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# Endemic mycoses: blastomycosis and coccidioidomycosis

Blastomycosis and coccidioidomycosis are lung infections caught by breathing fungal spores from soil in certain areas; they can spread to skin, bone or brain.

Updated 2026-11-01

## Structures involved

Tap one to see what it is and open it in 3D.

- [Skin](https://durgical.com/en/anatomy/skin/)
- [Mediastinal lymph nodes](https://durgical.com/en/anatomy/mediastinal-lymph-nodes/)
- [Pleura](https://durgical.com/en/anatomy/pleura/)
- [Lobar bronchi](https://durgical.com/en/anatomy/lobar-bronchus/)
- [Segmental bronchi](https://durgical.com/en/anatomy/segmental-bronchus/)

## Microorganisms that cause it

- [Coccidioides immitis](https://durgical.com/en/microbiology/coccidioides-immitis/)
- [Blastomyces dermatitidis](https://durgical.com/en/microbiology/blastomyces-dermatitidis/)

## Why it happens

- [Granulomatous inflammation: caseating vs non-caseating, the causes to know](https://durgical.com/en/general-pathology/granulomatous-inflammation-caseating-vs-non-caseating-the-causes-to-know/)
- [Innate and adaptive immunity: overview](https://durgical.com/en/physiology/innate-and-adaptive-immunity-overview/)
- [The alveolus: type I and II pneumocytes, surfactant, the blood–air barrier](https://durgical.com/en/histology/the-alveolus-type-i-and-ii-pneumocytes-surfactant-the-blood-air-barrier/)

## What it is

Infections by dimorphic fungi that live in soil of specific geographic areas and are inhaled as spores. Blastomycosis (Blastomyces) and coccidioidomycosis or valley fever (Coccidioides) usually cause a pneumonia that may resolve, become chronic or disseminate. Histoplasmosis and paracoccidioidomycosis, the endemic mycoses that matter most in Colombia, have their own pages.

## Who gets it

Blastomycosis occurs mainly around the Mississippi and Ohio river valleys and the Great Lakes of North America. Coccidioidomycosis is endemic in arid zones of the south-western United States, northern Mexico and dry areas of Central and South America, including the Guajira region bordering Colombia and Venezuela, where cases have been described. Most infections are mild or silent; neither spreads from person to person.

## Causes

- Blastomyces dermatitidis and B. gilchristii: spores from moist soil and decaying wood near waterways
- Coccidioides immitis and C. posadasii: arthroconidia from dry, dusty soil
- Inhalation of spores; at body temperature they turn into yeasts (Blastomyces) or spherules with endospores (Coccidioides)

## Risk factors

- Living in or travelling to endemic areas
- Outdoor work or activity that disturbs soil: farming, construction, excavation, hunting, military exercises
- Dust storms and earthquakes (coccidioidomycosis)
- HIV, transplantation, corticosteroids or TNF inhibitors
- Pregnancy (third trimester) and diabetes for severe coccidioidomycosis
- People of Filipino or African ancestry for disseminated coccidioidomycosis

## Pathophysiology

Inhaled spores convert to the tissue form in the alveoli and provoke a neutrophilic then granulomatous reaction. Blastomyces appears as large yeasts with a single broad-based bud; Coccidioides forms large spherules full of endospores. Cell-mediated immunity usually contains the infection; when it fails, the fungus disseminates through the blood to skin, bone, joints, the genitourinary tract (Blastomyces) or the meninges (Coccidioides).

## Classification

- Acute pulmonary infection (pneumonia, sometimes with erythema nodosum and arthralgias in coccidioidomycosis, "desert rheumatism")
- Chronic pulmonary disease: nodules, cavities, fibrosis
- Disseminated disease: skin, bone and joints, genitourinary tract, central [nervous system](https://durgical.com/en/anatomy/system/nervous-system/)

## Symptoms and signs

- Fever, cough, chest pain and shortness of breath weeks after exposure
- Fatigue, night sweats and weight loss
- Pneumonia that does not improve with antibiotics
- Verrucous or ulcerated skin lesions with irregular borders (blastomycosis)
- Erythema nodosum or erythema multiforme with arthralgias (coccidioidomycosis)
- Bone pain or swollen joints in disseminated disease

## Red flags

- Severe headache, confusion or neck stiffness (coccidioidal meningitis)
- Respiratory failure or diffuse infiltrates (ARDS)
- Progressive disease in a person who is pregnant, has HIV or receives immunosuppression
- Vertebral pain with neurological deficit

## Diagnosis

**Clinical**
Considered in pneumonia unresponsive to antibiotics, especially with [skin](https://durgical.com/en/anatomy/skin/) lesions, erythema nodosum or travel to or residence in an endemic area.

**Tests**
Microscopy and culture of sputum, bronchoalveolar lavage, skin or tissue (broad-based budding yeasts in blastomycosis; spherules in coccidioidomycosis). Antigen tests in urine or blood, and antibody serology (complement fixation titres for Coccidioides follow activity). Eosinophilia can occur in coccidioidomycosis. Lumbar puncture when meningitis is suspected.

**Imaging**
[Chest](https://durgical.com/en/anatomy/region/chest/) X-ray or CT: consolidation, nodules, hilar adenopathy, thin-walled cavities or miliary pattern; bone imaging or MRI for disseminated sites.

## Differential diagnosis

- Pulmonary tuberculosis
- Bacterial community-acquired pneumonia
- Histoplasmosis and paracoccidioidomycosis
- Lung cancer
- Sarcoidosis
- Squamous cell carcinoma or pyoderma for skin lesions

## Goal of treatment

Identify the patients who need antifungal therapy, treat severe, chronic or disseminated disease until it is controlled, and watch for relapse.

## Treatment

**Conservative**
Mild, uncomplicated acute pneumonia in an immunocompetent host may resolve without antifungals, with clinical and serological follow-up (common in coccidioidomycosis).

**Medical**
Oral azoles (itraconazole for blastomycosis; fluconazole or itraconazole for coccidioidomycosis) for mild to moderate, chronic or extrapulmonary disease, for months to a year; meningitis needs lifelong azole therapy.

**Medical**
Amphotericin B (lipid formulation preferred) for severe, rapidly progressive or disseminated disease, in pregnancy and in immunosuppressed patients, followed by an azole.

**Surgical**
Resection of persistent or bleeding cavities, debridement of bone and joint infection, and shunting for hydrocephalus in meningitis.

## Drugs for this condition

- [Amphotericin B](https://durgical.com/en/pharmacology/amphotericin-b/)
- [Itraconazole](https://durgical.com/en/pharmacology/itraconazole/)

## Complications

- Acute respiratory distress syndrome
- Chronic cavitary lung disease and haemoptysis
- Osteomyelitis and septic arthritis, including vertebral
- Meningitis with hydrocephalus (coccidioidomycosis)
- Prostatitis and epididymitis (blastomycosis)
- Relapse after stopping treatment

## Prognosis

Most immunocompetent people recover fully. About 5–10% of coccidioidomycosis cases leave chronic lung problems and about 1% disseminate. Coccidioidal meningitis is fatal without lifelong therapy; severe blastomycosis and disease in immunosuppressed hosts carry high mortality.

## Prevention

- Dust control and respiratory protection for workers who disturb soil in endemic areas
- Azole prophylaxis for some transplant recipients in endemic zones
- Awareness of the disease in travellers returning with pneumonia

## Test yourself

Think of the answer, then tap the question to see it.

## How are blastomycosis and coccidioidomycosis acquired?

By inhaling fungal spores from soil in endemic areas; they are not spread from person to person.

## What is the typical tissue form of Blastomyces?

A large yeast with a thick wall and a single broad-based bud.

## What tissue form defines Coccidioides?

Large spherules filled with endospores.

## Which skin finding with arthralgias suggests acute coccidioidomycosis ("desert rheumatism")?

Erythema nodosum.

## Which antifungal is used for severe or disseminated endemic mycoses?

Amphotericin B, followed by an oral azole.

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## Related conditions

- [Histoplasmosis](https://durgical.com/en/conditions/histoplasmosis/)
- [Paracoccidioidomycosis](https://durgical.com/en/conditions/paracoccidioidomycosis/)
- [Pulmonary tuberculosis](https://durgical.com/en/conditions/pulmonary-tuberculosis/)
- [Community-acquired pneumonia](https://durgical.com/en/conditions/community-acquired-pneumonia/)
- [Lung cancer](https://durgical.com/en/conditions/lung-cancer/)
- [Sarcoidosis](https://durgical.com/en/conditions/sarcoidosis/)
- [Erythema nodosum](https://durgical.com/en/conditions/erythema-nodosum/)
- [Cryptococcal meningitis](https://durgical.com/en/conditions/cryptococcal-meningitis/)
- [HIV infection and AIDS](https://durgical.com/en/conditions/hiv-infection-and-aids/)
- [Aspergillosis](https://durgical.com/en/conditions/aspergillosis/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Blastomycosis Basics | Blastomycosis | CDC](https://www.cdc.gov/blastomycosis/about/index.html) (Centers for Disease Control and Prevention, 2024); [About Valley Fever | Valley Fever | CDC](https://www.cdc.gov/valley-fever/about/index.html) (Centers for Disease Control and Prevention, 2024).

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Source: https://durgical.com/en/conditions/endemic-mycoses-blastomycosis-and-coccidioidomycosis/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/endemic-mycoses-blastomycosis-and-coccidioidomycosis/