Coccidioidomycosis in Europe: a systematic literature review of epidemiology, treatment and outcomes.

OBJECTIVES: Coccidioidomycosis (cocci) is a rare fungal disease with clinical manifestations ranging from asymptomatic to life-threatening severe pulmonary or disseminated infection. It is endemic to parts of the southwestern USA, Mexico and South America. Tourism and migration have led to cocci occurrences across Europe among those arriving from endemic areas. The pan-European epidemiology of cocci has not previously been systematically reviewed. METHODS: A systematic literature review was conducted with no limits for publication year, article type and language. We initially identified 797 records, and 61 publications were retrieved in accordance with the inclusion criteria. We identified 55 case reports and six case series, which spanned 20 countries. RESULTS: Overall, 197 cocci cases were reported in the literature between 1948 and 2022, with the highest number being from Spain (96 cases), Russia/USSR (35) and France (20). Ninety-eight cases were due to migration, 39 infections were travel-related, and 5 were donor derived. Infection sites included pulmonary (39%), CNS (10%) and bone/joint (1%). Infection site was not reported for 36% of the cases. Most patients had a differential diagnosis, resulting in delayed treatment. Fluconazole (27%) or amphotericin B (19%) were most frequently prescribed as first-line antifungal therapy. Mortality and stable disease rates were 7% and 6%, respectively, with higher rates in immunocompromised patients (24% and 14%). CONCLUSIONS: Clinicians should consider cocci in the differential diagnosis of patients with pneumonia and/or meningitis symptoms who have travelled from endemic regions.