Valley Fever: Timely Diagnosis, Early Assessment, and Proper Management

Valley Fever: Timely Diagnosis, Early Assessment, and Proper Management

>>Hello, I’m Dr Tom Chiller, chief of the Mycotic
Diseases Branch at the Centers for Disease Control and
Prevention in Atlanta Georgia. Welcome to this program
on valley fever. Timely diagnosis,
early assessment, and proper management. Today I’m thrilled to have with
me two experts on valley fever; Dr John Galgiani at the
University of Arizona and director of the Center for
Valley Fever for Excellence. Welcome John.>>Thank you.>>And Dr George Thompson in the
division of infectious disease at the University
of California Davis. Welcome to you both and thanks for joining this educational
activity on valley fever. Before we start the
conversation, I’d like to highlight that
we’re going to use a tutorial as an outline for this
program that was developed at the Valley Fever Center for
Excellence with the help of CDC. This is a great resource to
help learn how to recognize and manage patients with valley
fever or coccidioidomycosis. The tutorial in its expanded
form is available at the website of the Valley Fever
Center for Excellence. It uses a very useful
acronym which we’re going to use throughout this program
today; cocci, C-O-C-C-I. C, consider the diagnosis. O, order the right tests. C, check for risk factors. C, check for complications
and I, initiate management. So let’s start with a quick
review about valley fever. Valley fever or
coccidioidomycosis, which we often refer
to as cocci is caused by the fungi Coccidioides
immitis and Coccidioides posadas. Although around 10 to 20,000
cases are reported to us at the CDC each year, we know
that many more infections occur in the United States
with estimates in the hundreds of thousands. This map shows our
current understanding of the geographic range of
valley fever, but we know and we are identifying
the fungus in the environment beyond
these historic areas. And the potential geographic
range is much larger. This range is shown here
on the graph in red. This is critically important
for you and your understanding of this disease in order
to identify people at risk. We know, now, that areas of
risk are much more beyond the traditional geography that has
been described in the past. So Dr Galgiani, Dr
Thompson, John and George, let’s begin this program and
let’s use the following outline. Remember, C, consider
the diagnosis. O, order the right tests. C, check for risk factors. C, check for complications
and I, initiate management in our discussion today. So John, tell us about the
life cycle of valley fever.>>Yeah, well this is, as
you’ve mentioned, a fungus. It grows in the soil in
certain parts of the country. I live in one of those,
George lives in another, Central Valley California,
the Southwest, and you really showed a nice map
showing the expansion of that. In the soil it grows as a mold. It doesn’t look any different
really from bread mold. It’s a mycelial growth,
however, if you inhale one of these spores and we think
probably only takes one spore, then it does something unique
to this geneous Coccidioides, it rounds up, expands
centripetally, and then invaginates internally. So you get hundreds of
daughter cells inside, we called those endospores
and that takes, at least in mice,
about four days. And when one of those things
ruptures, it comes out and you amplify that
single colony forming unit to really two logs, maybe
even more in four days. So four days, eight days, pretty
soon you have a real disease and incubation time
in one to three weeks.>>So tell us now a little
bit about the spectrum of what that disease cases when these
spores are actually dividing.>>Yeah, so it’s possible to
have high amiculum disease, but we think most people really
get single spore infections and even though it’s, you
know sort of point source, single spore start, the spectrum
of this disease is amazing. Two out of three people
really get no symptoms, at least no symptoms
sufficient to send them to get medical attention, but
that’s one-third who do get sick and they typically have
a community acquired pneumonia syndrome. And, in fact, most of those,
whether they’re diagnosed or not, which can last
actually weeks to many months, it eventually gets
better on its own and only a small percentage go on to have really
spectacular complications. And we’ll talk about what
those are in a moment, but the vast majority are seen as a clinical community
acquired pneumonia.>>And what about symptoms? What kind of symptoms
are we seeing with that community
acquired pneumonia? Is there something
unique to valley fever or are we seeing more
general symptoms?>>Yeah, well most people
look like they have pneumonia and those symptoms
are not specific. They, chest pain, cough,
weight loss, night sweats. They feel like they have
a respiratory illness. A small percentage of people,
it’s actually they’re famous for this, have skin rashes. A synonym for valley fever
is dessert rheumatism and because joint
complaints are very common, so those syndromes actually
can have predominance and not have much of
the pulmonary disease, but those associations are
really the main spectrum of this disease.>>So when we’re
considering the diagnosis, what are we thinking about here?>>Well, you just, you
know they come in looking like community acquired
pneumonia. It could be a flu-like syndrome,
is often what the textbooks say, but my impression is that
they’re really a lot sicker than that, they tend to be. Walking pneumonia is
a very common disease. In fact, in Arizona,
one out of three people who are told they
have pneumonia have that ideology being
Coccidioides.>>So obviously the
geographic range, as we talked about,
is very important. So obviously travel history is
something that we want to do and see in these patients.>>Yeah, yeah if you live
there, it’s a high likelihood if the incubation is one to
three weeks, if you travel to see the Grand Canyon or go to Central Bakersfield,
you go home. If you get a pneumonia
in the next month, your chances are just the same
as in California or Arizona. So the C in cocci,
consider the diagnosis. Remember think about
the geographic range, patients with respiratory
symptoms, they can be very general. Patients with rheumatism-like
symptoms and you did mention, but rashes often commonly seen.>>Right.>>Can George, can you tell us, do you see rashes often
in these patients?>>We do and I think
when someone presents with community acquired
pneumonia and they do have a rash,
cocci really should be one of the things on the
differential diagnosis for those patients, particularly
if they’re coming back from an endemic area or reside
within the endemic region.>>And are the things
that you talk about, differential diagnosis,
clearly if it sounds like a very general
symptomatology, what do you use to help differentiate
those with valley fever and those with other illnesses?>>Yeah, so again I think,
so the first C is essential; consider the diagnosis. Take an adequate travel history, but next is to order
the appropriate tests. One thing that can be helpful
is on the routine test, the presence of an eosinophilia, just in their differential
can sort of push you toward the
possible diagnosis of cocci. When you order more
specific tests, you know serology is really
the main screen of diagnostics. And there’s multiple different
methodologies for that and a lot of places use an
EIA based method. Particularly some of the
larger reference centers, they [inaudible] some of those. But the EI is really a
better screening test. It has a high sensitivity,
but not as specific as some of the other methodologies. So complement fixation,
immuno diffusion, those are generally thought to
be much more specific for cocci and complement fixation
gives you a quantitaive value that can be helpful
prognostically, helpful sort of point you down different
roads if you need to look for dissemination to other sites
rather than just an alumni, and also complement
fixation is very helpful to follow longitudinally
while they’re on therapy to see what their response is.>>And so, you know
I realize a lot of people probably
don’t understand and order these tests routinely. Is this something you can
just ask your laboratory? Is this test generally
a send out? Are there certain laboratories
you want to consider when you’re ordering this test? And, you know what is sort
of the first line diagnostic?>>I think that really depends
when this age of contracts, what your hospital
has a contract with and if you’re going
to have a contract. One of the large labs
are probably going to do an EIA based method
as a screen and then most of those now send sort of for
a confirmatory test to one of the specialized reference
laboratories per complement fixation and immuno
diffusion testing. So I think it’s important
for clinicians to have a good understanding
of all three of those tests and their role in
the management. So again, EIA more of
a screen type test. Immuno diffusion and
complement fixation more helpful for management and
to follow patients.>>And so you didn’t mention –>>Let me just –>>Also that, you know
I agree completely. You may have, as a
clinician on the frontline, you may have no control over
what test you’ll get back. The critical thing is to
remember is to order it.>>Yes.>>And to get a cocci
antibody test and then when it comes back, if
something comes back positive, talk to somebody about
how to interpret it.>>Yeah, it’s again, key if
you get a negative test result that that’s not always
sort of the end of their diagnostic work up. Again, some of these patients if you order a test a little bit
too early, you’re probably going to need to repeat their
serology testing two to three weeks later.>>So you guys have talked
about serology, which sounds like it’s the most important
thing to think about, but what about culturing
this organism? Do you find it in microscopy? Do you, is there much success
in trying to get a culture?>>Yeah, so again, cultures
are routinely taken for a lot of patients with community
acquired pneumonia. So cocci may even be spuriously
found on those cultures and of course, that
confirms the diagnosis of cocci in these patients. You know, using culture alone as the diagnostic modality
is probably not that helpful. Most the patients do not have
positive respiratory cultures, which is again why we
prefer a non-invasive method such as serologic testing. The interesting about
cultures or even biopsy of a suspicious lesion is that cocci has a very
characteristic appearance on microscopy of those, you know
these spores are very large, up to 80 microns in size. You can see we have a nice
diagram of one that’s rupturing. You can see sort of what John
alluded to with this very rapid, logarithmic growth releasing
hundreds, even thousands of endospores per sort of
change over in its life cycle. So cultures can be really
helpful if they’re positive. If they’re negative,
they’re not that helpful. The patient still may have cocci and again need serologic
testing for diagnosis. So sort of to summarize again,
O, order the right tests and that really starts
with serologic testing.>>Great. So if laboratory
tests establish a diagnostic, right the next thing for
us to think about is to see if the patient has certain
risk factors and John, tell us about risk
factors that –>>Right.>>Make cocci worse.>>Well there are
several, but the absolute, overwhelmingly biggest one
is immunosuppression due to a lot of different things. HIV, back, free heart,
immunosuppression from organ transplantations,
those are famous for risk factors where complications occur many
score more frequently than, it’s just a really
obvious risk factor. Now, these days,
anti TNF therapies on the news you hear tell your
doctor if you live in an area where fungal infections
are common. They’re talking about our
areas as well as some others, but certainly cocci would
be one of those things on those differentials. So there’s many different
rheumatologic therapies and so forth. Any of those should be
triggers for major high risk for dissemination and
other complications. I also had mentioned that
diabetes is also done, actually it’s not really a
risk for disseminated disease, it’s pretty clear
though it’s associated with increased complications
in pulmonary disease.>>What about pregnancy? I know pregnancy is a
category that those of us who are treating valley
fever worry about.>>Yeah, absolutely. If someone has an uncontrolled
cocci infection before pregnancy or acquires cocci
during pregnancy, those patients don’t
generally do that well. They have a lot more
complications of disease, a much more drawn out course, and in some cases even do have
dissemination outside the lung during pregnancy. For a lot of reasons
that are sort of physiologically interesting,
but really one of the key points from this is to remember
that the Tryasol therapy, which is really the backbone of
therapy per cocci or transgenic, particularly in the
first trimester. There’s some debate about if
we can use those in the second and third trimester, but Tryasol
therapy during pregnancy is generally not recommended.>>And so what about
other risk factors that are not maybe disease
associated as you guys –>>Yeah, well there’s
genetics here. we think the reason that
some people get bad diseases and some don’t is because
of genetics and in fact, it’s pretty clear that men are
much more likely to disseminate than women and there’s a lot
of epidemiology suggesting that African-Americans
and Filipinos, especially, are more likely to have
disseminated disease, but the effect of those
factors are not nearly as huge as the effect of
immunosuppression, diabetes, and probably pregnancy.>>Great. So the third C,
check for risk factors. We’re going to want
to really think about immunosuppressive
states, as John mentioned. Also worry a little
bit about diabetes, pregnancy is a condition
that we definitely need to take special account of, and
you just mentioned that gender and race, ethnicity
might also play a role as you’re thinking
about these patients. So even in the absence
of risk factors that we’ve been mentioning,
there can still be dissemination and pretty severe
disease involvement. So tell us John, what are these
sort of complications look like?>>Yeah, well it’s, as it
turns out the complications of valley fever tend to
occur in the first weeks to months after the infection. It’s very different from
tuberculosis, for example, where you’re famously
have decades go by and then you have
reactivation of disease. And what you’re really looking
for is pretty easily screened by a good history and
physical and review of systems. You’re looking for focal
kinds of symptoms or signs. This disease, when
it causes disease, when the bug is growing, it
causes tissue destruction and that, there’s
a big recruitment of neutrophils and
you can see that. If things are swollen,
they hurt, so for example, if somebody has an
unexplained swollen knee, you’d want to think about
that as a complication of the newly diagnosed
valley fever. Back pain, think about
a vertebral lesion. Headache, actually headache
occurs 20% of the time, but most of those people don’t
have meningitis, but you have to make a decision which
of those people to tap.>>And so when you’re, when
you’re doing a physical exam, are there some specific places
that, you just mentioned a few, but are there some specific
places where you focus, when you’re looking for
that kind of focal lesions? Either of you?>>Yeah, I think,
John did a great job. The review of systems is
really what’s essential. You know, patients do complain
of areas that are likely to be infected, you know. It’s not useful to do sort of a very large scale radiologic
search for active disease or to do lumbar punctures
on patients, you know just for all comers. Patients will complain of areas
where there’s dissemination. So the review of
systems is really key, but I generally focus on
headache and neurologic symptoms to look for complications
of extra pulmonary disease. Ask a lot of questions about
skin or particularly lesions that won’t heal and then again,
dessert rheumatism came up and that can be a fairly
benign course and part of the immunologic course
of cocci, but it can also, for something like the
swollen knee, represent a side of extra pulmonary
coccidioidomycosis. So those are really
key things to focus on.>>Yeah, maybe I
could just say aches and pains are famous
with this disease.>>Absolutely.>>What they typically are
are symmetrical and they come and go to different places. They do not cause
tissue disruption. So if you see a, one joint or
one part of the bone that hurts and it stays there and slowly
gets worse in association with a newly diagnosed disease, that’s kind of what you’re
looking for, is something to pay particular attention to.>>Now I know that
thankfully the risk for meningeal involvement
is quite rare, but just, you know just briefly
tell us a little bit about cocci meningitis, which is
a challenging entity to manage.>>Yeah, absolutely. The management really
is difficult, but I think that really early
diagnosis is key for this group and again, a lot
of these patients with primary disease will not go onto have complications,
do have headache. But it’s the patients that have
persistent headaches for weeks or even months that really
meningitis needs to be explored as a possible complication
of disease. And again, for clinicians,
it’s important to remember cocci meningitis is
very different from pneumococcal from a meningococcal
meningitis, when they come in very acutely ill, very sick. Cocci is a chronic meningitis,
so it’s, often patients will go by with symptoms for
several weeks or months that have really
not been explored. So it’s important again, a
very good review of systems and to really explore those
with persistent symptoms.>>So good to hear about some
of these rare complications, but bringing it back a
little bit to the lung where we initially
get our disease. Tell me about some of the pulmonary complications
we can see with cocci.>>Yeah, so again, community
acquired pneumonia is by far the most common. I think really probably
the most easy to address, but really the complications of that they can have
pleural involvement which can be difficult to
manage, require the assistance of the thoracic surgeons. Patients with a high
amiculum can come in with ARDS and then end up intubated
in the ICU. Other types of just
really diffuse, acute pneumonia can be difficult
to manage and then some of the more interesting
aspects of cocci is some of these patients
with diabetes will go on to have cavitary
disease, really which needs to be followed, you know
clinically and radiographically over time during therapy. and then the last complication,
really that’s important to document, is to follow these
radiological manifestations to really resolution
and often the area of pneumonia will resolve to a
nodule and if you follow this to resolution, that can really
avoid an oncologic workup, you know 20 years down the road if you tell these
patients this nodule is from your recent
cocci infection.>>And so treatment
is clearly different for the different entities. Are we talking about
potentially long durations of anti-fungal therapy in
some of these patients?>>Yeah, again I think
it really depends, you know how severe was
their initial manifestation of disease. If patients come in
with very mild symptoms, a lot of them don’t need
to be treated at all. When they come in with
much more acute symptoms, a much larger burden
radiographically or symptom wise, we do
treat, you know generally all of those patients and then the
duration of therapy differs and it really is individualized. I generally treat most patients
for at least three months. A lot of them get up
to six months and then if they have a complication
of disease, really you need to weigh the pros and cons
of ever stopping therapy and have a long discussion with
the patient about those things.>>Maybe I could just
say, we’re focusing here on the most common
corners of this disease and most people fortunately
don’t get that, but when they do get that, that starts to become really
subspecialty referrals and those people, I think
in a primary care setting, you definitely want to
have either a pulmonary or infectious disease or some
other consultant familiar with this disease to
hold your hand to get through these complications.>>So that fourth letter, fourth
C, C check for complications. Clearly you guys
have both outlined that it’s critically important
to look for these complications and I think John, as
you just mentioned, and George I’m sure you would
agree, enlisting the help of expert clinicians,
infectious disease docs, they could be pulmonary docs is
really important for taking care of these complicated patients. So we just talked about now, sort of the more
challenging cases, but John, you already mentioned to
us earlier that really most of these patients present with either a primary
respiratory sort of syndrome or even a community
acquired pneumonia. How are you going to manage the
typical patient, I should say?>>Alright, so if, you
know show statistics of 10 to 20,000 people being diagnosed
a year and it’s probably two to three times that much if all the cases were actually
diagnosed at the frontlines. That, a lot of those
patients ought to, I think, stay in primary care. And so if they don’t have any of those complications
we talked about. They don’t have those
risk factors and if, at that point I think
it should be possible that primary could just
take care of those patients because the first thing
is to make a diagnosis and that allows you to give
prognosis to your patient, tell them what to expect, allay
fears, dispel concerns sometimes of cancer, other problems, you know the unknown
is a big problem. Just giving a diagnosis
to somebody is huge. It also allows you
to stop all sorts of further diagnostic tests. You’ve got an answer
and stop all of those therapies you might
have been using like antibiotics for bacterial infections,
which really are going to not help somebody that
has a fungal infection. So I think making
a diagnosis whether or not you treat the patient
is huge for the patient and probably saves
a lot of money because of all the unnecessary
things you could stop doing. And so the sooner you make that
diagnosis, I think, the better.>>And so when you’re,
just as general management of these patients, what
are you’re, what are some of the things that you’re doing or that you recommend
a primary care doc to do while they’re
managing someone –>>Yeah, well follow up
is probably critical. George mentioned that already,
that this is a pneumonia that you want to see get better
and I follow with an x-ray, not terribly frequently. Cat scans are probably not
needed once the diagnosis is made unless you start
having new complications and things you need
that kind of detail. So PA and lateral once
in a while, maybe three or four weeks after
the diagnosis. Again, three or four months
later and as George says, one, I recommend about a year later, just to see if there’s
a residual nodule, which you know what it is now
and needs no further workup. Follow up with serologies. George mentioned
they tend to go high when people are complicated. So watching them become normal
again is really reassuring especially, really the only test to do is the complement
fixation, titer 4018 test. But it’s actually
not the diagnosis, it’s not the disease,
it’s a marker. So sometimes patients and
George might speak to this, sometimes the serology goes up and the patient is
getting better and the patient is the rule. You know, follow the patient,
not so much the serology. Any thoughts about that?>>Yeah, absolutely. I think you’re again, just like John said the patient’s
symptoms are critical for what’s to follow. If their tighter is still 1:8,
but the patient has no symptoms, you know we can sort of
ignore the serologic titer at that time, but again you want
to see it come down over time and it is useful to just sort of follow these patients
longitudinally with that, but again patient symptoms
are key to follow long-term.>>So, and talking about
serology for a moment. We know this is not
a perfect test. We know that it’s hard to
find perfect tests out there, but if you have a patient
that has the geographic risk, that you’re concerned really
does have valley fever, but has a negative serology. How do you approach
that patient? I know that’s a challenging
question, but I want to hear
from both of you.>>Well I see it in
my clinic all the time and the bad news is you
don’t know what’s going on, but the good news is that
if it’s valley fever, you can manage it as a patient
who doesn’t have complications. You can’t find the lesions. Who doesn’t have a risk factors and so I manage them
supportively. And one of the commonest
symptoms and sometimes the most impacting
is fatigue and I treat those with physical therapy
and reconditioning because the fatigue will
lead to deconditioning and you can do something about
that, but I can’t do anything about the disease fatigue, but once that’s gone away
the person is deconditioned and may never have been
deconditioned before in their life, they don’t know
what it is, and physical therapy in that setting really helps.>>Yeah, yeah, I think that’s
really a key consideration. Again, symptom focused
for those patients and you know generally these
patients are not that ill when they first come
into the clinic to see and you do have some
time to wait on, you know serologic
testing or even to repeat serologic
testing in a few weeks. But yeah, you’re
absolutely right Tom, we have no perfect test
quite yet, but again, just general treatment, risk
factors, and some time to sort of sort things out are really
available for most of those.>>So I didn’t John, I didn’t
hear you mention anything about anti-fungal therapy
for these patients. So let me turn it
to George then. George, are you, you
have this primary patient with a respiratory
disease, no complications, do you consider using
anti-fungal therapy or not?>>Yeah, so I think
again it really depends on the degree of symptoms. If they have a lot of symptoms
with fatigue, still have fevers, weight loss, and they
do have a confirmed, at least serologic
test, for cocci, I generally do treat
those patients. I don’t know that I improve
their symptoms more rapidly than if they didn’t get treated. Fluconazole was generally a
fairly affordable medication. It’s generally devoid of side
effects for most patients. So in the absence of a
clinical trial, which we’ll talk about later, I generally
do treat patients if they have enough symptoms
to warrant treatment.>>Well now is later. Tell us about this
clinical trial.>>Yeah, so we’ve been
very fortunate, I think, really with partnership
with the CDC. A lot of experts around the
country, we’ve been able to design, you know a
prospective placebo controlled trail for patients that come in with community acquired
pneumonia that’s actually from cocci. We’re hopeful that this will
answer a lot of these questions. Does treatment actually
help improve the rapidity and resolution of
symptoms or not? That’s an answer we don’t know. It’s been debated for a long
time, but we’re very hopeful that this trial and
very grateful for the NIH’s full support for
this and this will answer some of these age-old
questions in the field.>>So then to summarize
our final and fifth letter, I, initiate management. What would you say the summary
of this discussion has been?>>Yeah, I think that’s a
really individualized approach and depends where you’re
used to practicing and –>>Well we, I think
you’ve heard, I think we pretty much agree
you want to make a diagnosis, you support the patient,
you give them prognosis, you stop using antibiotics, you make sure no new
complications occur over the next year or two. There’s disagreement because
there’s no data on whether or not to treat patients. So the spectrum is all over
the map, but I, you can make in a case that if you think
somebody needs treatment, that that should be
a referral patient, but others would say it should
just be part of primary care.>>Well I certainly look forward to the data coming
out from the trial. Thanks for addressing
these challenging subjects of treating primary disease. It’s incredibly important
to report this disease because it gives us,
at CDC, a better idea about how much disease
is occurring. Coccidioidomycosis or cocci
is a reportable condition in many states and so
please contact your local or state public health
department if you have a case to report then we can learn more about the true burden
of this disease. So I think we had a
nice discussion today about valley fever. It represents a substantial
public health problem, I think, because the clinical nature of
this disease is one that looks like many other diseases. It’s going to be important
for you, the clinician, to think about this
disease and be aware that it is probably occurring
in patients that either are from areas where
valley fever occurs or have travelled to a region. So remember, early diagnosis,
accurate diagnosis is essential for understanding this disease
and for managing this disease. Early identification of
valley fever is important for several reasons. It allows you one, to know what
the patient has and as John and George has both mentioned,
that’s key in the management because then it eliminates
the need for unnecessary antibacterial
use, reduces the need for additional diagnosis
and diagnostic tests, and helps you decide on an
early management strategy. Including dealing
with complications. Clinicians should maintain
a high level of suspicion for valley fever in
patients that have lived in the geographic areas
where we know cocci occurs or who have travelled
recently to an area where we know valley
fever occurs. Remember, ask about travel
history and please think about the expanding
geographic areas that we mentioned
earlier in this program. So remember the acronym;
cocci, C-O-C-C-I. For primary care of
coccidioidomycosis. C, consider the diagnosis. O, order the right tests. C, check for risk factors. C, check for complications and
finally I, initiate management. Well John, George, I
want to thank you guys for participating today. This has been fun and
interesting conversation about this important disease.>>Yeah, thank you.>>And I also want to thank
[inaudible] at the CDC who has worked tirelessly
behind the scenes to make this program
possible today and of course, thank you for participating
in this activity.

11 Replies to “Valley Fever: Timely Diagnosis, Early Assessment, and Proper Management”

  1. I am 48, F, live in Tempe, Arizona had valley fever 24 years ago, with body aches, walking pneumonia, horrible desert rheumatoid arthritis or desert rash, fever, vit. B12 def. I noticed I had the desert bumps on my legs so I asked my doc to run the tests as I was worried. Dr.'s office called, they said all tests were negative! I was notified by my local County Health Department that my dr. office sent my records to them as I was positive for IGM…Now my dr's office REFUSES to see me, because they claim I owe them money, but I have been making monthly payments to them, that I can afford(I am on a fixed/limited income due to disability) , yet now they was a large sum of money and to triple my monthly amount I pay! I just can't do that, as I don't have money to do it. I have extreme fatigue, desert rash/bumps, headache, really bad stiff neck/neck pain only on right side, and feel totally helpless, because I have no one I can see! 🙁

  2. I had all these symptoms, and my doctor in L.A. had no idea about Valley Fever. I had the rash on the palms of my hands, plus a lot of night sweats, chest pains, weakness, malaise, weight loss, etc. I was on my back for two weeks. I travel frequently to the central valley, Bakersfield area. I got sick about 5 years ago, but I feel good now. I got prayer for healing, which helped me, but no medical treatment.

  3. I have just been diagnosed with having Valley fever many years ago, a lot of scare tissue from this fungus. The physician who told me of this is a Pulmonary doctor here in New Mexico. I had no idea of this until now.

  4. uh. melanin is tropical peoples fungal armor for their climate. armies of foreign genetic native tropical people moving to the globally marketed usa "westcoast life". california especially. the foreign climate destroys their body and mind health the same as the tropics do to non tropicals who try to live in tropics. the illness that allowed the japanese smaller forces to so easily overrun the british in singapore, americans in philippines, french in vietnam, etc, etc ww2. its not rocket science. chinese medicine and ancient "physics" can explain it very clearly. but nothing will come of it bc globalism and uninformed travel/relocation is a goldmine for allopathic western for-profit medicines ubiquitous drugs and procedures. its absurd that so many of your people dont have access to a basic human need like health care or "insurance". meanwhile a small nation like taiwan can provide excellent quality healthcare for all people for only hundreds of dollars per year in insurance payment. usa, or anywheres, for-profit diseasecare system is a massive scam.

  5. almond harvesting in the central valley is out of control , when in season they create a very large dust storm that you can see for miles

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