Even in the absence of the risk factors previously discussed, it is important to assess patients with C. immitis infections for complications because they can also occur in patients without apparent reason. Complications from initial coccidioidal infections are divided into those that occur in the chest and those that involve parts of the body outside of the lungs (extrapulmonary dissemination). These two types of complications usually do not overlap. Most complications produce localized symptoms and signs of chronic or subacute inflammation. As a result, a careful review of symptoms and physical examination are usually a sufficiently sensitive initial screen.

Most complications manifest within the first year or two after the initial infection. If a new complaint develops in association with a recent coccidioidal infection, its possible relationship to the infection should be considered. For example, low back pain is a common symptom and mild discomfort of this nature is often managed symptomatically before extensive diagnostic studies are undertaken. However, if this symptom were to develop in a patient within of developing coccidioidal pneumonia, it may be useful to recommend a radionuclide scan to determine if the new symptom is due to infection in the lumbar vertebrae. This is done to detect complications early, before serious tissue destruction occurs.

Pulmonary Complications

Persistent or slowly resolving pneumonia. Most pulmonary infections are subacute in nature. Without treatment, symptoms usually improve within the first month but may not completely resolve for several months. In some patients, the course of illness is even more protracted. There is no consensus regarding how protracted illness must be before it is considered as slowly resolving. However, in studies of new therapies for coccidioidomycosis, entry criteria often specify that pulmonary disease must have been present for at least three months; in clinical practice, shorter periods of illness may be more reasonable.

Pulmonary cavitation. Cavities form in approximately 5% of patients with coccidioidal pneumonia. Of these, half will disappear within the first two years. Many cavities cause no symptoms. Others cause discomfort, cough, hemoptysis, and occasionally constitutional symptoms of fatigue, night sweats, and weight loss. Occasionally, a coccidioidal cavity will rupture into the pleural space.

Chronic fibrocavitary pneumonia. A few patients experience repeated development of pneumonia over a period of many years. Sometimes, this includes different lobes of the lung.

Diffuse fulminant pneumonia. In some patients coccidioidal pneumonia is very severe, causing hypoxia and requiring respiratory support to prevent respiratory collapse. This is obviously a major complication and is handled very differently than most infections.

Extrapulmonary dissemination

When infection spreads beyond the lungs, it usually does so within the first several months after the initial infection and nearly always within the first two years.

In this way, coccidioidal infections differ from tuberculosis which commonly returns decades after the initial infection. An important exception to this rule is in the intercurrent development of major degrees of immunosuppression of the nature discussed above. The most common sites of dissemination are skin, joints, bones and the meninges. However, virtually any part of the body can be affected.