The Dec}) Mycoses (Essentially or Potentially Systemic) 211 



cutaneous lesions of coccidioidomycosis have a greater tendency to multipl) 

 and their evolution is generally Easter. In the lungs, coccidioidal involve- 

 ment is more rapid and shows less tendency to cavitation. Extrapulmonary 

 lesions, particularly those in bones, arc more common than with tuber- 

 culosis. The roentgenogram should not be relied on to establish the diagno- 

 sis. An early cutaneous lesion of blastomycosis is not likely to be con- 

 fused with a lesion of coccidioidomycosis, but when the process becomes 

 extensive, particularly when involvement of the internal organs occurs, 

 clinical differentiation of the two mycotic disorders may be impossible 

 without cultural and histologic studies. Syphilis may simulate the fungous 

 disease, but syphilitic gummas are rarely multiple, the serologic reaction 

 may be positive and constitutional symptoms are rarely present. Pyogenic 

 infections, particularly of bone (osteomyelitis), are usually more rapid 

 in their development and more likely to attack children, and lesions of the 

 skin or of other regions are absent. When coccidioidomycosis simulates 

 influenza there is roentgen evidence of involvement of the parenchyma, 

 and the micro-organism (C. immitis) may be demonstrated in the sputum. 



(g) Prognosis.— While some cases terminate fatally, it is established that 

 many primary infections clear spontaneously. In the cases of acute involve- 

 ment of the lungs described by Dickson recovery was invariable. Periods 

 of remission may occur, and relapse after four or more years is not un- 

 known. The mortality is higher among those newly arrived in the endemic 

 territory. It has been said that when patients have cutaneous lesions on the 

 face the outlook is hopeless. 



(h) Treatment.— In evaluating the benefit from any form of therapy 

 we are handicapped by the fact that the disease shows periods of spon- 

 taneous remission. In the cases of acute benign involvement of the lungs, 

 symptomatic measures suffice. The patient should be kept in bed until there 

 is complete recovery. In all instances general supportive and symptomatic 

 treatment should receive consideration. The cases of cutaneous and sys- 

 temic involvement, particularly of the acute fulminating type, represent a 

 difficult and at times hopeless problem. Radical surgical procedures have 

 been advised for a nidus of infection which is early and localized. Before 

 such a measure is undertaken, a deep focus in the lungs should be excluded 

 by roentgen studies. There are scattered reports of success with the use of 

 various modalities and drugs. A short discussion of these follows. 



(1) Roentgen therapy.— This is useful in causing absorption of the exu- 

 date in any granulomatous process, and in coccidioidomycosis, healing of 

 the local lesion is frequently obtained. The effect may be only temporary. 

 Relief of pain may also result from the use of this modality. Intensive or 

 semi-intensive dosage should be used. 



