Table. Summary of cases of coccidioidomycosis involving the middle or outer ear or mastoid detected in multicentric case series of coccidioidal otomastoiditis, California, USA, and literature review of other cases*.

Case	Ref	Age, y/sex; race/ethnicity	Comorbidity	Syndrome	Symptoms	Diagnosis	Management	Outcome
1	(6)	23/F; Hispanic	Had been diagnosed with systemic lupus erythematosus 1 mo earlier on basis of fatigue, fever, arthralgias, proteinuria, and positive antinuclear antibodies, and treated with corticosteroids; in retrospect, sign/symptoms were probably caused by coccidioidomycosis.	Otitis externa → otitis media, mastoiditis	L ear pain, fever. After several months of antifungal therapy, partial L facial nerve paralysis developed.	Middle ear fluid culture grew Coccidiodes. immitis; CF 1:8.	Mastoid atticotomy, irrigation with amphotericin B (continued 3 weeks after final surgery); facial nerve decompression and temporal bone debridement, followed by IV amphotericin B for 5 d, followed by miconazole for at least 3 mo; irrigation of ear canal with amphotericin B (2 g) over 3 mo, including 3 weeks after final curettage	Good clinical response, with return of function to facial nerve almost entirely in all branches. No relapse through 1 y of follow-up.
2	(6)	43/M; White	None	Pulmonary and lymph node disease initially; otomastoiditis 1.5 y later	R ear pain and a “squishy” sensation	Histologic diagnosis of coccidioidomycosis from lymph node; C. immitis cultured from middle ear fluid. Coccidioides CF 1:4.	Tympanoplasty and mastoidectomy, myringotomy and revision tympanoplasty, grommet placement; local irrigation of mastoid with amphotericin B, systemic amphotericin B (267.5 mg IV for 7 d)	Drainage subsided by 5 mo. No evidence of disease recurrence at 1 y.
3	(7)	20; Hispanic	None	Otitis externa	Cutaneous lesion on external ear and periauricular skin	Histopathologic examination of skin biopsy specimen demonstrated spherules of Coccidioides.	Fluconazole (400 mg/d orally for unknown duration); frequent debridement of ear canal	Unknown
4	(8)	4/F; unknown	None	Otomastoiditis; incidental left lower lobe lung cavity.	6-mo history of R ear pain, mild hearing loss, intermittent fever; swelling behind R ear	Histopathologic examination of mastoid biopsy demonstrated spherules of Coccidioides; biopsy of same grew C. immitis.	Mastoidectomy; amphotericin B (IV) for 6 wk	No recurrence (timeline not stated). Serial decrease in C. immitis antigens.
5	This study (case 1)	76/M; White	None	Otomastoiditis	Cutaneous lesion over L tragus and cheek, L hearing loss	C. immitis cultured from middle ear fluid.	Fluconazole (400 mg/d orally for 3 mo); debridement; itraconazole (200 mg 2×/d orally for 6 mo)	Persistent hearing loss after 6 mo of follow-up.
6	This study (case 2)	52/M; unknown	None	Mastoiditis	Headache and jaw pain	Histopathologic examination of mastoid biopsy demonstrated spherules of Coccidioides. CF titer 1:8; ID positive for IgG.	Fluconazole (400 mg PO daily for 26 mo), then no longer available for follow-up	Residual pain and ongoing radiographic evidence of mastoiditis after 26 mo of therapy.
7	This study (case 3)	42/M; White	None	Pneumonia, followed 18 mo later by otomastoiditis	R ear fullness and tinnitus; later ipsilateral facial nerve palsy developed	Coccidioides cultured from middle ear fluid. CF titer 1:4; ID positive for IgG	Fluconazole (800 mg/d orally for 3 y)	Resolution of ear effusion and tinnitus, partial resolution of facial palsy, radiographic improvement, CF titer decreased to undetectable. Well in follow-up with negative CF titers for 21 y.
8	This study (case 4)	22/M; Hispanic	Diabetes mellitus type 1	Pulmonary coccidioidomycosis →osteoarticular coccidioidomycosis→ otomastoiditis	Left ear pain, purulent drainage, hearing loss, headache, nausea, and vomiting	C. immitis cultured from mastoid biopsy. CF titer 1:256	Otomastoiditis developed after poor adherence to fluconazole (800 mg); mastoidectomy and tympanoplasty, followed by liposomal amphotericin B (IV) for 6 wk, followed by posaconazole (400 mg/d orally) for several months before patient was no longer available for follow-up	Clinical improvement. Gradual return of hearing. CF titer decreased to 1:8. Long-term follow-up data unavailable.
9	This study (case 5)	25/M; Hispanic	Diabetes mellitus type II	R otomastoiditis→R internal jugular vein thrombus and dural venous thrombus→ septic emboli	R ear pain, purulent drainage, R mastoid tenderness and shortness of breath	Coccidioides cultured from mastoid tissue (along with Staphylococcus aureus) and later a neck abscess. CF titers 1:32	Mastoidectomy and myringotomy tube placement, followed by liposomal amphotericin B (IV) and fluconazole (800 mg/d orally); heparin infusion for thrombosis	Clinical improvement, pending follow-up imaging to determine regression of dural venous thrombus

*CF., complement fixation; ID, immunodiffusion; L, left; R, right; ref, reference.