COCCIDIOIDOMYCOSIS 
CONTROL PROGRAM 
for the 
A. A. F. W. F. T. C. 
HEADQUARTERS 
ARMY AIR FORCES WESTERN FLYING TRAINING COMMAND 
Office of the Surgeon 
1104 West 8th Street, Santa Ana, California HEADQUARTERS 
ARMY AIR FORCES WESTERN FLYING TRAINING COMMAND 
1104 'TEST EIGHTH STREET, SANTA ANA, CALIFORNIA 
OFFICE OF THE SURGEON 
IJ/ht 
September 15, 1943 
Requests for the syllabus ’’Coccidioidomycosis Control Program for the 
VJCAAFTC", published in October, 1942, have exhausted the supply of avail- 
able copies, necessitating this second edition. The text has been com- 
pletely re-written and some new X-ray reproductions have been added. It 
is hoped that this presentation on Coccidioidomycosis will aid flight 
surgeons and Army doctors everywhere in acquiring a practical working 
concept of the many manifestations of this bizarre disease. 
/ / 
M. G. HSALY, ' 1 
Colonel, Medicsgl Corps, 
Surgeon. headquarters 
ARMY AIR FORCES WESTERN FLYING TRAINING COMMAND 
OFFICE OF THE SURGEON 
II0I4. TiTest 8th Street 
Santa Ana,California 
710 (Coccidioidomycosis) 
SUBJECT; Coccidioidomycosis Control Program for the AAFWFTG 
TO: Surgeons, All Stations This Flying Training Command 
1. The coccidioidomycosis control officer of this command mil visit 
each of the basic, advanced and specialized schools in the AAFVJFTC for the 
purpose of training medjlcal officers in (1) the detection of sub-clinical 
cases by standardized coccidioidin skin testing and (2) the diagnosis and 
treatment of clinical cases of coccidioidomycosis which may develop at the 
various stations. 
2. Each station surgeon will assign one (1) medical officer from the 
personnel already on duty at his station as a station coccidioidomycosis con- 
trol officer. The officer chosen will be a key man and one likely to remain 
at the station indefinitely. If possible, the man selected should be a pedia- 
trician or a physician trained in contagious diseases, so that he may act as 
epidemiologist and care for all contagious disease outbreaks at the station 
in addition to his duties in connection with the coccidioidomycosis problem. 
3. Each station surgeon will be responsible for the effective execution 
of the coccidioidomycosis control program at his station. The duties of the 
station coccidioidomycosis control officer will include; 
a. Skin testing with coccidioidin of all 
(1) Enlisted personnel and officers assigned to the station as 
of 1 November 19n2, the results to be noted on each man’s 
immunization register, Form M.D. #81. 
(2) Additional enlisted personnel and officers subsequently 
assigned to the station immediately upon their arrival, and 
a repeat coccidioidin skin test on all enlisted men and 
officers on duty at the station trace yearly thereafter for 
the duration of the war, 
(a) during the week of January 1 to 8 and 
(b) during the week of July 1 to 8 
(9) Enlisted personnel and officers prior to their transfer 
from each station. 
(ij.) Cadets during their 61+ examination prior to their gradu- 
ation from advanced training courses, the results to be 
recorded on the 6I4. record and compared with the results 
of the first coccidioidin test which will be performed 
on each cadet during his first week at SAAAB. b. The diagnosis and treatment of all active cases of coccidioido- 
mycosis, - including coccidioidin skin testing, chest x-ray 
studies, sedimentation rates, etc. 
c. The sending by Air Mail to Dr. Charles' Smith, Stanford Univer- 
sity School of Medicine, San Francisco, of 10 cc. of whole 
blood for precipitin and complement fixation reactions from: 
Cl) Patients with a protracted course and a persistently pro- 
longed sedimentation rate, 
(2) Patients with a doubtful prognosis and a possibility of 
dissemination, and 
(3) Cases of serious diagnostic doubt. 
These blood specimens will be sent in containers, especially 
provided each field the coccidioidomycosis control officer 
of the AAF17FTC, accompanied by a brief clinical abstract in- 
cluding statement as to past residence in endemic area, date 
of onset and any outstanding clinical symptoms such as ery- 
thema nodosum, state of coccidioidin sensitivity, etc. 
d. Sending a clinical epidemiological summary of each new patient 
with the diagnosis of coccidioidomycosis to the control officers 
AAFWFTC on forms provided by this office. 
e. The monthly reporting to the coccidioidal control officer at 
AAF.7FTG of all: 
(1) Coccidioidin skin testing, - the number of tests performed 
and the names, rank, organization, etc. of all those with 
positive reactions. 
(2) Hospital cases including: 
(a) Now cases of coccidioidomycosis occurring during the 
month*since the previous report. 
(b) Old cases previously reported but still on the wards, 
and 
(c) The total number of hospital days spent during the 
month by patients with proved diagnosis of coccidi- 
oidomycosis. 
4. >.Each cadet arriving at SAAA3 should be skin tested with coccidioidin 
and the results noted on the 64 examination record for comparison with the re- 
peat coccidioidin skin test to be done at the time of the cadet’s graduation 
from advanced training. This information will be most helpful in those cadets 
who may develop clinical coccidioidomycosis during their training period. A 
negative coccidioidin test at SAAAB, for instance, and later a positive skin 
test during an acute illness in one of the endemic areas, would be significant 
5. ill patients with a diagnosis of coccidioidomycosis or 
patients who have had clinical evidence of an active infection for a protract- 
ed period (over three months) will be transferred from the various station 
hospitals to the hospital at SAAAB for further study. 
6, Such a program will be helpful (1) in obtaining more accurate in- 
formation concerning the incidence of coccidioidomycosis in the various 
stations, this Command; (2) in effecting early diagnosis of active cases 
of coccidioidomycosis and continuing treatment sufficiently long to prevent dissemination-*'-';and (.35' in accumulatingydata through Routine coccidioidin 
testing of all cadets, enlisted personnel-and officers in' the AAFWFTC which 
later may aid the Veterans' Bureau in the disposition of possible claims 
against the government. 
I f&Jf-cdc, 
J. G. MEALY f 
Colonel, Medicai Corps 
Surgeon 
3 IncIs; 
1- Coccidioidal infection report, AAFVJFTG (Blank Form) 
■ 2- Monthly Report 
3- Syllabus on Coccidioidomycosis 
Note;- 
The Army Air Forces Western Plying Training Command is grateful to 
Dr. Charles E. Smith of the Stanford University School of Medicine for 
his invaluable assistance in establishing the coccidioidomycosis control 
program and to Dr. R. A. Garter, roentgenologist of the Eos' Angeles County 
Hospital, for permission to reproduce" some of his films showing the bone 
lesions of progressive coccidioidomycosis. HEADQUARTERS 
,ARMY,AIR FORCES WESTERN FLYING TRAINING COMMAND 
OFFICE OF THE SURGEON 
,. . . , . , ,■ 1104 West 8th Street 
.. Santa Ana,.'.‘California 
R-ell 
WC 710 (Coccidioidomycosis) 
SUBJECT; Coccidioidomycosis Control Program 
TO : Surgeon, All Basic, Advanced and Specialized Schools 
of the AAFVJFTC (Attention; Coccidioidomycosis Control Officer) 
1. In accordance with directive dated October 16, 1942 which was 
included in the syllabus on Coccidioidomycosis, you will send monthly re- 
ports as of the last day of each month, to reach this office not later 
than the fifth day of the following month, concerning the activities of 
the Coccidioidomycosis Control Officer. These reports should include data 
on; 
(a) Coccidioidin skin tests of; 
(1) Officers and 
(2) Enlisted personnel assigned to your post as of November 
1, 1942, the testing to be done now. All additional officers or enlisted 
men assigned subsequently to that date should be tested within 4B hours 
after their arrival at your field. 
(3) Repeat coccidioidin skin testing of; 
(a) Officers and enlisted men on duty at your post, 
twice yearly thereafter, the testing to be done during the weeks of January 
1 to 8 and July 1 to 8. 
(b) Officers and enlisted men prior to their transfer 
from your field. 
(c) Cadets during their 64 examination prior to grad- 
uation from Advanced Training Schools, the results to be recorded on their 
64 record. Each new Cadet arriving at SAAA3 will be skin tested with cocci- 
dioidin during his first 64 examination. If the "repeat” coccidioidin test 
is positive, include report of the SAAA3 coccidioidin test in your summary 
for comparison. 
The skin tests should be read 44 to 48 hours after the intracutaneous in- 
jection of 0.1 cc of 1;100 dilution of coccidioidin. The reactions should 
be interpreted thus: 
Definite induration and erythema, but less than 1cm in diameter. 
Induration of 1cm in diameter 
Induration of 1cm in diameter plus flare of erythema of 1cm or more 
Induration of 2cm or more 
Vesiculation. 
2. Seriously ill patients with a diagnosis of coccidioidomycosis or 
patients who have had clinical evidence of an active coccidioidal infection 
for a protracted period (three months or more in hospital) should be trans- 
ferred from the various station hospitals at the basic, advanced and special ized schools to the station hospital at SAAA3 for further study. 
3. The coccidioidin testing material, tuberculin syringes, platinum 
needles, rubber stamps for reporting (“coccidioidin, positive" and "coccidi- 
oidin, negative") report blanks, etc. will be supplied by Office of the Sur- 
geon, Hdqrs., AAFWFTC. Santa Ana, California;; ; ; • • ' - * 
M. G. HSALY f" 
■ Colonel, Medical Corps 
Surgeon 
2 IncIs; 
(1) Sample Copy, Monthly Report 
(2) Sample Copy, Coccidioidal 
Infection Report HEADQUARTERS .=. • 
ARMY AIR FORGES MiESTERN FLUNG TRAINING' C0M11AND' 
! ■ -OFFICE OF THE SURGEON 
-■ 1104 West 8th Street 
v . -1 ' Santa Ana, California 
• BUB;sir 
7.io 
SUBJECT: Concerning Laboratory Procedures in the Diagnosis of Coccidioid- 
omycosis. 
TO, ; The Surgeon, All Schools Except Army Air Forces.GTD*S,■ ■ ■ 
This Training Command (Attention: Coccidioidomycosis Control 
Officer). 
1. Sputum examinations - 
Routine sputum studies are not indicated in patients suspected 
of having coccidioidomycosis because: 
a. Most patients do not cough sufficiently to raise adequate 
amounts of sputum for examination. 
b. Failure to recover the fungus from sputum does not rule out 
the possibility of infection. 
e. Carefully carried-out sputum studies are both tedious and ex- 
pensive. Further, short-cut methods, such as a cover-slip examination, 
are not dependable, and, 
d. Other procedures, especially-'determination of precipitins and 
the complement fixation titre, are. more accurate in the event that the diag- 
nosis of coccidioidomycosis cannot .be made on the basis of history., ‘clinical 
picture, characteristic chest X-ray and an elevated sedimentation rats. 
2. Blood specimens for determination -of precipitins and complement- 
fixation titre - 
Blood specimens should be sent, by Air Mail if possible, to Dr. 
Charles Smith, Stanford University School of Medicine, San Francisco, 
Specimens should be sent in sterile bottles, previously autoclaved, and in 
special containers, both of which will be supplied thru the office of the 
Coccidioidomycosis Control Officer, AAFWFTG. No attempt should be made to 
separate the blood Pells from the serum. *u ■ 
Blood specimens for the determination of precipitins and the 
complement fixation titre1' should be sent only from: 
a. Patients with a protracted course and a persistently pro- 
longed sedimentation rate.-' 
b. Patients with a doubtful prognosis and a possibility of dis- 
semination and 
£. Cases of serious- diagnostic doubt. 3. Coccidioidin dilutions for skin testing - ;i... 
All routine coccidioidin testing should be done with a 1:100 
dilution of coccidioidin. However, hospital patients who present skin 
lesions (erythema nodosum, erythema multiforme, etc.) and who are sus- 
pected of having coccidioidomycosis, should be tested initially with a 
1:1000 dilution, because of the unusual sensitivity to coccidioidin in 
such instances. If this first test is negative, a second test, using 
a 1:100 dilution of coccidioidin, is indicated before ruling out the 
disease in the differential diagnosis. ‘ • •. ■ 
4. Positive reactors to coccidioidin skin tests - 
During- the. course of routine coccidioidin skin testing, all 
men who show: 
a. a 3 plus or a 4 plus reaction on the initial test or 
b, a definitely positive reaction (1 plus thru a 4 plus) on 
re-testing, (having previously shown a negative coccidioidin reaction) 
should have a sedimentation rate determination, and an X-ray of the 
chest, if the sedimentation rate is appreciably,above 12 mm. 
A normal sedimentation rate (12 rain, or below by the Cutler 
method) and a negative chest X-ray, in the presence of a positive coc- 
cidioidin skin test, indicate a previous-coccidioidal infection which 
has completely healed by the time the test was performed. 
Those patients with evidence of activity (increased sedimenta- 
tion rate, characteristic chest X-ray and suggestive clinical symptoms and 
findings) should be hospitalized. 
For the routine re-testing of personnel on duty at your post 
during the weeks, of January 1 to 8 and July 1 to 8, it will be unneces- 
sary to re-test those individuals who reacted positively to coccidioidin 
with previous tests. 
5. Monthly reports of positive reactors - 
The monthly reports of positive reactors to coccidioidin skin 
tests should be listed in the order of the severity of the skin reaction, 
beginning with 4 plus, then 3 plus, 2 plus, 1 plus and ending with the 
plus-minus reactions. 
The residence of,each positive reactor, or the probable state 
in which the infection was acquired, should' be listed in addition to his 
name and ASN. 
6. These instructions are considered by the Surgeon to be a sup- 
plement to the pamphlet on Coccidioidomycosis Control and one (1) copy 
will be inserted in that publication on file at your station. 
M, G, HEALY, / 
Colonel, Medical Corps, 
Surgeon, MONTHLY REPORT - COCCIDIOIDOMYCOSIS CONTROL PROGRAM 
STATION: 
DATE OF REPORT 
SECTION ONE 
TOTAL NUMBER • 
OF TESTS 
TOTAL NUMBER OF 
POSITIVE TESTS 
COCCIDIOipiN SKIM TESTING 
(upon arrival at this Post) 
Officers: 
Enlisted Personnel: 
iu te; 
Colored; 
SECTION TWO 
•-REPEAT COCCIDIOIDIN SKIN TESTING 
Officers: (Semi-annually only or prior 
to transfer from Post) 
Enlisted Personnel: (Semi-annually 
only or prior to transfer from Post) 
White: 
Colored; 
Cadets: (By classes'at final 
64 exam) 
Class 
Grad. Date 
Class 
Grad. Date 
SECTION THREE 
WHITE 
NUMBER 
COLORED 
a.- New patients since previous report. 
(Report each new patient on-special blank) 
b. Patients previously reported' but still in 
. hospital on date of report. 
£. Total number of hospital days during current 
month for all patients"'with coccidioidomycosis 
d. Name, Rank, A.3.N., Organization, etc, of all 
personnel, except cadets, with positive tests, 
should be listed in the order of their degree 
of reaction, i,e., ////: ///: //'-/• • ' STATION 
DATE: 
COCCIDIOIDAL INFECTION REPORT, AAFWFTC 
Name 
Age_ 
Nationality^ 
Rank & Organization 
_ 'Birthplace 
Residence ,ihi 
.(How long in each and when?) 
Texas 
New Mexico 
Arizona 
California (what sections) 
Other states 
Previous Amy Assignments: 
(List states and how long there) 
When did patient arrive at this field 
Present Illness 
(Dates) 
Headache Cough Malaise , Joint Pains 
Conjunctivitis Anorexia Chill Backache 
Night Sweats Nervousness Fever Pleurisy 
Skin Lesions (description) 
Other symptoms: 
Dates: 1st Dispensary visit 
Hosp. Admission 
Discharge^ 
Physical Examination (Date) 
Tenipe rat ure_ 
Chest Examination 
Skin Lesions 
Other findings; 
X-Ray Findings (Date) 
Laboratory Findings and datesT', _ 
VLB.C. and differential: 
Sedimentation rate;. . .> 
Precioitins; -• 
Complement Fixation; ..\ 
Coccidioidin Tests; (Dates arid -readings) 
Course; (Use other side for details, if necessary) 
M.C. HEADQUARTERS 
ARM! AIR FORCES WESTERN FLYING TRAINING' COMMAND 
OFFICE OF THE SURGEON - ,: 
1104 V/est 8th Street i/r 
Santa Ana, California 
SYLLABUS’ON'COCCIDIOIDOMYCOSIS 
Definition 
Coccidioidomyco sis, ‘ an Infection caused by the fungus Coccidioides immitis, 
occurs in two forms; (1) primary coccidioidomycosis, an acute, benign, 
self-limited respiratory infection; and (2) progressive coccidioidomycosis, 
a chronic, disseminated, usually fatal disease, which is manifested by cu- 
taneous, subcutaneous, visceral, and osseous lesions, ■ ■ 
Historical Data 
Coccidioidomycosis was first observed and reported in’1892 by Posadas and 
Wernicke in South America. In 1894 Rixford reported the first case in the 
United States, a patient, from the San Joaquin Valley of California, with a 
severe, fatal, generalized granulomatous infection. ' Later Ophuls and Mof- 
fitt gave the first adequate description of the fungus. Subsequent to 
Rixford’s famous case, other patients with similar'findings, granulomata 
of skin, bones, joints and various organs, were seen from time to time, 
most of them originating in the San Joaquin Valley. It soon became appar- 
ent, however, that other regions adjacent to the San Joaquin Valley were 
also points of origin. 
For 40 years disseminated coccidioidomycosis was the only known form of 
this disease. In 1935, however, Gifford and Dicksbh observed a similarity 
between the prevalent "valley fever" or "desert rheumatism" and coccidi- 
oidal granuloma, as it was then called, and demonstrated that 
immitis is the etiological agent in both conditions. Dickson proposed 
the terms primary and secondary coccidioidomycosis to■designate.the two 
types of this "disease. Since : then, a., considerable literature has accumu- 
lated with the work of C. E. Smith, .of ,Stanford University Medical School, 
and at present consultant for the Secretary of War, especially contribut- 
ing to our knowledge of this disease*' r' u: hr-,' 
Epidemiology and Etiology 
The chief -endemic foci are the southern part of the central valley (San 
Joaquin) of California, southern Arizona,. and. western Texas. Another . 
known focus'is San'Benito Cquqty pf California, while occasional cases 
have been reported'in rldah’O/w southern, Utah,' southern California, and New 
Mexico. Outside the United States coccidioidomycosis has been observed 
infrequently in Mexico, Hawaii, and Italy, as well as in Uruguay, Bolivia, 
Argentina, and Brazil. Coccidioidin testing of military personnel who 
have served in dusty regions of Australia, northern Africa, the Near East, 
etc. may indicate a more universal distribution of the fungus than has 
heretofore been realized. In the endemic regions the climate is hot, dry, and dusty, with the high- 
est incidence of acute infections occurring during the drjr summer and fall 
months. A definite correlation has been observed between the number and 
severity of dust storms and the incidence of new cases of coccidioidomy- 
cosis in endemic areas. Inhalation of spore-laden dust from hay, produce, 
and other products from endemic areas, as well as dust on clothes and 
motor vehicles which have been transported a considerable distance from 
these regions, has caused the disease in susceptible individuals. 
Because man and many animals apparently become infected only by the in- 
halation of dust which contains the chlamydospores of Coccidioides immitis, 
some reservoir, such as the soil, or a living host, plant or animal,.must 
exist in endemic areas, thereby providing for the propogation and dissem- 
ination of the fungus. If the fungus grows in soil, few susceptible ani- 
mals, especially those living in burrows in infested ground, should escape 
infection. However,, Emmons trapped many soil-dwelling rodents in widely 
separated areas of Arizona, and demonstrated that only certain species, 
principally pocket -mice and kangaroo rats, constitute a probable reservoir 
for the disease. In the lungs of these infected animals, this investiga- 
tor found typical coccidioidal lesions from which Coccidioides immitis.was 
cultured. Similar species of rodents, trapped in a part of New Mexico 
where coccidioidomycosis is not endemic, did not show these changes. 
Emmons isolated another fungus, Haplosporangiura parvum, from even a greater 
percentage of desert rodents in Arizona, and suggested that this fungus 
may be related etiologically to Coccidioides immitis, inasmuch as some in- 
dividuals with a positive coccidioidin test also react positively to skin 
testing material prepared from Haplosporangium parvum. 
•Coccidioidomycosis is most common in newly arrived residents in endemic 
areas, A large proportion of the population of these regions will react 
positively to coccidioidin skin tests, indicating previous infection. The 
percentage of positive skin tests will vary from 10% to 30$ of those who 
have resided less-than a year in the area to at least 75% of those who 
:have lived there for ten yeahs or more. All age groups are susceptible, 
although male adults with occupational exposure to agricultural dust are 
most likely to develop infection. The disease tends to disseminate much 
more frequently in men than in women. The dark-skinned races, especially 
negroes, Filipinos, Mexicans, and Orientals, have a greater susceptibil- 
ity to coccidioidal infections, in addition to a greater tendency to de- 
velop the disseminated or progressive form of the disease than have the 
■white races. -' 
The Causative Agent. 
Coccidioides immitis usually is grouped with the fungi imperfecti. In 
tissue the parasite causes a granulomatous reaction with a tendency to 
central caseation or suppuration. In purulent exudate, in particular, 
the fungus often appears in'remarkable abundance.' It is a spherical 
structure, varying from 5 to;80 microns in diameter, with an average of 
30 microns. As the spherule- develops, the capsule thickens and becomes 
more refractive. The very coarsely granular protoplasm contained therein 
breaks up into a large number (50 to 100) of spores of irregular shape 
and .only .a few microns in diameter. With rupture of the capsule these 
minute bodies are discharged :into the tissue,- where they swell, become 
spherical, and grow until they reach the sporulating-'stage. On solid media the fungus develops in a few days, even at room temperature, 
as a fluffy white mass composed of irregularly arranged branching septate 
filaments 2-8 microns in diameter. The appearance of cultures varies with 
age, temperature, and, nutrient conditions. In contrast to the endosporu- 
lation seen in tissue, the organism reproduces in culture by budding and 
fragmentation of the mycelium. Pieces of dead wood, strips of' cactus, 
potatoes, and other vegetables, are favorable to its growth.' The organ- 
ism ris resistant- to drying, and dry cultures , are an opvl6Xf6 laboratory 
hazard. Most laboratory personnel who work with ;Co,ccidioidds <immitis 
invariably acquire the infection by inhaling the almost imperceptible 
dust of the mycelia while'working with cultures, Details of the-1 transi- 
tions between-the spherule and mycelial stages are incomplete, and. almost 
nothing is known of the existence of -the fungus in nature where it has 
never been observed directly. It has-been described as an agent of spon- 
taneous infection in a variety of animals, but such infections are rare. 
Attempts to cultivate the fungus from soil in endemic arenas-‘have proved 
almost entirely futile, although isolation from soil by animal inoculation 
has been more successful. . ' ' '• '■ 
Although the spherule is infectious, no proved instance of man to man, 
animal to animal, or animal to man transmission has been recorded. .'Guinea- 
pigs have been infected experimentally at Santa, Ana Army Air Base by in- 
oculations of extracts of dust from rooms in which patients dying of dis- 
seminated coccidioidomycosis have been housed. This would” indicate that 
the chiamydospores may develop in cracks and crevices in the floors and 
'walls, and might serve as a potential source of infection for other pa- 
tients in the ward. The danger, however, seems remote and can be obvi- 
ated by daily lysolizing of the floors, etc. in rooms housing these 
patients. 
Pathogenesis. 
As in tuberculosis, coccidioidal infection usually occurs by inhalation 
of the specific agent after an incubation period of ten to fourteen days. 
Only in endemic areas, however, is the air .contaminated with the chlamy- 
dospores of Coccidioides immitis, and in these areas the disease is prev- 
alent chiefly during the hot and dusty months. A history of skin abrasion, 
puncture wound, or other trauma■sometimes precedes certain rare instances 
of chronic infection, the/fungds'being introduced directly into the subcu- 
taneous tissues. Old, pulmonary ‘lesions containing typical spherules have 
been observed in patients dying of ’other causes..-After lying dormant for 
many years such lesions might'conceivably,flare up,and result in a dis- 
seminated infection and death'. Only one such instance, however, is on 
record. " m 
The disease is unlike tuberculosis in that the initial infection usually 
confers permanent immunity.-again&t/subsequent reinfection. Even though 
residents in endemic areas, such as the San doaquin* 'Valley in 
and southern. Arizona, continue•■•tio be exposed to repeated inhalations of 
infected dust thrpughbut lives,, the, incidence of progressive coccid- 
ioidomycosis is extremely1 low, fpiobably no more than one patient with the 
disseminated form to every five hundred cases of the benign, primary 
c o c c idioidomyco s i s. As our knowledge of the disease has increased, the diagnosis of primary 
,coccidioidomycosis has been made with greater frequency. In most patients, 
however, the* infection still is not recognized clinically, the symptoms 
being attributed to a cold or an influenzal infection. Further, it is 
probable that many patients acquire the infection without showing clinical 
symptoms or findings during any stage of the disease other than the subse- 
quent positive reaction to coccidioidin. 
In the clinically recognized patient with coccidioidomycosis, varying de- 
grees, of pneumonitis, sometimes associated with hilar adenopathy, is a 
common finding. This primary focus apparently is walled off, as in tuber- 
culosis, and most often undergoes complete resolution, sometimes, however, 
with, fibrosis and calcification resulting. In some of the nodular paren- 
chymal lesions, necrosis occurs with the production of a small, thin- 
walled cavity./. Usually there is only one such lesion, although multiple 
cavities: have been, observed. Any area of the lung can.be involved. The 
absence of surrounding parenchymal reaction is a characteristic feature 
of. coccidioidal cavitation. During the many months which usually elapse 
before complete closure is evident by X-ray, the cavity serves as a res- 
ervoir for the growth of Coccidioides immitis. Apparently, however, there 
is little, danger of dissemination during this time or subsequently. Al- 
though the-patient’s sputum may contain the fungus or blood, as there may 
be hemorrhages of varying degree in some patients, the coccidioidal cav- 
ity is usually silent,. Further, a normal sedimentation rate, a low titer 
or disappearance of complement fixation, and absence of fever and consti- 
tutional symptoms indicate that the infection is inactive and well focal- 
ized. Coccidioidal cavitation usually always represents a part of a 
primary infection. 
Occasionally primary coccidioidomycosis is manifested by a primary pleural 
effusion, similar to that seen in tuberculosis. Coccidioides immitis may 
be recovered from the fluid. Within a comparatively short period the fluid 
usually disappears completely, leaving a slight pleural thickening as the 
only residual evidence of infection. 
In contrast to the benign nature of the primary infection is the serious- 
ness of the disseminated or progressive form of coccidioidomycosis.• In 
most instances death occurs after a prolonged course of many weeks up to 
six months or more, during which time the fungus disseminates throughout 
the body in a manner somewhat suggestive of miliary tuberculosis. It 
must be remembered, however., that an occasional patient with progressive 
coccidioidomycosis will focalize-his infection, usually after a prolonged 
period of bed rest, and make a 'complete recovery. This progressive type 
of coccidioidal infection is not ’'secondary,n as is implied in the usual 
classification (’'primary" and "secondary") of the two forms of this- dis- 
ease. It occurs in certain individuals as one continuous, progressive 
disease, although the serious form may not be recognized as such until 
several weeks or months have elapsed after the infection first becomes, 
evident. , :■ 
Symptomatology of Primary Coccidioidomycosis 
Many cases of primary coccidioidomycosis are subclinical and can be de- 
tected only by a positive coccidioidin skin test. After an incubation 
period of ten to fourteen days, those with clinical manifestations run a low grade fever (usually 99° ~ 101°) which sometimes is associated with 
chills, night sweats, anorexia, backache and headache. A non-productive, 
brassy cough may be present, although most patients will raise small 
amounts of muco-purulent sputum which occasionally is blood-streaked. 
More characteristic, when it occurs, is the chest pain which some patients 
describe as a sensation of constriction in the upper chest, while others 
complain of sharp pleuritic pains which may be mistaken for coronary oc- 
clusion, fractured ribs, or nephrolithiasis. These initial symptoms repre- 
sent the acute respiratory phase which subsides usually in one to two weeks. 
In 3% of the cases, a second phase follows in from three to twenty-one days, 
during which fever recurs and erythema nodosum, similar to that seen in pri- 
mary tuberculosis, is a prominent finding. Usually the lesions of erythema 
nodosum are most marked on the shins, but in some patients they occur on 
arms, thighs, buttocks, and scalp. Within two to three days the marked 
tenderness subsides and the lesions begin to fade, leaving only a brownish 
pigmentation which may persist for weeks. In rare instances a secondary 
crop of erythema nodosum occurs after an interval of some weeks. Lesions 
of erythema multiforme also may appear on the margins of the palms, the 
face, neck, and upper extremities at the same time, with or without ery- 
thema nodosum. Patients with erythema hbdosUm or multiforme are least like- 
ly to develop the progressive form of the disease. 
Other occasional findings are phlectenular conjunctivitis and acute arthri- 
tis, with the knees and ankles most likely to be involved. The joints are 
tender on pressure and painful on motion, but usually not as edematous as 
in rheumatic fever. The dramatic response to large doses of salicylates 
is usually lacking in coccidioidal arthritis, providing a helpful point in 
differential diagnosis. . •* 1 
For the most part,, however, patients with primary coccidioidomycosis rarely 
appear or feel ill. A visitor in the coccidioidomycosis "wards in station 
hospitals of the AAFWFTC, such as those at Minter, Leraoore, Luke and 
Williams Fields, usually is impressed with the appearance of well-being in 
most of the coccidioidal patients. This is born out by the 'average patient’s 
most frequent question: "Why must I stay in bed when I feel so well?" 
Physical examination at the onset of acute coccidioidomycosis reveals few 
significant findings other than a low grade fever. A mild naso-pharyngitis 
may be evident, but usually this- represents a coincident infection during 
the early stages of the disease. Only occasionally, even when pleuritic 
pain is present, can slight suppression of the breath sounds, dullness and 
rales be demonstrated. An X-ray of the chest, however, will show one or 
more of the characteristic changes in at least four out of every five pa- 
tients. These X-ray changes usually consist Of (X): soft, fuzzy hilar thick- 
ening, (2) pneumonia-like infiltrations, (3) nodular parenchymal lesions, 
or (4) mediastinal and hilar adenopathy. (See section on The Roentgen Di- 
agnosis of Coccidioidomycosis). 
Residual pulmonary coccidioidal cavitation is an infrequent complication of 
acute'coccidioidomycosis and is demonstrable only by X-ray, there being no 
symptoms other than occasional hemoptysis and sometimes spherule-laden spu- 
tum. However, coccidioidomycosis must be considered whenever pulmonary cavi- 
tation occurs in a patient with negative tuberculin tests and no. demonstrable tubercle bacilli in his sputum. Because the coccidioidal cavity occurs in 
one ox the areas of consolidation, it is not evident £pr at least several 
months after the onset of the infection in most instances. • When the cavity 
is diagnosed the infection usually is well focalized.as indicated by,a nor- 
mal sedimentation rate together with a low titer or.complete absence of 
complement fixation in the patient’s serum. Although•these’cavities-event- 
ually close spontaneously, a continuous rest regime will hasten complete 
healing of the pulmonary lesion. ■ - ' - i bk • , 
Erythema nodosum occurs in only 3% of patients with primary coccidiodorayco- 
si$. The lesions appear as -well-defined, red, tender podules of various 
sizes, usually on the-extensor surfaces of the legs and arms. Patients with 
erythema nodosum always show a markedly increased sensitivity to coccidioid- 
iru Occassionally erythema multiforme is present with symmetrically distrib 
uted macules, papules, or vesicles on the face, neck, or extensor surfaces 
of the'extremities. 
Synipt,omatblop;y of Progressive - Coccidioidomycosis. 
In direct contrast to the benign nature of primary coccidioidomycosis is 
the seriousness of the progressive form of the disease, whiph sometimes is 
referred to as "secondary coccidioidomycosis," "coccidioidal granuloma," 
"San Joaquin Valley Fever," "California Disease," or "desert fever." 
Fortunately, the incidence of dissemination is extremely low,, probably not 
more than one patient in five hundred failing to combat successfully the 
initial infection. Actually the patient with progressive coccidioidomycosis 
shows evidence of dissemination within a few weeks?or months after acquiring 
the infection. His clinical picture at first is similar to that of primary 
coccidioidomycosis. Without a let-up, however, the initial symptoms and 
'.physical findings crbhtinue with the sedimentation-' rate remaining elevated, 
'the serology revealing ah increase in the titer of/both precipitins and com- 
plement fixation,' and X-rays revealing' further extension of lung infiltra- 
tion. In some instances, involvement of -bones and ‘joints, lymph nodes, 
skin .and bieninges become apparent, • 
patients with progressive coccidioidomycosis run a slow, down-hill 
coursei lasting from a few months to a year or more1 in-some instances. In 
those'cases in which the pulmonary pathology predominates, low grade fever, 
Cough, spherule-laden sputum, marked weakness, and,Toss, of weight are prom- 
inent symptoms. As the end approaches the cyanosis jahd dyspnea are pro- 
nounced, being proportionate to the degree of lung infiltration. $o little 
functioning lung tissue remains in such, patients that anoxia ap- 
pears to be the principal factor in the immediate1, cause, of death. Patients 
with generalized miliary dissemination usually have high ...fever, chills,, -pro- 
fuse sweats, and become-emaciated due to•progressive loss of weight. ’Large 
'subcutaneous abscesses, containing, a creainy purulent, mat e-rial filled -with 
spherules, are a frequent finding in addition to deeper;abscess formations, 
which in most instances are first discovered at autopsy. Arthritis is an 
occasional finding, with the involved joints becoming redp somewhat- swollen, 
and painful. Some destruction of the adjoining bone as;demonstrable by X- 
ray. Any bone of the body may become involved in progressive- coccidioidomy- 
cosis with cyst-like areas of bone destruction, usually in .the o.alcellous 
bone, and periostitis the most 'characteristic lesions.. Throughout-the entire  of the disease, efen in those patients with the most extensive pul- 
monary pathology, the physical findings are far less prominent than the 
,degree of involvement would suggest. 
Just why approximately 499 of every 500 patients'with primary coccidioido- 
mycosis can control the .infection within a few weeks time in most instances, 
ivhile the remaining patient'‘disseminates during many weeks or months, with 
death usual-ly resulting, is not known. However, such factors as racial, 
sexual, and individual resistance seem important. Especially is this true 
in negroes and other pigmented patients who disseminate much more frequent- 
ly than do white patients with coccidioidal infections. So far the only 
deaths in the AAFV/FTC have‘occurred in seven negro patients, while the ac- 
tual incidence of primary coccidioidomycosis in negroes stationed in this 
command has been approximately three to four times greater than in white 
soldiers, 
Diagnosis. 
Primary coccidioidomycosis is sometimes mistaken for influenza or pneu- 
monia, while the progressive form of the disease may be confused with tu- 
berculosis. , Especially is this true in those patients with coccidioidal 
meningitis in whose spinal fluid the spherules are as difficult to demon- 
strate as are the tubercle bacilli in tuberculous meningitis. Inasmuch as 
the chest X-ray may show the Msnow storm” appearance of miliary dissemina- 
tion or other comparable findings in both diseases it is necessary to es- 
tablish the diagnosis of definite coccidioidal infection by laboratory pro- 
cedures. The bone lesions also may be similar in coccidioidal infections 
and tuberculosis. Other mycotic diseases may produce symptoms and findings 
similar to coccidioidomycosis;' Haplosporangium parvum, especially, may 
cause confusion,' inasmuch as many patients with proved coccidioidomycosis 
in Arizona hospitals also reacted positively to an antigen made from this 
fungus .which apparently is:also endemic in that state. 
Some form of laboratory confirmation is necessary in making the diagnosis 
of coccidioidomycosis. In most cases with a suggestive history, as well as 
characteristic physical and X-ray findings, only-a positive-coccidioidin 
skin^test and an elevated .sedimentation rate In some in- 
stance's, however, .the fungus must be demonstrated either in tissue sections 
or by culture of sputum and exudates with subsequent animal inoculations. 
Testing the patient’s serum for precipitins and complement fixation, using 
cqcdidioidin as antigen, is extremely helpful in making the diagnosis in 
doubtful cases, in addition to aiding in the early discovery of those pa- 
tients in whom the fungus infection is most likely to disseminate. 
The coccidioidin skin test is as important in the diagnosis of coccidioi- 
domycosis as the tuberculin test is in tuberculosis. In the. AAEWPTC coc- 
cidioicjin is used which is prepared at Stanford University School of Medi- 
cine by growing many strains of coccidioides -on' Bureau of 'Animals' Industry 
asparagine medium for one to ;two months. The material is tested for poten- 
cy;- and '.specificity on previously infected, as well as'normal, individuals 
before'being released for clinical use.' Undiluted coccidioidin'remains 
potent; f6r at least three to four years, while'a- 1:100 dilution in normal 
saline is satisfactory for skin testing for one to two month-s if kept re- 
frigerated. The* skin test is" performed iff the same manner as is the Mantoux test for tuberculosis. For routine testing, 0.1 cc of a 1:100 dilution of 
coccidioidin is injected intrademally on the right forearm, arid the test 
is read in 4B hours; The consistent use of the right forearm for coccidi- 
oidin testing and the left forearm for tuberculin testing will avoid con- 
fusion in the interpretation of results. A special "tuberculin syringe" 
should be used for this test exclusively. False positive reactions are 
likely if the same syringe is used for tuberculin and other tests as well 
as for coccidioidin skin testing. A positive test will show a reaction of 
more than 0,5 cm. in diameter, with erythema, induration,' and- sometimes ves- 
iculation. Usually-the local reaction to coccidioidin is considerably more 
pronounced than is' a corresponding reaction to old tuberculin in h proved 
tuberculous patient. In spite of an occasional violent skin reaction, 
which may cover the entire forearm, there is little danger to the patient 
of dissemination or of reactivating an old, arrested process; 
A positive test is usually recorded 1 plus, 2 plus, 3 plus, or 4 plus, 
according to the degree of reaction. However, the size of the local reac- 
tion represents the patient's allergic response to coccidioidin and is. not 
a measure of present activity. A positive test, therefore, regardless of 
the size of:the local reaction, may indicate either an old infection ac- 
quired many years previously, or a recent and active involvement. However, 
a change-over from a previously negative reaction to a positive skin reac- 
tion to coccidioidin is extremely helpful in making the diagnosis of active 
coccidioidal'infection. 
Since October, 1942, every aviation cadet who received his pre-flight train- 
ing at Santa Ana Amy Air Base has been skin tested and the results "Coc- 
cidioidin positive" or"Coccidioidin negative" noted at the top of his "64" 
examination record. Approximately 5% of these men have reacted positively, 
indicating residence in an endemic area and a primary infection previous 
to beginning cadet training at Santa Ana. Subsequent coccidioidin testing 
of every squadron prior to graduation from an advanced school has revealed 
positive reactions in an additional 10$ indicating coccidioidal infection, 
which may or may not have been recognized clinically, at some time during 
their months of actual flight training. This figure includes all cadets, 
many of whom were trained at various fields in the AAFIJFTC which are not 
in coccidioidal endemic areas. The infection rate, as indicated by a change- 
over from a negative to a positive coccidioidin test,/is much higher in 
cadets trained at fields in the San Joaquin Valley (Minter, Lemoore, and 
Gardner especially), in central and southern Arizona (Luke, Williams, and 
Yuma especially), and in western Texas (Pecos and Marfa especially). Re- 
testing of officers and enlisted personnel stationed in those areas for a 
year or more has shown a change-over to a positive coccidioidin test as 
high as 30% at some of these fields. 
The significance of the test is comparable to that of-the tuberculin test. 
Just as a positive tuberculin test indicates a sensitivity to tuberculin, 
a positive coccidioidin skin test indicates sensitivity to coccidioidin, 
due to a present or a past infection, but does not necessarily mean that 
an active infection exists at the time the test is performed. The major- 
ity of patients who have recovered from primary coccidioidomycosis will 
continue to react positively to subsequent skin tests for the remainder of 
their lives. A positive coccidioidin test is significant of clinical coc- 
cidioidomycosis in the presence of a suggestive history, physical signs, and laboratory findings, particularly:in patients who at. some previous 
time may have shown a negative reaction to coccidioidin. ..A negative skin 
test in a patient with other findings suggestive of the disease is not 
conclusive; another skin testy using the same dilution (1:100) should be 
-performed seven to ten days, 'later, Coccidioidomycosis patients with ery- 
thema nodosum are unusually sensitive:to coccidioidin, showing a markedly 
positive skin test. On the oth£r.hand, patients in the advanced stages of 
progressive coccidioidomycosis may not react to coccidioidin even■ when a 
1:10 dilution is used, just as a.p&tient with miliary tuberculosis may not 
react to the usual dilutions of;old tuberculin or purified protein deriva- 
tive. In the routine testing of military personnel,, many men from Michi- 
gan, Illinois, Iowa, Ohio, Indiana, Kentucky, West Virginia, Pennsylvania, 
and parts,of Texas havershown a false positive reaction to coccidioidin. 
In none of these states is there a known endemic area for this disease, 
but the plus-minus reaction may indicate a cross sensitivity to other 
fungus infections which are endemic in those sections of the country/-; 
The sedimentation rate is helpful. ,(1) in the significance of a 
positive coccidioidin test, pafients with either primary or progressive 
coccidioidomycosis almost always showing an elevated rate, and (2) in.mak- 
ing a prognosis. A continuously high sedimentation rate is present in 
most patients with progressive coccidioidomycosis, while the originally 
elevated rate gradually returns to normal (below 12 mm by Cutler method) 
as the process is arrested in patients with the. primary form of the dis- 
ease. In addition, this test is a fairly accurate-therapeutic guide, for 
the coccidioidal patient should be kept on a bed rest regime until the 
.sedimentation ■ rate is consistently normal. >£-•. 
The blood count usually shows an dnitial leukocytesis with a marked in- 
crease in the number of eosinophiles in some instances early in the course 
of the disease. In progressive■coccidioidal infections, even during the 
days prior to death, the blood counts are not significant except for an 
iron deficiency anemia. d 
Coccidioidin serological tests have proved an extremely useful and accurate 
diagnostic and prognostic aid. Using coccidioidin,SlS antigen, the patient’s 
serum may be tested for precipitins and complement fixation in (1) doubtful 
cases, (2) in patients with a protracted course and.a. persistently pro- 
longed sedimentation rate, and (3) in patients with; a doubtful prognosis 
due to the possibility of dissemination. The tests usually are negative*• 
in the very mild infections, .In mors severe infections, i;howrever, precipi- 
tins are present in fairly high dilutions with the titer of complement 
fixation directly proportionate ;to the degree of the coccidioidal involve- 
ment. A rise in titer of complement fixation or the maintenance of a 
positive reaction at high levels indicates dissemination of the infection. 
As patients recover from primary coccidioidomycosis these tests become 
negative, although in some instances, in cavity cases especially, serum 
may fix complement in low dilutions for many months following clinical re- 
covery, On the other hand, a patient with a large coccidioidal cavity, 
demonstrable by X-ray, may show no evidence of complement fixation,...in- ; 
dicating a well focalized infection with no signs of activity. 
While microscopic and. cultural methods of•demonstrating the fungus provide 
indisputable proof ot coccidioidal infection, seldom is the diagnosis de- pendent upon these lengthy and tedious laboratory procedures. Sputum 
studies are none too reliable because of the lack of adequate sputum in 
most patients and because of the difficulty in demonstrating the spher- 
ules by coverslip examinations. Further failure to recover the, fungus 
‘does hot rule out the possibility of infection. Animal inoculation fol- 
lowing sputum culture on Sabouraudls medium will provide positive diag- 
nostic proof of coccidioidal infection in doubtful cases. About ten to 
fourteen days after a heavy saline suspension of the culture is injected 
intra-peritoneally in a mouse, the animal usually dies, and spherule-* 
containing lesions can be demonstrated in the mesentery, lungs, spleen, 
and other organs. The fungus-also can be recovered in a guinea-pig fol- 
lowing intra-testicular inoculation of sputum treated with copper 
sulfate solution. Fortunately animal inoculations are rarely necessary 
to establish a- definite diagnosis of coccidioidomycosis. Other simpler 
laboratory procedures will confirm the diagnosis more easily and' with less 
work and danger for the laboratory personnel.1' 
The Roentgen Diagnosis of Coccidioidomycosis; 
Primary Coccidioidomycosis. 
Some patients who present all of the clinical manifestations of primary 
coccidioidomycosis will show no recognizable roentgenographic-changes. 
'When present, however, the X-ray findings are restricted to the chest, 
and Consist of the folowing changes, either alone or in combination: 
1. Hilar thickening, consisting of soft, fuzzy, peri-bronchial infiltra- 
tion in either hilar region, is the mildest change and usually clears 
within one to two weeks. There is nothing diagnostically specific- about 
this manifestation; only by correlation with the clinical picture can 
differentiation be made from other fungus infections; non-specific tracheo- 
bronchitis, primary tuberculosis, or first stage silicosis. Hilar thicken- 
ing is frequently associated with other chest findings, such as hilar or 
mediastinal lymphadenopathy, pneumonia-like infiltrations, or pleural fluid. 
2. A pneumonia-like infiltration, the most frequent radiographic finding 
in primary coccidioidomycosis, is typically of a soft, hazy, homogeneous 
type, occurring either as an isolated patch or as ah:infiltration extend- 
ing from the hilar region into the middle or lower1 lung field. Only in 
rare instances is the-upper lung field involved and in these patients this 
pneumonia-like infiltration simulates the adult type of tuberculous infec- 
tion. This form'of coccidioidal involvement- resembles certain primary a - 
.typical pneumonias (virus pneumonitis, psittacosis, etc.), being more 
uniform, less blotchy* and more circumscribed than'the usual bronchp- 
-.pneumonias, and only rarely suggests1 lobar distributibn. In most patients 
this X-ray finding will persist for only a short time-after subsidence of 
all .clinical symptoms of active infection. Sometimes, however, the in- 
filtration will be evident for many -weeks or-months1after"clinical recovery. 
3.- - '.Nodular parenchymal lesions represent the most 'characteristic and 
diagnostically specific finding of primary coccidioidomycosis. This lesion 
is an isolated, well circumscribed nodular focus, averaging two to three 
centimeters in diameter, and occurring most., frequently ..the ’id:ddle or 
lower lung field. In most patients these nodular lesions occur singly 
and are unaccompanied by other X-ray findings in the chest. They resemble metastatic or embolic foci or uncalcified primary tuberculous nodules, 
•If followed;roentgencgraphically for periods of many months, this "type 
of lesion is remarkably indolent, slow in evolution, and benign in char- 
acter. * 'Most of these.lesions will develop central cavitation eventually. 
A coccidioidal cavity'-differs from other infectious excavations in the 
total .lack of- inflammatory change in the surrounding parenchyma. These 
cavities are thin walled and appear remarkably cyst-like, being sometimes 
mis-diagnosed as an infected congenital cyst. A coccidioidal cavity will 
disappear eventually, sometimes after many months, or shrink to a small 
residual fibrous nodule which may undergo calcification, 
4. Mediastinal and hilar adenopathy is a relatively infrequent finding 
in primary coccidioidomycosis. When present, it is usually associated 
with parenchymal infiltration and a comparatively prolonged or severe 
clinical course. Occasionally, such adenopathy occurs alone and may be 
indistinguishable radiographically from Hodgkin’s disease or other forms 
of mediastinal enlargement. 
Pleural effusion is encountered in approximately one-fifth of all 
cases of primary coccidioidomycosis, usually in association with infil- 
tration in the adjacent lung fields. The fluid is ordinarily unilateral 
and so limited in amount that it seldom more than obliterates the costo- 
phrenic angle. . It resorbs rapidly and completely. 
Progressive Coccidioidomycosis. 
The great majority of primary coccidioidal infiltrations will disappear 
completely in five or six weeks so that continued spread of infiltration 
after this time is suggestive of the progressive form of the disease. 
Discovery of extra-pulmonary foci, particularly bone involvement, confirms 
the presence of progressive coccidioidomycosis and -is of serious prognos- 
tic significance. The X-ray findings in progressive coccidioidal infec- 
tions present the following characteristics, either alone or in combination 
1. Acute progressive pneumonic consolidations, which are especially;prone 
to wide-spread dissemination,- with death resulting within a few weeks or 
months; • , ;\ • v •. • 
2. Tuberculous-like infiltrations, localized at the apices or subapices, 
simulating the adult type of pulmonary tuberculosis in both location and 
character (clouding, mottling, fibrosis, and cavitation-). Such a finding 
occasionally is seen in primary coccidioidomycosis when it resembles the 
exudative,type of tuberculous infection. 
3. Mediastinal adenopathy provides one of the most frequent and outstand- 
ing radiographic characteristics of progressive coccidioidomycosis. It 
is present in at least two-thirds of all cases in contrast to.about one- 
sixth of all patients with primary coccidioidomycosis in which:it is sel- 
dom so striking a feature as in the progressive type of the disease. - 
When associated with primary, coccidioidomycosis, it usually indicates a 
severe or prolonged infection. ■ 4. . Bone anciJoint involvement is frequent in the progressive form of the 
disease,, .occurring in approximately one-fourth of all patients.. The le- 
sions are ’typically cyst-like, sharply circumscribed areas of bone destruc- 
tion, one-half 'to three centimeters in size with little change in the sur- 
rounding bonoi Less commonly, a .proliferative periostitis occurs, with 
or without-accompanying destructive changes in the subjacent bone. These 
lesions are.iprone jto localize in cancellous bone, particularly in bony 
ridges or prominences such as the-tibia! tubercle, malleoli, olecranon, 
styloid, processes, acromion processes, and angles of the scapulae. They 
are also found in -vertebral bodies,, ribs, and the small bones of the 
hands and feet. Joints are involved by direct extension from sub- 
articular foci, .but only,occasionally does primary synovial joint■in- 
volvement occur. The latter type of arthritic lesion may closely "simu- 
late tuberculous arthritis. As in tuberculosis, the non-weight-bearing 
portions of the joints are primarily-affected, and the joint cartilage 
is spared in the early stages of the disease. 
5. Miliary dissemination is a frequent terminal manifestation of pro- 
gressive coccidioidomycosis and is similar in its radiographic appearance 
to miliary tuberculosis, though the individual shadows tend to be less 
sharply defined and more fuzzy in outline than comparable lesions in 
tuberculosis. A high incidence of destructive bone foci accompanies 
the miliary phase of the disease. The appearance of small, punched-out 
areas of bone destruction at the margins of ribs, scapulae, or clavicles, 
in association with miliary involvement of the lungs, is nearly always 
pathognomonic of this form of progressive coccidioidal infection. 
Prognosis. 
No deaths have been reported, as the result of primary coccidioidomycosis. 
Even with pulmonary cavitation the prognosis is excellent. On the other 
hand, the progressive formof-ihe disease presents a grave outlook. 
After dissemination occurs, there is little chance of recovery. The 
course is sometimes rapid, terminating within four to six weeks, but in 
most instances, the patient lives for many months, sometimes for a year 
or more. -In rare instances the patient 'successfully focalizes his*‘in- 
fection after an illness of long standing, and makes an eventual recovery. 
Treatment 
In primary cpccidioidpmycosis the essential treatment is bed rest until 
complete clinical recovery is evidenced by; (1) the absence of physical 
findings; (2) a normal sedimentation rate; (3) a. normal chest X-ray or 
at least roentgen evidence of regressing lung pathology; and (4) a low 
titer or a complete absence of precipitins,-and complement fixation in 
the patient's blood .( if serologic tests are: necessary). Even though.'many 
individuals in endemic areas have gone through an undiagnosed primary 
coccidioidal infection without difficulty, qLt is possible that some in- 
stances of progressive coccidioidomycosis could have been prevented by 
a strict rest regime in.the early, stages-with the hope of arresting the 
infection and preventing dissemination. Isolation of the patient is not 
necessary, but the floors"and walls of rooms and wards housing patients 
with progressive coccidioidomycosis should be lysolized daily to prevent 
growth of the fungus in cracks and crevices and to minimize dust formation Pulmonary cavitation requires no additional treatment, except pneumo- 
thorax or possible thoracic surgery in the rare patient with extensive 
pulrnbhary hemorrhage. ' - v 
Patiehts with progressive coccidioidomycosis usually have'been unaffected 
by the wide variety of drugs and'vaccines which have been used in the 
past. These include sulfonamides, iodides, thymol, copper, antimony, 
and potassium tartrate intravenously, with x-ray therapy and various * 
vaccine extracts of the fungus. Occasional "cures” have been reported, 
although most observers now attest to the hopelessness of the outcome in 
the majority of patients with the progressive form of the disease regard- 
less of the treatment administered. 
Military Considerations. 
Coccidioidomycosis is of considerable importance to the Army Air Forces, 
especially the Western Flying Training Command, because of the location 
of a large number of training fields in the endemic areas. So far the 
mortality from progressive coccidioidomycosis has been exceedingly small, 
only seven deaths (all in negroes) having occurred in this command. 
Even though the mortality will continue to be low, due to the small num- 
ber of disseminated infections, the morbidity of the primary form of the 
disease has been, and will continue to be, relatively high. Because of 
the advisability of rather prolonged hospitalization, even in patients 
with the milder form of the disease, the number of hospital days charged 
to coccidioidomycosis will always be considerable with a comparatively 
high non-effective rate resulting. 
The increased susceptibility of negroes to both forms of coccidioidal 
infection makes it advisable to keep only essential colored troops on 
duty in endemic areas. 
The recent observations indicating that desert rodents constitute a 
natural reservoir of coccidioidal infections in endemic areas offer a 
practical method of determining whether certain regions are safe for 
troop concentrations and maneuvers. The examination and culturing of 
the lungs from samples of rodents in various localities provide a depend- 
able method of detecting whether Coccidioides is present in the environ- 
ment. Alert Army doctors may very possibly discover new endemic areas 
during this global war. 
From the viewpoint of the military surgeon, the important points in coc- 
cidioidomycosis are (1) recognition of the disease, and (2) prompt hosp- 
italization of all clinical cases with continued bed rest until each 
patient’s X-ray shows a progressive regression of the lung pathology, 
his sedimentation rate is normal, and until he is free from clinical 
signs of activity. With one-third of all American pilots and bombard- 
iers receiving their cadet training in the Western Flying Training Com- 
mand, it is possible that many of these men will acquire unrecognized 
coccidioidal infections during their training in endemic areas of the 
AAFWFTC, and that weeks or months after completing their training, evi- 
dence of a still active infection may be discovered. Therefore Amy doctors everywhere, particularly flight surgeons assigned to tactical 
units, should be thqro.ughly ■familiar with all of the manifestations of 
this/disease so that they will be able not only to diagnose acute and 
residual coccidioidal lesions, but to treat intelligently all military 
personnel‘with coccidioidal ‘infections. BIBLIOGRAPHY 
1. Alderson, H. E.’: Coccidioidal Granuloma; Arch. Derm, & Syph., 
25, 4, 728, 1932. 
2. Abbott, K. H. & 0. I. Cutler: Chronic Coccidioidal Memingitis; review 
of. literature and report of 7 cases; Arch. Path., 21,320-330, March 1936 
3. Ahlfeldt, F. E.: Studies in Coccidioidal Granuloma; Mode of Infection; 
Arch. Path., 2, 206-216, August 1926. 
4. Ahlfeldt, F. E.: Special Observations on Morphology of Coccidioides 
Irnmitis; Journ. Infect. Dis., 44, 277-231, April 1929. 
5. Aronson, J. D. & J. R. Gallagher; Sensitivity to Coccidioidin (an 
explanation of pulmonary calcifications) among boys in an Eastern 
Preparatory School; Am. Journ. Publ. Health, 32, 636-639, June 1942. 
6. Aronson, J. D., R. M. Saylor & E. I, Parr: Relationship of Coccidi- 
oidomycosis to Calcified Pulmonary Nodules (in Indian children with 
negative tuberculin reactions); Arch. Path., 34,.31p48, July 1942. 
?. Ashburn, L. L. & C. W. Emmons; Spontaneous Coccidioidal Granuloma 
in Lungs of Wild Rodents; Arch. Path., 34, 791-300, November 1942. 
3. Baker, E. E. & E. M. Mrak: Spherule Formation in Culture by Coc- 
cidioides Irnmitis, Rixford & Gilchrist 1896; Amer, Journ. Trop. Med., 
21, 589-95, July 1941. 
9. Baker, E. E. & C. E. Smith; Utilization of Carbon and Nitrogen Com- 
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162. Stowe, W.P.: Simple Technique for Finding Coccidioides Immitis; 
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163. Tager, M. & A.A. Liebon: Intranasal and Intraperitoneal Infection 
of Mouse with Coccidioides Immitis; Yale Journ. Bio. & Med., 15, 
41-59, October 1942. 
164. Taylor, R.G.; X-ray Findings in Coccidioidal Granuloma; Calif. & 
West. Med., 22, 226, 1924. 
165. Taylor, R.G.: Coccidioidal Granuloma; Amer. Journ. Roentg., 10, 
551-B, July 1923. 
166. Thomer, J.E.: Erythema Nodosum in Children Associated with In- 
fection by Oidium Coccidioides, 7 Cases; Arch. Pediat., 56, 628- 
33, October 1939. 
167. Thorner, J.E.: Coccidioidomycosis, Relative Value of Coccidioidin 
and Tuberculin Testing Among Children; Calif. & West. Med., 54, 
12-15, January 1941. 
l6S. Tomlinson, C.C. & P. Bancroft; Granuloma Coccidioides, Further 
Observations on Use of Antimony and Potassium Tartrate and Roentgen 
Therapy; J.A.M.A., 102, 36-3B, January 6, 1934. 
169. Van Cleve, J.B.: Coccidioidal Granuloma; Journ, Kansas Med. Soc., 
37, 54-55, February 1936. 
170. Wernike, R.: Ueber einen Protozoenbefund bei Mycosis fungoides; 
Centralbl. f. Bakt., 12, 856, 1892. 
171. Winn, W.A. & G.H. Johnson: Primary Coccidioidomycosis; Roentgeno- 
graphic Study of 40 Cases; Ann. Int. Med., 17, 407-22, September 1942. 
172. Winn, W.A.: Treatment of pulmonary Cavitation due to Coccidioidal 
Infection: Calif. & West. Med., 57, 45-47, July 1942. 
173. Winn, W.A.: Coccidioidosis Associated with Pulmonary Cavitation; 
Arch. Int. Med., 68, 1179-1214, December 1941. 
174. Wolbach, S.B.; The Life Cycle of the Organism of Dermatitis Coc- 
cidioides; Journ. Med. Research, 8, 53-60, December 1904. 
175. Wolbach, S.B.: Recovery from Coccidioidal Granuloma; Boston Med. 
& Surg. Journ., 172, 94-96, 1915. 
176. Yegian, D. & R. Kegel; Coccidioides Immitis Infection of the Lungs; 
Case Resembling Chronic Pulmonary Tuberculosis; Amer. Rev. Tbc., 41, 
393-7, March 1940. 
177* Ziesler, E.P.: Chronic Coccidioidal Dermatitis; Unusual Case; Arch, 
Derm..& Syph., 25, 52-71, January 1932. 
178. Zelman, J.; Disseminated Coccidioidal Granuloma; Calif. & West. Med. 
47, 327-9, November 1937. -25- r'ij. 1, Primary coccidioidomycosis. 
Ihizzy peribronchial ri£hi hilar tPicheninj Fig. 7• Primary coccidioidomycosis. 
Left hilar thickening. Slight prominence of right medias- 
tinal border due to associated lymphadenopathy. Tig. 3- Primary coccidioidomycosis. 
Local zone of infiltration in the medio-basal portion 
of right lung. Fig. lu Primary coccidioidomycosis. 
Small amount of infiltration at the left base associated 
with slight pleural effusion. Fig. 5-A. Primary coccidioidomycosis. 
Pneuraonia-like infiltration in the left lower lung 
field. Fig. 5-3. Primary coccidioidomycosis. 
The pneumonia-like infiltration shown in Fig, 5-A has 
largely but not entirely cleared after a period of 
three weeks• Fig. 6-A. Primary coccidioidomycosis. 
Pneumonia-like infiltration in the right lower lung 
field. Fig. 6-B. Primary coccidioidomycosis. 
The pneumonia-like infiltration shown in Fig. 6-A 
has largely cleared after an interval of one week. ?ig- 7-A- Primary coccidioidomycosis. 
Severe illness. Massive hilar and mediastinal lymph- 
adenopathy. Local zone of consolidation right lower 
lobe. Fig. 7-B. Primary coccidioidomycosis. 
The mediastinal and hilar lymphadenopathy shown in 
Fig. 7-A has regressed after a period of six weeks; 
the local zone of infiltration at the right base 
has been replaced by an isolated ring-like cavity. Fig, 7-C. Primary coccidioidomycosis. 
The mediastinal and hilar lymphadenorathy shown in 
Fig, 7-B has further regressed after a period of ten 
weeks; the cavity previously present has disappeared 
leaving a residual nodule. Fig. 8-A. Primary coccidioidomycosis. 
Modular, '.veil circumscribed lesion in the lower lext 
lung field* Fig. 3-3. Primary coccidioidomycosis. 
The nodular lesion in the left lower lung field shown 
in Fig. 8-A is developing central cavitation after a 
period of six months. Fig. 9. Primary coccidioidomycosis. 
lypical ring-like cavity in the left raid-lung field. Fig. 10. Primary coccidioidomycosis. 
Ring-like cavity in the right subclavicular region simulating 
tuberculosis. The wall of the cavity became pencil thin after 
a three months' interval, resembling that of a congenital cyst. 
The outlines of this cyst-like lesion then gradually "melted 
away" after a six months' interval. Fig. 11. Primary coccidioidomycosis. 
An unusual case show:ng multiple nodular foci simulating metas- 
tatic carcinoma or multiple septic emboli. Central cavitation 
is visible in some of the nodules. This patient has shown 
progressive improvement both clinically and radiographically 
without evidence of extra thoracic dissemination. Fig, 12. Primary coccidioidomycosis. 
Lumpy mediastinal broadening. Infiltration radiating from the 
hilar regions. (Chest films entirely normal after a period of 
two and one-half months). Fig. 13. Secondary coccidioidomycosis (coccidioidal granuloma). 
A. local zone of soft exudative infiltration is seen in the 
right first interspace. Note the lumpy, widened right medias- 
tinal border due to associated mediastinal lymphadenopathy. Fig* Ih. Secondary coccidioidomycosis (coccidioidal granuloma). 
Tuberculosis-like patchy and strand-like infiltration at both 
apices and sub-apices. 
Mote the thin wall cavities just below the clavicles on each side. Fig. 15. Secondary coccidioidomycosis (coccidioidal granuloma). 
Hilar and mediastinal lymphadenopathy. Fig. 16. Secondary coccidioidomycosis (coccidioidal granuloma). 
Massive mediastinal lymphadenopathy simulating lympnoblastoma. 
General dissemination with fatal termination four months after 
onset. Fig, 17# Secondary coccidioidomycosis (coccidioidal granuloma). 
Dense shadow projecting from the right mediastinal border con- 
sisting of mediastinal lymphadenopathy and associated parenchymal 
infiltration. Terminal miliary dissemination. Fig* 18. Secondary coccidioidomycosis (coccidioidal granuloma)* 
Diffuse pneuraonia-like infiltration radiating from the right 
hilura. Broad mediastinum due to associated lymphadenopathy. Fig, 19. Secondary coccidioidomycosis, (coccidioidal granuloma). 
Extensive diffuse nodular infiltration throughout both lungs. 
Confluent zone of consolidation at the left apex. 
Mediastinal lymphadenonathy. Fig. 20. Secondary coccidioidomycosis (coccidioidal granuloma). 
Miliary spread. Note area of bone destruction in tubercle 
of loft first rib. Fig. 21. Secondary coccidioidomycosis (coccidioidal granuloma). 
(Upper) - Destruction of a portion of the cuboid bone. 
(Lower) - Cyst-like areas of destruction in the distal tibia, 
malleoli and talus. Fig. 22. Secondary coccidioidomycosis (coccidioidal granuloma). 
(Upper) - Destructive arthritis involving non-weight bearing 
portions of joint. 
(Lower) - Proliferative periostitis at anterior surface of 
patella. JU-g. 23* Secondary coccidioidomycosis (coccidioidal granuloma). 
(Upper) - Destructive osteo-periosteal lesion of the medial 
malleolus. 
(Lower) - Destructive lesion involving the tibial tubercle. 2h* Secondary coccidioidomycosis (coccidioidal granuloma). 
Cyst—like areas oi bone destruction in the centers oi mid- 
thoracic vertebral bodies. Figure 1 a 
Sputum culture of C. immitis on Sabouraud's medium, showing white, 
cottony fungus growth. 
Figure 1 b 
Microscopic appearance of old culture of Coccidioides immitis 
showing fragmented chlamydospores. This is the”inTective' form of 
the fungus occurring in nature. Figure 2 
Development of spherules. 
a. Chlamydospores in tissue. 
b. Chlamydospores rounding up to form spherules. 
c. Protoplasm appearing within the spherule. 
d. Protoplasm divides into endospores. 
e. Mature spherule ruptures, releasing endospores. Endospores 
are carried by lymphatics or blood stream. Each endospore increases 
in size and becomes mature spherule (repeating stages c, d and e.). Figure 3 
a. Spherules in coverslip preparation. This shows a. double contoured 
spherule without protoplasm, one with undifferentiated protoplasm and a mature 
spherule with characteristic endospores. 
h. A tissue section of coccidioidal granuloma showing a characteristic 
mature endosporulating spherule within a giant cell. 
Figure 1 a 
Sputum culture of C. immitis on Safcouraud's medium, showing white, 
cottony fungus growth. c v L r or * ‘ 1 ' 
> CoccidiaBycohlB V 
Shaded areas - 
Cross Hatch - Case 
Prom study nflde hy Dr. of Stanford 
DkiiTersity at Lespon£ Bakersfield, and 
fcft Air Bases. / S 
Tfader direction Wa|PTC Surgeon L.X1.1 4 KKWfXt:; ; ; 
CASC5 OF COCQIOIOIOOMYCOSIS 
-HUMe„ 
-jN^W^EJ^^F^AgE^rREMAlN«N& 
NUMBER OF CASES 
fox rue wee* 
£ND/N<3 ARMY AIR FORCES WESTERN FLYING TRAINING COMMAND 
Cases of Primary Coccidioidal Infection 
Data of 
Data of 
Length of 
Data of tha 
No. of daya 
*0! 
arrival 
the on- 
tiaa in 
diaeharga 
Hospitalizad 
SYMPTOMATOLOGY 
in tha 
aat of 
caap 
froai tha 
baad- 
Ml- 
joint 
anor- 
back 
night 
Skin 
area 
... , .. 
hoaoital 
ache 
cough 
aisa 
peine axle 
chill 
ache 
aweat 
Lesiona 
18 
10/4/41 
11/4/41 
30 
12/5/41 
30 
♦ 
♦ 
♦ 
19 
7/8/41 
9/3/41 
56 
9A7/41 
2 
♦ 
♦ 
19 
8/16/41 
11/24/41 
99 
12/3/41 
7 
♦ 
♦ 
♦ 
19 
8/1/41 
6/21/42 
321 
8/1/42 
40 
♦ 
19 
11/25/41 
12/23/41 
30 
1/29/42 
38 
♦ 
♦ 
♦ 
♦ 
♦ 
♦ 
20 
2/1/42 
7/9/42 
159 
8/7/42 
29 
♦ 
♦ 
♦ 
20 
6/9/41 
11A9/41 
160 
11/28/41 
18 
♦ 
♦ 
21 
5A0/41 
8/10/41 
96 
8/27/41 
17 
♦ 
♦ 
♦ 
♦ 
21 
6/21/41 
4/21/42 
300 
5/29/42 
39 
♦ 
♦ 
21 
1/1/42 
3/24/42 
84 
5A5/42 
52 
♦ 
♦ 
♦ 
21 
4/26/42 
6/11/42 
47 
8/13/42 
62 
♦ 
♦ 
♦ 
♦ 
♦ 
♦ 
21 
7/1/41 
IO/23/41 
113 
11/1/42 
8 
♦ 
♦ 
♦ 
♦ 
♦ 
♦ 
n 
9/13/41 
1/27/42 
132 
3/3/42 
36 
♦ 
♦ 
♦ 
♦ 
♦ 
a 
9/1/41 
9/29/41 
28 
10/20/41 
21 
♦ 
♦ 
♦ 
22 
9/13/41 
10/24/41 
41 
11/24/41 
26 
♦ 
♦ 
♦ 
♦ 
22 
3/1/42 
7/9/42 
129 
8/10/42 
29 
♦ 
22 
3/21/42 
6/2/42 
72 
7/17/42 
45 
♦ 
♦ 
♦ 
22 
8/1/41 
3/25/42 
235 
7/15/42 
110 
♦ 
♦ 
♦ 
♦ 
♦ 
♦ 
♦ 
♦ 
22 
2/1/42 
5/1/42 
90 
6 A 8/42 
47 
♦ 
♦ 
♦ 
♦ 
♦ 
22 
1/1/42 
7/12/42 
222 
8/7/42 
25 
♦ 
♦ 
♦ 
♦ 
22 
1/6/42 
3/3/42 
59 
jA4/42 
69 
♦ 
♦ 
♦ 
♦ 
♦ 
♦ 
♦ 
♦ 
22 
7/10/42 
10/31/42 
111 
11/16/42 
16 
♦ 
♦ 
♦ 
♦ 
♦ 
♦ 
♦ 
22 
8/5/41 
1/1/42 
146 
I/20/42 
19 
♦ 
♦ 
♦ 
♦ 
♦ 
♦ 
♦ 
23 
7A1/41 
10/23/41 
102 
11/22/41 
26 
♦ 
♦ 
23 
4/23/42 
5/20/42 
27 
6/9/42 
19 
♦ 
♦ 
♦ 
23 
3/10/42 
5/28/42 
68 
7/29/42 
61 
♦ 
♦ 
♦ 
♦ 
♦ 
♦ 
♦ 
23 
8/5/41 
11/1/41 
85 
11/19/41 
18 
♦ 
♦ 
♦ 
23 
11/3/41 
12/8/41 
25 
12/23/41 
15 
♦ 
♦ 
♦ 
23 
11/1/42 
5/28/42 
208 
6/12/42 
14 
♦ 
♦ 
♦ 
♦ 
♦ 
23 
3A0/42 
5/28/42 
78 
7/29/42 
60 
♦ 
♦ 
♦ 
24 
7/7/41 
9/20/41 
73 
11/21/41 
25 
♦ 
♦ 
♦ 
♦ 
2k 
lA/42 
7/21/42 
201 
8/1/42 
10 
♦ 
♦ 
♦ 
♦ 
2k 
1/16/42 
6/29/42 
191 
7/29/42 
30 
♦ 
♦ 
♦ 
♦ 
♦ 
24 
12/25/41 
1/16/42 
21 
1/29/42 
13 
♦ 
♦ 
♦ 
♦ 
24 
8/5/41 
3/24/42 
229 
4/25/42 
30 
♦ 
♦ 
♦ 
♦ 
♦ 
24 
1/16/42 
6/29/42 
163 
7/29/42 
30 
♦ 
♦ 
♦ 
♦ 
♦ 
23 
4/7/42 
7/3/42 
86 
8/25/42 
52 
♦ 
♦ 
♦ 
♦ 
♦ 
25 
7A/41 
5/3/42 
333 
6/7/42 
34 
♦ 
♦ 
♦ 
♦ 
26 
6/3/41 
5/20/42 
412 
7A5/42 
55 
♦ 
♦ 
♦ 
♦ 
♦ 
♦ 
26 
(1A6/42 
for a period of 16 days..*.) 
(4/1/42 
5/6/42 
25 
8/13/42 
97 
♦ 
♦ 
♦ 
♦ 
♦ 
26 
8/6/42 
u/23/41 
107 
1/8/42 
45 
♦ 
♦ 
♦ 
♦ 
26 
8/5/41 
3/17/42 
222 
4/28/42 
41 
♦ 
♦ 
♦ 
♦ 
♦ 
♦ 
26 
6A/41 
4A5/42 
285 
4/28/42 
13 
♦ 
♦ 
♦ 
♦ 
♦ 
27 
5/22/42 
8/10/42 
78 
8/20/42 
10 
♦ 
♦ 
♦ 
♦ 
♦ 
♦ 
♦ 
♦ 
27 
7A2/42 
7/15/42 
3 
8/19/42 
34 
♦ 
31 
7A/42 
7A7/4 2 
17 
8/1/42 
13 
♦ 
♦ 
31 
3/7/42 
4/30/42 
53 
5/30/42 
30 
♦ 
♦ 
♦ 
32 
3A/42 
5A2/42 
72 
8/3/42 
81 
♦ 
♦ 
♦ 
33 
8/16/41 
9/16/41 
30 
11/29/41 
71 
♦ 
♦ 
♦ 
♦ 
36 
3A3/42 
6/2/42 
79 
7A3/42 
41 
♦ 
♦ 
♦ 
♦ 
TOTAL 30 
CASES 
1749 
30 
37 
742 
45 
902 
10 
2« 
33 
66* 
16 
322 
15 
302 
13 
?6* 
12 
.24* . . 
TOUHKEi The average length of time hospitalized eaa Jj, days. Of the 30 emmaa presented, 62* or J1 emi were hospitalised for • period of 33 
day or laaaj 86X or 43 eases were hospitalised for a period of 60 daya or laaa. The alnlim period of hospitalization waa Z daya, the miitaie 
period 110 daya. 
The average time elapae between the date of arrival and the onaet of the dlaeaae aaa 121 daya. Of the 3° oaaea presented 64* or J2 
cases contracted the dlaeaae 121 daya or laaa after arrival into the area. 
In the accompanying chart the aaaaa were taken purely at random from among those oaaea at Bakersfield add Gardner Field, California. 
• This ease stated that ha had bad a cough for years. LABORATORY 
STANFORD U. 
REPORTS OF BLOOD PRECIPI- 
TINS & COMP. FIXATIONS 
BLOOD SPECIMENS FROM PTS. FOR 
PRECIPITINS & COMP. FIX TO STAN- 
FORD LAB. 
CASES OF CHRONIC COCCIDIO- 
DOMYCOSIS (3 MOS. OR LONGER) 
TO BE TFRD. TO STATION HOSP- 
ITAL, SAAAB 
SPECIALIZED 
MONTHLY SUMMARY: 
CLINICAL CASES 
HOSPITAL DAYS 
NO. OF SKIN TESTS 
CLINICAL SUMMARY QF EACH 
REQUESTS FOR COCCIDIOIDIN. 
EJQ, 
KINGMAN AFS 
LAS VEGAS AFS 
COCCIDIODOMYCOSIS CONTROL OFFICER FOR AAFWFTC 
STATION HOSPITAL. SAAAB 
1 DIRECTIVES 
2 COCCIDIOIDIN REPORT BLANKS, BLOOD CONTAINERS & OTHER 
SUPPLIES. 
3 REPORTS OF PRECIPITINS & COMP FIX OF BLOODS SENT TO 
STANFORD UNIV. 
BLOOD SPECIMENS FROM PTS. FOR PRECIPI- 
TINS TO STANFORD LAB, 
HQS. A-AFWFTC- 
CARLSBAD AFS MATHER AFS 
DEMING AFS ROSWELL AFS 
DOUGLAS AFS STOCKTON AFS 
HOBBS AFS WILLIAMS AAFAFS 
KIRTLAND AAFAFS YUMA AFS 
LA JUNTA AAFAFS 
LUKE AAFAFS 
MARFA AFS 
CASES OF CHRONIC COCCIDIODOMY- 
COSIS (3 MOS.OR LONGER)TO BE TFRD. 
TO STATION HOSPITAL, SAAAB 
MONTHLY SUMMARY: 
CLINICAL CASES 
HOSPITAL DAYS 
NO. OF SKIN TESTS 
CLINICAL SUMMARY OF EACH CASE. 
REQUESTS FOR COCCIDIOIDIN, ETC. 
ADVANCED 
BLOOD SPECIMENS FROM PTS. FOR 
PRECIPITINS & COMP. FIX TO STAN- 
FORD LAB. 
MONTHLY SUMMARY: 
CLINICAL CASES 
HOSPITAL DAYS 
NO. SKIN TESTS 
CLINICAL SUMMARY OF EACH 
CASET 
REQUESTS FOR COCCIDIOIDIN, 
CASES OF CHRONIC COCCIDIO- 
OOMYCOSIS (3 MOS.OR LONGER) 
TO BE TFRD. TO STATION HOSP- 
ITAL, SAAAB 
BASIC 
CHICO AFS 
GARDNER AAFBFS 
LEMOORE AFS 
MARANA AFS 
MERCED AFS 
MINTER AAFBFS 
LANCASTER AAFBFS 
PECOS AFS 
STATION HOSPITAL 
SAAAB 
REPORTS OF DISPOSITION 
OF CHRONIC CASES TFRD. 
FROM OTHER FIELDS 2683—Santa Ana—8-30-43—550