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Lung Spots & The Arizona Flu 

I am breaking away from my traditional discussion of chronic pain to discuss a very interesting and important health awareness that happen to become personal.

In December 1999, my then sixty-four year-old mother asked me my opinion regarding screening physicals. I explained to her that most physicals find nothing, but that I thought that an X-ray, blood and Ultrasound screening on a person over fifty, at least periodically, can catch the occasional cancer, or other disease process.

So my mother plodded off to her doctor to get a series of blood and x-ray examinations. Unfortunately, her chest x-ray demonstrated a single solitary lesion on the left upper chest and enlarged nodes in her chest. These changes were very suspicious for lung cancer, so a CAT scan was arranged. 

The CAT scan demonstrated a definite suspicious lesion in the left upper lung zone, multiple enlarged lymph nodes and even possible lesions in the liver. Now this picture was looking very ominous, and that she might have literally weeks to live. The plan was to do a lung biopsy or lung resection, which is a big operation where they remove a full section of your lung. An operation not without complications.

However, I had trouble believing this picture as she was a non-smoker, had lost no weight, had no cough or pain, and had absolutely normal blood tests. The reality was I did not know. But I also knew that my parents had traveled to Arizona three times over the past three years, and that there was a condition called the "Arizona flu" that could cause a similar looking picture. 

The Arizona flu, or Coccidioidomycosis, is caused by an air-borne fungus that is easily inhaled called "Coccidioides imminis." So I contacted the Valley Fever Center for Excellence in Tucson, which is directed by Dr. John N. Galgiama. 

I was fortunate to be able to speak with Dr. Galgiama who explained the basics of the disease and some clues for diagnosis. 

I ordered a series of blood tests, the most important for my mother turned out to be the Coccidioidomycosis titre which has a one to three week waiting period.

Now our excellent respirologist, Dr. Lawrence Chau,  had also arranged a very unusual test called a PET Scan of the lung in Hamilton. 

A PET scan looks for cell activity, which is present in both cancer and infection. Cancer can be quite hot, but so too can be an infection. 

My mom’s scan demonstrated an activity pattern of multiple hot spots in the left lung, none in the right lung, none in the abdomen, and only one small one around the aorta. 

These findings were indicating cell activity, but in a different pattern than the Cat scan. It had cleared the abdomen of any activity; a point which was very important in terms of cancer. 

But it was also different in that the pattern was much like "as if you had inhaled an infection or fungus", like the Arizona Flu. I spoke with Dr. Galgiama about PET scans and the Arizona Flu, and he did not know, as there was no data. 

The PET scan is primarily a research tool at this time. However, on discussion with several radiologists, it would appear to point in the direction of a lung infection, but unfortunately not conclusively.

The plan was to go ahead with the lung biopsy under CAT scan guidance, and await the blood test. The Biopsy was done expertly under the guidance of Dr. Wayne Tonagai, an Oakville Radiologist. 

Although the lesion was unapproachable from the back because it was hidden by the shoulder blade, Dr. Tonagai thought he could reach it from the front with a long four-inch needle. The major risk being an almost certain collapsed lung. If he could not reach the lesion, the only other method would be by partial lung resection.

Fortunately, he was able to reach the lesion and successfully biopsy the site. 

Although my mom had a very small collapsed lung, she was able to go home, and felt little or no pain (However, she’s pretty tough!)

Later that day, Public Health contacted us with the good news that the blood test did come back positively testing for Coccidioidomycosis exposure. This meant that my mother had been infected in the past, probably at least a year ago with the fungus. 

However, it did not conclusively prove that the lung spot was not a cancer. The lung biopsy was sent for cytology or cell analysis, culture in special media, and special staining. 

Days later, the biopsy also proved positive for the Arizona Flu, and the scare was finally over. 

No treatment is necessary for her, but not all will be so fortunate.

Interestingly, one of the leading physicians with Public Health explained to me that he travels the country attempting to educate the public about this condition because of the large number of traveling Canadians picking up the "desert flu," and being unaware.

• C. immitis is a soil-dwelling fungus of dry climates, and is present in parts of Arizona, California, Mexico, Central and South America.
• The fungus is inhaled into the lungs from infected ground areas.
• Most cases of Valley fever are mild causing flu-like symptoms including fatigue, cough, chest pain, fever, rash, headache and joint aches.
• The usual recovery is within six months
• Many people never develop any symptoms, and develop long-standing immunity
• It is generally not considered infectious by person to person.
• 5% develop lung nodules resembling lung cancer, which may not be definitively diagnosed without testing by biopsy, bronchoscopy or lung resection.
• 5% develop lung cavities, but this is typically the older individual, and often without any symptoms or problems.
• 1 to 2 % of those infected can develop disseminated or spreading disease. Typically it spreads to the skin, but rarely can spread to the bone, joints, and even cause meningitis.
• Most of the people with disseminated disease have weakened immune systems from other illnesses such as AIDS, cancer, diabetes, organ transplantation, third-trimester pregnancy, or chronic prednisone usage.
• Diagnosis is made by microscopic identification in the body fluid samples, growing a culture of C. immitis from tissue or fluid, and/or detection of antibodies against the fungus in blood or body fluids. Unfortunately, negative tests do not mean you are not infected, as a third of individuals will not test positive for a year or more after the infection.
• It is uncommon that an individual actually needs treatment. However, there are oral therapy may consist of a choice of ketoconazole, itraconazole and fluconazole. Intravenous treatment is reserved for the very ill, and is often treated with Amphotericin B.
• Residents of endemic areas test positively for antibodies in their blood at rates of 30 to 40%, bust most are asymptomatic.
• High-risk occupations include construction, agricultural, and archaeology due to increased risk of exposure to infected soil.
• Blowing dust, windstorms, and recently disrupted soils (construction zones) can increase risk of exposure. So watch the winds when you are golfing.
• Animals are at risk as well; however dogs are the most at risk, and may require life-time therapy.

The Valley Fever Center For Excellence Hot Line Number is:

(520) 629-4777 or 1-(800) 470-8262

or contact them at 

Valley Fever Center for Excellence

Mail Stop 111, 3601 S. 6^th. Ave.,

Tucson, AZ 85723.

I would like to thank all the doctors and nurses involved in my mother’s care.

The above article has been edited from information published by the Valley Fever Center for Excellence "Who Gets It", and by the article published by the Center for Disease Control "Morbidity and Mortality Weekly Report, December 13, 1996/Vol 45/ No. 49 , page 1069-1071."

G. Blair Lamb MD, C.C.F.P.

Pain and Rehabilitation Consultant

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