Ambulatory Management of Valley Fever Training Presentation John Galgiani MD or Fariba Donovan MD PhD Banner University Valley Fever Program Disclosures Drs Galgiani and Donovan Have no conflicts of interest to disclose ID: 916063
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Banner Clinical Practice forAmbulatory Management of Valley FeverTraining Presentation
John Galgiani MD or Fariba Donovan MD PhD
Banner University Valley Fever Program
Slide2DisclosuresDrs. Galgiani and DonovanHave no conflicts of interest to disclose
Slide3What Is Valley Fever?Caused by soil fungiCoccidioides immitisCoccidioides posadasiiOther names:Coccidioidomycosis“COCCI”Inhalation of one spore causes infectionSpectrum of diseaseSub-Clinical: 60%Self-Limited: 30%Complicated: 10%After infection, most persons develop life-long immunity to a second infection
Slide4The Valley Fever Corridor:
2/3 of all
U.S.
disease
occurs
here
Slide5Common “Mild” Self-Limited Valley FeverSigns and Symptoms, < 1 months from exposure:Cough, chest pain, fever, weight lossFatigueBone and joint pains (a.k.a. Desert Rheumatism)Skin rashes (painful or intense itching)Course of illness:Weeks to months25% of college students are sick for > 4 months50% of workers lose > 2 weeks
Slide6Arizona CAP ~ 25% - 30% due to Coccidioides BUT< 15% are tested for Coccidioides~ 1,000 new AZ medical licenses/year12% received MD in AZ40% no AZ GME80% didn’t know: VF is reportableVaccine does not exist40% of clinicians are not confident to treat VFCurrent Clinical Practice for Valley Fever
Slide7Delay of Valley Fever DiagnosisBUMC-P45% of DiagnosesDelayed > 1 month
Slide8Delay of Valley Fever Diagnosis
BUMC-T
30% of Diagnoses
Delayed > 1 month
Slide9What Do Weeks of Delayed Diagnosis Mean?Unnecessary anti-bacterial drug useProtracted patient anxiety and fearOver-utilization CT scans and bronchoscopies, even thoracotomiesHypothesis: Earlier diagnosis would improve outcomes and reduce cost
Slide10Primary Care of Coccidioidomycosis C
onsider
the diagnosis
O
rder
the right tests
C heck for risk factors C heck for complications I nitiate management
Slide11Slide12Slide13Consider the diagnosis in ArizonaIn Arizona, Valley Fever is very common. It should be in the differential often.More frequent between the monsoons and the winter rains.Syndromes:Always in community acquired pneumonia.Rheumatism.Rashes.Jan Jun Dec
Slide14Slide15Order the Right Tests: EIA screen for Coccidioidal AntibodiesEnzyme Immunoassay (EIA) testA positive test is very specific and usually is diagnostic.A negative test never rules out Valley Fever. Repeated testing improves diagnostic sensitivity.
Slide16Slide17Check Risk Factors forPulmonary ComplicationsDiabetes mellitusCardio-pulmonary or other co-morbidities (Evidence: “common sense”). Disseminated InfectionMajor and criticalCell immunodificiencyPregnancyMinor and small effectMales > FemalesRacial backgroundAdults > Children
Slide18Slide19Detecting Focal Lesions in CoccidioidomycosisReview of Systems: Pain or discomfortHeadacheBack painJoint pain or loss of functionPhysical Examination:Skin lesionsSubcutaneous fluctuationJoint effusions
Slide20Fibro-cavitary CoccidioidomycosisComplexThin-walled
Slide21WidelyDisseminatedCoccidioidomycosis
Slide22Disseminated Coccidioidomycosis
Slide23Disseminated Coccidioidomycosis
Slide24Disseminated Coccidioidomycosis
Slide25Disseminated Coccidioidomycosis
Slide26Disseminated Coccidioidomycosis
Slide27Check for ComplicationsMost complications are focalA review of systems and physical examination will usually detect or exclude the possibility of complications.New focal findings warrant either evaluation or referral for Infectious Diseases or Pulmonary consultation.
Slide28Primary Care of CoccidioidomycosisC onsider the diagnosis
O
rder
Cocci Serologies
C
heck for complications
C
heck for Risk Factors
+
N
Specialty Referral
Retest
-
I
nitiate management
N
Repeated evaluations
Slide29Management Low Risk, Simple Early InfectionFollow-up office visitsSerial body weightsCheck for new symptoms or signsRepeat coccidioidal antibody testingRepeat Chest PA and Lateral X-raysMost patients do not need therapy
Slide30New DiagnosisF/U #1 2-5 weeks
Slide31F/U #2 2-3 monthsF/U #3 3-8 months
Slide32Management Low Risk, Simple Early InfectionFollow-up office visits for one year 2-3 weeks ROS; Exam; Chest X-ray 2-3 months ROS; Exam; serology 3-8 months ROS; Exam; Chest X-ray
Slide33Follow-up Chest X-raysWhat to order?Purposes:Identify if infiltrate cavitates.Determine if there is a residual nodule (could be confused with cancer in later years)In most patients, these objectives can be accomplished with simple PA and lateral X-rays; CT scans are usually not needed.
Slide34October 26Primary Coccidioidal Pneumonia
Slide35November 3Primary Coccidioidal Pneumonia
Slide36November 14Primary Coccidioidal Pneumonia
Slide37December 15Primary Coccidioidal Pneumonia
Slide38Peripheral Coccidioidal nodule
Slide39Follow-up Coccidioidal SerologyHow do they help?As patients improve, titers generally decreaseThe decrease typically occurs over several months, occasionally even slower.If titers increase, re-evaluate for possible complications.Titers are a marker, not a disease
Slide40Fatigue: Often the Last SymptomTypical ProblemPrimary coccidioidal pneumonia diagnosed serologically in an otherwise healthy active person.Over several weeks, weight returns to normal, fever resolves and pulmonary symptoms gone. ESR becomes normal. CF low or neg.However, patient complains of profound inability to carry out normal activities.How should this be managed?
Slide41Potential Causes of FatigueIn some, striking deficit in O2 utilization (VO2 peak <10% of predicted)*Physical deconditioning because of decreased activity.Lack of experience by the patient with subacute or chronic disability.Patient with excessive expectations of own performance.
Slide42Management Strategies for fatigueExclude objective evidence of tissue destruction or focal lesions.Patient EducationProlonged fatigue common and resolvesNo evidence of permanent damageDeconditioning and unrealistic expectationsPatient ActionsKeep a journalRefer patient to Physical Therapist for reconditioningAntifungal drugs? May or May Not be Helpful
Slide43Clin Infect Dis, 2016
Slide442016 IDSA GuidelinesTreatment of Coccidioidomycosis“It should be emphasized that no randomized trials exist to assess whether antifungal treatment either shortens the illness of early uncomplicated coccidioidal infections or prevents later complications.”
Slide45Median days to ≥50% decline in total clinical scoreP = 0.899Ampel et al. CID 2009
Slide46Outcome of Subjects(> 1 month follow-up)50 not treatedMedian follow-up: 3.1 yearsAll without complications51 treatedMedian follow-up: 2.9 years38 off-therapy and without complications 5 remained on treatment 8 had relapses5 with pulmonary disease3 with extrapulmonary disseminationRelapses occurred up to 2 years after stopping treatmentAmpel et al. CID 2009
Slide47The Valley Fever Tool KitSupport ResourcesProcess Flow pocket guide.Wall posters and patient educational brochuresNurse Navigator referral support? (proposed)EMR alerts? (only if wanted by the clinicians)Training ResoucesWebinar OverviewPrimary Care TutorialPowerpoint presentation onlineCME presentations at individual clinical practices.
Slide48Metrics to Track Implementation# of EIA serologies ordered% of EIA tests that are positive# of new ICD10 diagnoses of Valley Fever# of antibacterial Rx are written before Valley Fever diagnosis% of new Valley Fever patients are referred for Infectious Diseases or Pulmonary consultation
Slide49SummaryBanner Health and the UA Valley Fever Center for Excellence are changing the way Arizona clinicians recognize and manages patients with Valley Fever.Central to this change will be the expanded roll of primary care clinicians in earlier diagnosis and management of uncomplicated Valley Fever.
Slide50New Banner Clinical Practice forAmbulatory Management of Valley FeverThank-You
Valley
Fever
Center for
Excellence
For more information:
http://vfce.arizona.edu/toolkit