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A Fever in the Dust

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A Fever in the Dust

Valley Fever
Friday, April 24, 2020

By Lauren J. Young and Kerry Klein

Arthur Charles used to start each day with a morning walk with his wife. The loop around his neighborhood in Bakersfield, California wasn’t usually difficult for the 50-year-old to complete. Then one day, two years ago, Charles could barely reach the corner of his street. The routine walk felt like he was running a marathon. 

“I couldn’t breathe. I was tired,” he recalls.  

Charles visited his doctor, who thought he might have pneumonia, and prescribed a round of antibiotics. Charles was sent home. Later that evening, he was pouring sweat, running a fever, and vomiting. Unexpected trips to urgent care continued for three weeks—but no one could figure out what was wrong. One evening, his wife noticed that he was barely breathing while he dozed off. They rushed to the hospital, where Charles' oxygen levels were alarmingly low. “They said if I would have went to sleep that night, I wouldn't have woken up.”

After he was admitted to the hospital, his symptoms—shortness of breath, vomiting, dizziness, and extreme exhaustion—grew worse. 

"That was the first time I’ve ever felt like I can’t do anything. I just felt helpless," he says. "I've never felt so weak and so beat in my life."

Finally, after several misdiagnoses, a blood test revealed that Charles did not have a bacterial or viral infection. He had breathed in a fungus that had hijacked his lungs—and was headed for the rest of his body.

The doctor told Charles’ family he might die.

Arthur Charles is a resident of Bakersfield, in the southern Central Valley of California. He works as a major league baseball recruiter and rec specialist at West Side Recreation and Park District. Credit: Kerry Klein/KVPR



Charles had Valley Fever, which he continues to battle today. This disease, medically known as coccidioidomycosis, is caused by the fungus Coccidioides, or Cocci for short. The dangerous fungus lingers in the soil and dust in the American West, as well as Mexico, and Central and South America. Anyone who lives, or even passes through, these regions has a chance of becoming infected.

Valley Fever isn’t contagious. It doesn’t spread from person to person like the common cold or flu. All it takes to get Valley Fever is a single breath of the fungus when it’s swept up by the wind. 

The latest numbers show that in 2018, about 15,600 people were diagnosed with Valley Fever in the United States, with most cases coming out of southern Arizona and California’s San Joaquin Valley. But these numbers only reflect known cases reported to the Centers of Disease Control. “That number is probably a drastic underestimate of the true number, because people and doctors are not looking for this disease,” says Orion McCotter, a former CDC epidemiologist who tracked outbreaks of Valley Fever. 

Even though Valley Fever isn’t well-known in other parts of the country, if you live in endemic regions, it’s likely that you know someone who’s had the disease. I grew up just outside of Fresno, and have family living all through the Central Valley, an agriculture cradle surrounded by a fortress of periwinkle mountains. Many of my relatives have worked the fields and orchards that sprawl between the valley’s quickly-growing cities.

My mother grew up in the small town of Dinuba, and she contracted Valley Fever when she was a teenager. She was working her uncle’s onion farm in Madera one summer, unloading bin after bin of the dried red bulbs. “Every time you dumped one out, you could see all the dust flying in front of you. Every day we’d be inhaling it, inhaling it,” she tells me.

She started having coughing fits at night. She brushed it off as a cold at first, but then her lungs began to rattle and her fever began to climb. She noticed strange red-purple lumps on her legs that she confused for bug bites, and that wouldn’t go away. Then she became unusually tired. 

“I thought, this is not my norm. I didn't know what it was.”

The most common symptom of Valley Fever is exhaustion. Many people who get infected have symptoms similar to the flu—a mild cough, a low fever. Usually, these people can fight off the infection on their own. They may not even realize they were sick with the fungus.

“A lot of times, when people hear about fungal diseases, they think about toenail fungus and skin infections,” says McCotter, now an epidemiologist for the state of Oregon. “But really, fungal diseases can cause very severe infections.” 

Approximately 40% of Valley Fever patients develop a pneumonia-like condition that requires medical attention. My mother was able to fully recover after doctors identified she had Valley Fever, but others, like Charles, may get treated for the wrong disease. Valley Fever is a commonly misdiagnosed illness because many symptoms are similar to the flu and pneumonia—an issue we've also been seeing with COVID-19. It can even be mistaken for lung cancer, as the fungus can create nodules and scarring in the tissue, which look similar to tumors in a chest X-ray.

But in some severe cases, the fungus can leave the lungs and spread to other parts of the body. It can invade the skin, bones, nervous system, and even the brain—turning into disseminated disease. Without proper antifungal treatment, the disease can last a lifetime, or even be deadly.

For these patients, “it’s either a death sentence, or a life sentence,” says Anita Sil, a microbiology and immunology professor studying fungal diseases including Valley Fever at the University of California, San Francisco. “Their lives are changed forever, and they’re on antifungals forever. They don’t get their normal health back, so the consequences are huge.” 

People with severe Valley Fever can lose their ability to work. Some lose limbs. Others lose their homes to pay medical bills. And in the most dire cases, what’s lost are their lives. These severe, disseminated cases of Valley Fever are rare, only about 1%. But, it is more common among immunocompromised patients, women in late stage pregnancy, and African Americans, Filipinos, and Native Americans, according to the CDC and public health departments. 

The many ways the fungus can make people sick has long puzzled scientists studying the disease. Why does the fungus cause a cough in some people, but a deadly meningitis in others? 

“I've always been interested in immune dysfunction,” says Katrina Hoyer, an immunologist and assistant professor at the University of California, Merced. “What is different about the immune response in the people that get severe disease, and what is wrong with that immune response? Can we manipulate it?”

Researchers like Hoyer are racing to understand the fungus better—especially as the pathogen is moving north and east. They’re trying to discover how the fungus grows in the soil to better understand where Valley Fever may expand in the future as the climate warms.

A scanning electron microscope image of the spherules of Coccidioides posadasii, one of the species of fungus that causes Valley Fever. The species is named after Argentinian physician Alejandro Posadas who was the first to identify the disease in a 33-year-old cavalryman in San Juan in 1892. Credit: Bridget Barker

The Immune System Wages War

Coccidioides is a shapeshifter: It has one form in the soil and another in the host’s lungs. 

Many fungi can change their structure under certain conditions, an ability known as dimorphism, explains Anita Sil at UCSF. Cocci belongs to a group of fungal pathogens called thermal dimorphs, which change their cell shape in response to temperature. Once the fungus is inhaled, temperature differences between the environment and the mammalian host help trigger Cocci’s transformation, Sil says. 

“When they get into a mammal, they change their program entirely, the shape of the cells changes dramatically,” Sil says. It morphs into a large capsule, called a spherule, that is filled with spores. These changes mean the fungus is ready to invade.

The body’s immune system wages war. Normally, a variety of immune cells each have different jobs. Cells on the defensive line are watchdogs for pathogens and signal the alarm when they enter the body. Some immune cells are like generals, in charge of directing and turning on immune responses. Others are like soldiers, battling against specific intruders. The body’s immune cells typically would engulf a bacterium or a virus to fight the infection. But these fungal spherules are big, making them difficult to swallow.

“It’s sort of like a King Kong-type mechanism, like you have this enormous beast that is too big for mere mortals to conquer,” Sil says. 

If not stopped, the spherules can pop like an overfilled balloon, unleashing more of the fungus to migrate through the body.

This photomicrograph reveals the spherules of one of the species of Valley Fever fungus, Coccidioides immitis. Within these spherules, you can see the spores. Credit: CDC/Public Domain

Antifungal medication is the only treatment doctors know can quell Valley Fever. It works best if the disease is caught early. Years before Charles got sick, his middle son had Valley Fever in 2008. His doctor quickly diagnosed and treated him, tipped off by the strange lesions growing on his legs—a symptom that Charles himself did not develop. His son made a full recovery after a year of antifungal medication.

But some people say that the antifungals are as bad as the disease itself, if not worse. Since the biology of fungi is very similar to the biology of our cells, antifungal medication can also cause damage while attacking the invader, says Katrina Hoyer at UC Merced. It leads to a cache of brutal side effects—constant dry skin, nausea, abdominal pain. Some patients with severe Valley Fever receive an IV of the antifungal amphotericin B, nicknamed “amphoterrible” for causing side effects akin to chemotherapy. 

The other problem with antifungal drugs is that they don’t always destroy the fungus. They only inhibit the growth of the fungus enough for your immune system to try to kill it. 

Despite treatment, Charles' immune system can’t eradicate the fungus completely. He must continue to take antifungal medication to control its growth. He is prescribed one of the more common antifungal drugs, fluconazole (Diflucan). He points to a swollen crack on his lower lip, a result of constant dry skin and dehydration from the medication. 

“I think I should have stock in chapstick because I use so much of it,” Charles says. “There's just so many different side effects to the medication that it's ridiculous. But I have to take it if I want to live.”

In the worst cases, the fungus proves near impossible to control. This is what happened with Charles’ older sister, Deborah.

“My sister was amazing. She was athletic, she loved to cook and bake,” Charles says. He likes to brag that he was Deborah’s favorite sibling. “She would bake all my favorite desserts. She would make a thing called a sock-it-to-me cake, pineapple-upside-down cake, pound cake.”

But a few years after graduating college, Deborah was hospitalized. She was misdiagnosed and given antibiotics multiple times before doctors concluded she had Valley Fever. 

“When they figured it out, it was too late,” Charles says. 

The fungus had already wreaked havoc in her body. The spores proliferated, spreading from Deborah’s lungs, to her bones, to her spinal column, to her brain. It caused her to develop meningitis, a severe swelling of the brain’s membrane. Deborah lost her eyesight. Her weight dropped from around 165 pounds to about 70 pounds.  

“She lost everything,” Charles says. “To watch her go from being vibrant and beautiful and strong as ever, to almost being an infant again was tough.” 

Deborah was only in her mid-twenties when she died from Valley Fever.

Charles’ family has been hit three times by Valley Fever. Each case shows how different the progression of the disease can be.


The Mystery of Misfit Immune Cells

In her lab, Hoyer is investigating differences in the immune response of Valley Fever patients—watching for red flags when it goes awry. She surveys anomalies in the numbers and behaviors of immune cells. In a 2018 study with pediatricians at Valley Children’s Hospital in Madera, Hoyer was able to narrow in on a specific type of immune cell: regulatory T cells. “Their job is to be the brakes on the immune system,” says Hoyer. 

She and her colleagues took blood samples from 20 children who were healthy, and 30 children who were infected with Valley Fever, and found a potential key difference in their cell numbers. “It looks like patients that will go on to have chronic or more persistent infection have a higher frequency of these regulatory cells.” 

A Growing Threat with Climate Change

Better understanding the disease will be essential, as Valley Fever numbers have been climbing, and show no signs of stopping. 

“Our numbers are on the rise. The past three years, we've had record years for infections,” says Hoyer.

California documented over 7,500 cases of Valley Fever in 2018, the highest of all states. In 2018, in Kern County, Valley Fever numbers rose for the fourth year in a row, according to the most recent data. Increasing rates have been seen in Arizona, Nevada, New Mexico, and Utah. 

These southwest states have some of the country’s fastest growing cities. As populations increase, so do the number of cases. Health clinicians may also be getting better at reporting and diagnosing the disease—some states only began keeping records of Valley Fever in 1992. 

The California Department of Public Health releases a provisional monthly report on valley fever. This analysis is based on the January - November 2019 report that includes the number of confirmed, suspected, and probable cases of valley fever by county.  Credit: Harriet Blair Rowan/California Healthline Source: California Department of Public Health

But the fungus itself also seems to be spreading. As hot, arid environments expand with climate change, Valley Fever territory could, too.

Valley Fever was reported in Washington state for the first time in 2014. Soil tests came back positive for the fungus, confirming that these cases originated from within the northwest state. It surprised many researchers that the disease could be found so far north. It may soon move even further, as the climate becomes more favorable for the fungus across the United States. 

“Valley Fever is an example of a disease that will probably be more widespread from climate change,” says Morgan Gorris, a postdoctoral research fellow at Los Alamos National Laboratory and a former graduate student at UC Irvine, who maps out environmentally influenced diseases, like Valley Fever. “I anticipate we will see larger health impacts from this disease in the future.”

Current maps of the disease are incomplete at best. Valley Fever is not required to be reported to the CDC. Texas, a state on the edge of the endemic region, chooses not to report Valley Fever cases nationally.

“Texas has been known to have cases since the 1930s,” says Gorris. “Some counties do report their case counts, but the whole state does not. It's not mandated. I feel like I would have a lot better understanding of where the boundary of this disease is if I had case data for Texas.” 

The CDC’s maps are based on skin test data, a test which revealed if you had been exposed to the fungus. While useful, that data was published in the 1950s, with a handful of updates from available outbreak numbers and studies. “The population makeup was very different then,” says Hoyer. “We also don’t know exactly the endemic region anymore.”  

Read more about the study at KVPR Valley Public Radio. Credit: Morgan Gorris/UC Irvine/GeoHealth

Gorris and scientists at UC Irvine created a new map to show where Valley Fever might expand by 2095, published in the journal GeoHealth in August 2019. The map used current and future climate factors, including both temperature and rainfall. Places likely to become hot and dry, like the endemic areas today, show up on the map in hot pink. That hot pink reaches as far north and east as North Dakota—well within the midwest. Under the highest climate warming scenario, Valley Fever’s endemic region could more than double and the number of cases could increase by 50% by 2095. 

“In the U.S., I think Valley Fever will be high up on the importance list, especially if the endemic region expands the way our model projects it will,” Gorris says.

While it may look ominous, this map can help healthcare workers prepare. Public health officials can create better surveillance and disease awareness now that they can anticipate which counties and states will begin to develop cases where they may not have before, Gorris says. 

“Your time to diagnosis can be decreased, and your chances of a more serious form of the disease decrease,” she says. “So, really, although it is projected to possibly impact more people, we want this to be used as a tool for preventing those infections, or at least mitigating the health impacts.”

Coccidioides isn’t the only fungal disease that may benefit from climate change, spreading beyond its original home. Some scientists suggest that global warming could cause fungal pathogens to become a greater threat to humans. There are over five million species of fungi. While only a few hundred of those cause disease, fungal pathogens are responsible for approximately 1.6 million deaths every year. 

“There's a lot of attention that is placed on viral diseases and bacterial diseases, but fungi are everywhere,” says McCotter, who has witnessed Valley Fever first hand in his dad and pet dogs growing up in Tucson. “I think that [fungal pathogens] are definitely under recognized.”

The warmer temperatures might also change the way the fungus works in our bodies. One of the first lines of defense against the fungus is our body temperature. Our internal temperature helps us kill off pathogens. It’s why we get fevers when we get sick; it’s the body’s way to prevent the rapid growth and spread of the pathogen, explains Hoyer. 

“That poses a challenge for the fungus, and gives our immune system a fighting chance,” says Hoyer. 

If the fungus adapts to the warmer temperatures, it’ll make it tougher for our bodies to kill the fungus. “That reduction in that difference in temperature [between the environment and our bodies] is going to be more of a problem,” she says.

Valley Fever might soon be affecting many more of us. But research scientists and survivors like Charles are keeping a close eye on its movement, spreading awareness to help mitigate the impact of the disease.

“It's not a disease that is restricted only to the southwest,” says McCotter. “It's something that's important for clinicians and the public to be aware of across the U.S.”


"It Won't Let Go"

Arthur Charles is out on the frontlines helping others in his community understand the severity of the disease. In February in Taft, a city 45 minutes from Bakersfield, Valley Fever survivors and supporters stretch and warm up for a 5K run and 2K walk. Kern Medical’s Valley Fever Institute and the West Side Recreation and Park District put on the event to help spread awareness of the disease—and it was all Charles’ idea.

“I wanted to have it out here because it affects so many people,” he says. 

Arthur Charles helped host the first annual Valley Fever 5K Run and 2K Walk, with Valley Fever Institute at Kern Medical. Listen to participants and learn more about the event in an audio story on KVPR Valley Public Radio. Credit: Kerry Klein/KVPR

Charles has lived nearly his whole life in Bakersfield. Growing up, he played baseball and was on his high school’s first basketball team to win the state championship. He runs around Kern County, recruiting baseball players as an associate scout for the Tampa Bay Rays, and works as a rec specialist for West Side Recreation and Park District. 

But today, his Valley Fever can leave him breathless and zapped of energy. Some days, it’s hard to walk to his mailbox at the end of his street, let alone make it to work. “I always would stay busy and do activities, and now, I just take it one day at a time and see what I can do,” he says.

For now, Charles continues to take his antifungal medication. Until there’s a cure, he’ll likely need them for the rest of his life. “It won't let go of me,” he says.

But he isn’t giving up. 

"I'm a fighter. So this is gonna be a battle, you know? If I go out, I'm gonna go out swinging and that's for sure.”

[This story was produced by Science Friday with Valley Public Radio, and republished by the USC Center for Health Journalism Collaborative.]

Our Methods: What Inspired This Story?

The American Southwest is growing. It supports some of the fastest growing cities in the United States. It is filled with development projects and construction. It grapples with drought, dust storms, and drying farms. It is home to millions who are at risk of becoming infected with the fungal disease, Valley Fever. I became familiar with Valley Fever while growing up near Fresno in the Central Valley of California. My mother had caught the fungal disease when she was a teenager. When she told me about her experience, I was captivated: a fungus that grows in the soil and floats in the wind could cause disease in humans. 

She was able to recover after visiting the doctor, but some aren’t as lucky. I hadn’t understood the damage it can do to patients and their families until I began to listen to those currently struggling with Valley Fever, like Arthur Charles in Bakersfield, California. Science Friday also received an overwhelming response from those impacted by the Valley Fever, with over 50 calls to the SciFri VoxPop app and dozens of listener emails. Reading and listening to each story revealed the sheer diversity of symptoms and outcomes—fever, rash, lung scarring, seizures, lost limbs, lifetime medication, death. 

Among these drastically different cases lies a disparity issue. Reports have shown that more severe Valley Fever occurs in African Americans, Filipinos, and Native Americans. Valley Fever is also gaining attention nationally, as its endemic region could expand with climate change. The latest findings and stories are not only important in creating a better picture of the disease today—but where it might be headed in a future warming climate.    


Rebecca B. from North Carolina, talks about her husband:
Hi, my name is Rebecca Brown, and my husband, Dusty, has Valley Fever. He was diagnosed in 2017 with Cocci meningitis. It disseminated to his brain, and he has had four or five strokes. And we moved to North Carolina so his dad can help me take care of him.

Matt from Cripple Creek, Colorado:
I had Valley Fever so bad that, eventually, I lost my right ankle. Doctors said when they diagnosed it, I had Valley Fever so bad that I was going to die. And if I didn't take this medicine, called amphotericin. I took it, went into seizure. I woke up the next morning, but I fought Valley Fever for 20 years.

Guillermo N. from Saint Paul, Minnesota, talks about his mother in northwest Phoenix:
Late last year, my 83-year-old mother showed some kind of shadow, some kind of scarring in her lungs in a CT scan. After more tests, including a biopsy, they found that what she had was a scar that resulted from Valley Fever. After we went through the test and looking more into it, many of her friends have been in the past diagnosed with valley fever. It seems to be endemic to that region.

Mary M. from Tucson, Arizona:
Forty years ago I had Valley Fever, and it took me more than a year to recuperate from it. Twenty years ago my best friend had Valley Fever, and it ended up killing him. Five years ago, my dog got Valley Fever and she recovered completely in only five months. So I think it's safe to assume that pretty much everybody who lives in Tucson knows someone who has been affected by Valley Fever.

How Did We Report This Piece?

This project drew upon over a year of research, interviews, field reporting, and production. Partnering with Valley Public Radio, we reported throughout the San Joaquin Valley of California. We traveled to UC Merced and Fresno in November 2019 and Taft, near Bakersfield, in February 2020. We spoke to many experts—in Valley Fever hot spots and across the U.S.—who contributed contextual and historical information about this disease. We conducted over 15 interviews with immunologists, clinicians, climate scientists, soil ecologists, epidemiologists, and fungal disease experts. We spoke with several Valley Fever patients to understand what it is like living with this disease, with the assistance of Kern Medical’s Valley Fever Institute and Valley Fever Americas Foundation. We were also able to hear from patients and family members on the SciFri VoxPop app and the Science Friday listener email. 

Credit: Lauren J. Young


About This Series

This project results from an innovative reporting venture – the Center for Health Journalism Collaborative – which currently involves the Bakersfield Californian, Radio Bilingüe in Fresno, Valley Public Radio in Fresno and Bakersfield, Vida en el Valle in Fresno, Hanford Sentinel, the Voice of OC in Santa Ana, the Arizona Daily Star in Tucson, La Estrella de Tucsón and the Center for Health Journalism. The collaborative is an initiative of the Center for Health Journalism at the University of Southern California’s Annenberg School for Communication and Journalism.


A Fever in the Dust

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