Medical Mystery Solved: What Sent a Pregnant Prison Worker to the Hospital?

Jasmine worked at a prison in Central California. She became sick with flu like symptoms when she was 8 months pregnant. Read her work history here. She was hospitalized with fever, cough, shortness of breath, and severe muscle pain and diagnosed with pneumonia. After a blood test, Jasmine’s doctors diagnosed her with Valley Fever or Coccidioidomycosis. Although Jasmine’s pregnancy puts her at high risk for disseminated infection (or spread outside of the lungs), she was relieved to learn that Valley Fever is not passed from an infected mother to her baby. However, she needs to follow the instructions given by the healthcare provider about antifungal treatment and follow up appointments so that they will both stay healthy.

Exposure

Jasmine could have been exposed in a number of ways where she worked.  Valley Fever is a disease caused by a fungus of the Coccidioides species, which grows in the soil in semiarid areas. Valley Fever is acquired by inhaling Coccidioides spores that get into the air when construction, natural disasters, or wind disturb soil contaminated with the fungus [CDC 2013a]. It has been suggested that human illness could be caused by a single spore [Pappagianis 1988; Galgiani 1993].

The infection cannot be spread from person to person, or from animals to people. Most people who get the disease live in or visit places where the fungus is in the soil and engage in activities that expose them to soil dust. Jobs that can put workers at risk include construction, agricultural work, military field training, and archeological exploration [CDC 2013a].

Valley Fever is endemic (or native and common) in the southwestern United States, the Central Valley of California, Mexico, and parts of Central and South America [CDC 2013a]. The disease is considered hyperendemic in six California counties (Kern, Kings, Fresno, San Luis Obispo, Tulare, and Madera) that have consistently had the highest incidence of Valley Fever. In 2016, 5,372 cases of Valley Fever were reported in California, the highest number of cases ever reported in one year in California. [Cooksey et al.]. About 150,000 new infections occur annually in the United States [Galgiani et al. 2005] though only 11,800 cases were reported in 2016 in the United States, suggesting that the disease is greatly underreported.

Symptoms, Diagnosis and Treatment

About 60% of individuals with Valley Fever infections do not show any symptoms [Chiller et al. 2003]. Those who develop symptoms may experience a flu-like illness with fever, cough, headache, rash, and muscle aches. Symptoms usually resolve on their own without treatment, but antifungal medications can be used. People at increased risk for severe pulmonary disease are the elderly, those with diabetes or recent smoking history, and people of low socioeconomic status [CDC 2014]. A small percentage of infected persons (< 1%) may develop widespread disseminated infection (or infection that spreads beyond the lungs) [Chiller et al. 2003]. People at greater risk for developing disseminated infection include people of African American and Asian (particularly Filipino) descent, pregnant women during their third trimester, and immunocompromised persons [CDC 2013a].

Diagnosis of Valley Fever can be made by looking for Coccidioides antibodies or antigens in blood or other body fluids. Diagnosis can also be made through a tissue biopsy, in which a small sample of affected tissue is taken from the body and examined under a microscope or by culture where the fungus can be grown from the sample on special nutrient plates. Currently, there is no vaccine available for Valley Fever.

Valley Fever has been shown to be costly and debilitating, with nearly 75% of patients in whom the disease has been recognized missing work or school because of their illness and more than 40% requiring hospitalization [Tsang et al. 2010].

Prevention

The following prevention recommendations were provided in the NIOSH Health Hazard Evaluation, Evaluation of Coccidioides Exposures and Coccidioidomycosis Infections among Prison Employees.

Recommendations for Employers

• Wet soil before disturbing it, and continuously wet it while digging to keep dust levels down.
• Install door sweeps and seal gaps around doors and windows. Keep doors and windows closed as much as possible.
• Replace air filters in the ventilation systems as needed.
• Provide education and training during work hours to all prison employees on Valley Fever and ways to minimize exposure.
• Consider closing the prison yards and advising inmates and employees to stay indoors during dust storms and unusually windy or dusty days.
• Consider offering the coccidioidal spherulin skin test to employees. This test may help employees evaluate their personal risk for Valley Fever.
• Encourage prison employees to report suspected symptoms of possible Valley Fever to a supervisor.
• Review injury and illness records for reports of Valley Fever infections among prison employees to look for trends over time.

Recommendations for Employees

• Keep doors and windows closed as much as practical.
• Avoid driving vehicles off pavement to keep dust levels down.
• Follow agency policies, including those regarding excavation safety and respiratory protection.
• Report suspected symptoms of possible Valley Fever to a supervisor.

Julie Tisdale-Pardi, MA, is the NIOSH Science Blog Coordinator. 

This is an installment in the NIOSH Workplace Medical Mystery Series. This fictional “mystery” is loosely based on a Health Hazard Evaluation (HHE) conducted by NIOSH and other sources, and any recommendations made herein were for the specific facility evaluated and may not be universally applicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved. HHEs are publicly available at https://www.cdc.gov/niosh/hhe/ but the names of individuals and facilities mentioned in in this series are fictional. For more information on the NIOSH HHE program, visit  the website.

Resources

NIOSH Health Hazard Evaluation: Evaluation of Coccidioides Exposures and Coccidioidomycosis Infections among Prison Employees

NIOSH Coccidioidomycosis (Valley Fever) Topic Page

Emerging Infectious Diseases: Coccidioides Exposure and Coccidioidomycosis among Prison Employees, California, United States

CDC’s Valley Fever Info

Valley Fever and Pregnant Women – California Department of Public Health

References

Centers for Disease Control and Prevention (CDC) [2013a]. Coccidioidomycosis. [http:// www.cdc.gov/fungal/coccidioidomycosis/]. Date accessed: January 2014.

Centers for Disease Control and Prevention (CDC) [2013b]. Increase in reported coccidioidomycosis —United States, 1998–2011. MMWR 62(12):217–221.

Centers for Disease Control and Prevention (CDC) [2014]. CDC health information for international travel 2014. New York: Oxford University Press.

Chiller TM, Galgiani JN, Stevens DA [2003]. Coccioidomycosis. Infect Dis Clin N Am 17(1):41–57.

Cooksey GS, Nguyen A, Knutson K, et al. Notes from the Field: Increase in Coccidioidomycosis — California, 2016. MMWR Morb Mortal Wkly Rep 2017;66:833–834. DOI: http://dx.doi.org/10.15585/mmwr.mm6631a4.

Galgiani JN [1993]. Coccidioidomycosis. West J Med 159(4):153–171.

Galgiani JN, Ampel NM, Blair JE, Catanzaro A, Johnson RH, Stevens DA, Williams PL [2005]. Coccidioidomycosis. Clin Infect Dis 41(9):1217−1223.

Pappagianis D [1988]. Epidemiology of coccidioidomycosis. Curr Top Med Mycol 2:199–238.

Tsang CA, Anderson SM, Imholte SB, Erhart LM, Chen S, Park BJ, Christ C, Komatsu KK, Chiller T, Sunenshine RH [2010]. Enhanced surveillance of coccidioidomycosis, Arizona, USA, 2007–2008. Emerg Infect Dis 16(11):1738–1744.