Core Competency in Valley Fever

Knowledge Assessment

1. Most patients infected with coccidioidomycosis can be recognized by

a. A relatively simple history and a brief physical examination

b. Specific laboratory tests

c. A detailed exposure history

d. Characteristic chest X-ray findings

2. An important generalization about coccidioidal serologic tests is that:

a. They are both sensitive and specific

b. They are neither sensitive nor specific

c. They are sensitive but nonspecific

d. They are specific but not very sensitive

3. A 37 year-old male patient was told that he had Valley Fever ten years ago because Coccidioides immitis was isolated from a bronchoscopy specimen. Serial chest X-rays showed the pulmonary infiltrate evolved into a 1.7 cm pulmonary nodule and coccidioidal serologies became nonreactive. He received no treatment and otherwise has been in excellent health. Recently, the patient has noted increasing fatigue. A repeat chest X-ray shows the pulmonary nodule to be unchanged. The proper management of this situation would be

a. Start an oral antifungal drug.

b. Start a parenteral antifungal drug

c. Refer the patient for a surgical consultation to remove the pulmonary nodule.

d. Ignore the prior history of Valley Fever and begin looking for an alternative explanation for the fatigue.

4. A 26 year-old male graduate student developed pulmonary coccidioidomycosis. A coccidioidal antibody test was positive. The respiratory symptoms, fever, and weight loss improved over the course of five weeks but diffuse arthralgias and fatigue persisted. This pattern

a. Is within the spectrum of simple uncomplicated primary coccidioidal infection.

b. Is unlikely to be due to coccidioidal infection.

c. Likely represents spread of infection outside of the lungs many extra-pulmonary sites.

d. Is typical of patients reported to benefit from threatment with an antifungal drug.

5. The risk of infection with Coccidoides immitis is greatest during

a. hot months

b. rainy months

c. Arid months

d. Cold months

6. The estimated annual risk of infection with Coccidioides immitis is

a. 0.5%

b. 3.0%

c. 10 %

d. 20 %

7. A 49 year-old female nurse who had had smoked for 20 years until five years ago, ws found to have a 3.2 cm pulmonary nodule on a pre-employment chest X-ray. The patient had had a previous chest X-ray 4 years ago which was normal. She has lived her entire life in the Phoenix area. Coccidioidal antibodies were not detected in her serum and all other laboratory studies were normal. The least appropriate management strategy would be

a. Resect the lesion by thoracotomy

b. Resect the lesion by pleuroscopy

c. Perform a percutaneous fine needle aspiration (FNA) and resect the lesion if tissue demonstrates cancer.

d. Perform serial chest X-rays every 3 to 6 months and resect the lesion if it enlarges.

8. A 28 year-old patient with no concurrent medical problems develops pleuritic chest pain, an increased erythrocyte sedimentation rate, and a dry cough of two weeks duration. A chest X-ray shows a right lower lobe pneumonia with ipsilateral hilar adenopathy. A coccidioidal serology is positive. The best treatment for this patient is

a. Unknown

b. Treatment for 6 weeks with an oral antifungal drug at a prescription cost of $900

c. Treatment for 1 year with an oral antifungal drug at a prescription cost of $9,000.

d. Treatment for 2 months with amphotericin B at a prescription cost of $9,000.

9. A 53 year-old insulin-requiring adult-onset diabetic female sought medical attention because of hemoptysis. As part of the initial evaluation, a chest X-ray demonstrated a left apical cavity of 3 cm in diameter. Coccidioidal serology was positive and pulmonary consultant recommended beginning an oral antifungal treatment which was done and the patient’s disappeared. In counselling the patient, which of the following statements would be most accurate.

a. If the patient takes all of the prescribed medicine for the entire course of treatment, the cavity will resolve.

b. There is a good chance that the cavity will eventually have to be removed surgically

c. When treatment is stopped there is a significant (~30%) chance that symptoms will recur.

d. Improvement is most likely fortuitous and not related to the treatment.

10. Significant risk factors for spread of a coccidioidal infection outside of the lungs include all of the following except

a. AIDS

b. Hodgkins disease

c. Organ transplantation

d. Hypo-gammaglobulinemia

11. A 67 year-old grandmother who recently retired to Sun City, Arizona, was diagnosed with coccidioidal pneumonia after 4 weeks of respiratory symptoms. All evidence suggests that her illness is improving. She is concerned that she is not yet well. Appropriate patient education would include all but which?

a. To reduce the risk of spreading her coccidioidal infection, avoid contact with her grandchildren until the respiratory symptoms have fully resolved.

b. Reassurance that fatigue is a common symptom of coccidioidal pneumonia and may be the last symptom to resolve.

c. Indicate that treatment is possibly something to try if symptoms persist but that most people become better without treatment.

d. The patient might benefit from starting a journal in which weekly entries would detail symptoms and physical limitations. This might help determine how much better or worse she was before her next visit.

12. Most coccidioidal infections that have spread beyond the lungs

a. Do so because the patient was exposed to a very large number of fungal spores when aquiring the infection.

b. Occur because the patients’ immune defenses are different in some way from patients who are able to control a coccidioidal infection without its spread beyond the lungs.

c. Are associated with some pulmonary evidence of recent infection.

d. Involve the stomach or small intestines.

13. A woman who is 25 weeks pregnant is newly diagnosed with pulmonary coccidioidomycosis. On chest X-ray, the infection appears to be localized to a portion of one lobe and her symptoms are bothersome but not incapacitating. As her primary care physician, you recommend:

a. Immediately begin treatment with an oral antifungal.

b. Immediately begin treatment with amphotericin B.

c. Reassure the patient that Valley Fever is very common and usually does not cause serious problems.

d. Immediately refer the patient to a pulmonary or infectious diseases specialist.

14. A patient residing in Tucson, Arizona, was discovered to have a thin-walled peripheral pulmonary cavity approximately 2.5 cm in diameter in the right upper lobe. There were no associated symptoms or other medical conditions. Appropriate recommendations for management could include all of the following EXCEPT:

a. Coccidioidal serology.

b. Percutaneous fine needle aspiration (FNA).

c. Surgical resection.

d. Periodic radiographic reassessment without intervention if the condition remains stable.

15. Factors associated with increased risk of disseminated coccidioidal infection include

a. Diabetes

b. Smoking

c. Neutropenia

d. AIDS