of Central and South America.3,4The classical description of coccidioidomycosis in children5 includes: (1) primary pulmonary infection, such as community-acquired pneumonia; (2) primary coccidioidal granuloma, a benign local skin lesion resulting from direct inoculation or trauma; and (3) disseminated disease, a chronic, systemic, granulomatous disease.When coccidioidomycosis is suspected, serologic tests are the first tests.3 The enzyme immunoassay (EIA) often is performed initially because it is sensitive and provides rapid results. If the EIA is positive, then the immunodiffusion test (more specific) and/or complement fixation (more sensitive) are used to confirm the infection.4,6 Cultures and histopathology are useful but often require invasive procedures.3The frequency and severity of coccidioidomycosis have increased in children over the past 25 years. Clinicians should be familiar with its areas of endemicity, myriad clinical manifestations, and diagnostic approach.A concurrent publication from California and Arizona documents wide clinician variability in the assessment of pediatric coccidioidomycosis, which has a self-limited duration in most children and does not require treatment in many cases.7