DIAGNOSIS 143 



pathological material of primary coccidioidomycosis has not been 

 available for histological study. It is evident that even when cavita- 

 tion occurs and Coccidioides is present in the sputum the infection 

 is usually effectively controlled and remains well localized.*- ^' ^' ^°' ^^ 



In a very few primary infections, perhaps one in 500 or 1000, dis- 

 semination of the fungus occurs. This happens if at all usually 

 within a few weeks or months after the primary infection. In some 

 cases this secondary form (originally designated coccidioidal granu- 

 loma) may be the first recognized manifestation of the disease. This 

 was invariably true in the early history of the mycosis, but its rela- 

 tionship to initial coccidioidomycosis is now better understood. 

 This form of the disease is properly designated progressive or dis- 

 seminated coccidioidomycosis. In its clinical manifestations dissemi- 

 nated coccidioidomycosis closely mimics tuberculosis and a differ- 

 ential diagnosis can be made only by demonstration of the fungus, 

 although in certain cases the coccidioidin and tuberculin reactions 

 are helpful. There may be multiple subcutaneous and joint abscesses. 

 Skin lesions may present a verrucous appearance or there may be 

 extensive ulceration. Although in some cases a skin lesion may be 

 the first recognized evidence of infection there may have been, and 

 probably was in most cases, an earlier unrecognized pulmonary in- 

 fection. When dissemination occurs there may be miliary spread to 

 the meninges, bones and joints, lymph nodes, peritoneal cavity, and 

 to any organ, with the notable exception of the digestive tract which 

 is usually spared. The lesions, except for the presence of the fungus, 

 resemble those of tuberculosis to a remarkable degree. 



Diagnosis. The diagnosis rests finally upon the demonstration of 

 the fungus in pus, sputum, or tissues. Coccidioidin skin and sero- 

 logical tests are, however, helpful, and investigations based on the 

 use of these methods have contributed greatly to knowledge of the 

 disease. Coccidioidin is prepared by growing the fungus for 2 

 months in a broth medium similar to that used in making old tuber- 

 culin. The formula, as recommended by Dr. C. E. Smith, is as 

 follows. 



Ammonium chloride (NH4CL) 7.00 grams 



1-Asparagine 7.00 grams 



Dipotassium phosphate c.p. (K2HPO4) 1.31 grams 



Sodium citrate c. p. (NasCeii^OTd'^AUiO) 0.90 gram 



Magnesium sulphate U.S. P. (MgS04 -71120) 1.50 grams 



Ferric citrate U.S.?. VIII (scales) 0.30 gram 



Glucose of the grade known as cerolose U.S.P. X 10.00 grams 



Glycerol c.p. (U.S.P.) 25.00 ml. 



Water to make 1000.00 ml. 



