Frequency, Timing, and Patient Factors Associated with Recurrence of Disseminated Cutaneous Coccidioidomycosis

TL;DR

This study finds that recurrence of skin infections from Coccidioides is common, especially in people not on antifungal therapy, and often happens at old infection sites.

Contribution

The study identifies recurrence patterns and risk factors for disseminated cutaneous coccidioidomycosis, emphasizing immunocompetent patients and treatment discontinuation.

Findings

24.4% of patients experienced recurrence of disseminated cutaneous coccidioidomycosis.

Recurrences mostly occurred at previously affected sites and while patients were off antifungal therapy.

Immunocompetent patients had a higher recurrence rate compared to immunosuppressed individuals.

Abstract

Disseminated cutaneous coccidioidomycosis (DCC) is an uncommon manifestation of Coccidioides infection resulting from hematogenous spread to the skin. While recurrence after treatment discontinuation has been reported in 17 to 50 percent of cases, associated frequency, timing, and risk factors are not well defined. We conducted a retrospective review of biopsy-proven or probable DCC cases between January 2008 and March 2024, and investigated for evidence of recurrence. Demographic, clinical, and treatment data were abstracted, including antifungal regimen, adherence, immune status, and coccidioidal titers. A total of 45 subjects met the inclusion criteria, including 27 immunocompetent and 18 immunosuppressed patients. Eleven (24.4%) experienced one or more recurrences, totaling 22 recurrences; 19 of these (86.4%) occurred at previously affected sites. Ten immunocompetent patients (37.0%) had 21 total recurrences, while one immunosuppressed patient (5.6%) experienced a single recurrence. Median antifungal-free interval before recurrence was 14 months (range, 1–96), and 10 recurrences (90.9%) occurred while off antifungal therapy. Ten patients underwent initial surgical excision, with four (40.0%) experiencing a total of 11 recurrences afterwards. DCC recurrence was common, mostly among immunocompetent individuals not on suppressive antifungal therapy, and frequently presented with multiple recurrences. Recurrences were almost always at prior lesion sites, often years after treatment discontinuation.

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