Climate controls on valley fever incidence in Kern County, California

Coccidiodomycosis (valley fever) is a systemic infection caused by inhalation of airborne spores from Coccidioides immitis, a soil-dwelling fungus found in the southwestern United States, parts of Mexico, and Central and South America. Dust storms help disperse C. immitis so risk factors for valley fever include conditions favorable for fungal growth (moist, warm soil) and for aeolian soil erosion (dry soil and strong winds). Here, we analyze and inter-compare the seasonal and inter-annual behavior of valley fever incidence and climate risk factors for the period 1980–2002 in Kern County, California, the US county with highest reported incidence. We find weak but statistically significant links between disease incidence and antecedent climate conditions. Precipitation anomalies 8 and 20 months antecedent explain only up to 4% of monthly variability in subsequent valley fever incidence during the 23 year period tested. This is consistent with previous studies suggesting that C. immitis tolerates hot, dry periods better than competing soil organisms and, as a result, thrives during wet periods following droughts. Furthermore, the relatively small correlation with climate suggests that the causes of valley fever in Kern County could be largely anthropogenic. Seasonal climate predictors of valley fever in Kern County are similar to, but much weaker than, those in Arizona, where previous studies find precipitation explains up to 75% of incidence. Causes for this discrepancy are not yet understood. Higher resolution temporal and spatial monitoring of soil conditions could improve our understanding of climatic antecedents of severe epidemics.     

Modeling valley fever (coccidioidomycosis) incidence on the basis of climate conditions

Valley fever (coccidioidomycosis) is a disease endemic to arid regions within the Western Hemisphere, and is caused by a soil-dwelling fungus, Coccidioides immitis. Incidence data for Pima County, reported to the Arizona Department of Health Services as new cases of valley fever, were used to conduct exploratory analyses and develop monthly multivariate models of relationships between valley fever incidence and climate conditions and variability in Pima County, Arizona, USA. Bivariate and compositing analyses conducted during the exploratory portion of the study revealed that antecedent temperature and precipitation in different seasons are important predictors of incidence. These results were used in the selection of candidate variables for multivariate predictive modeling, which was designed to predict deviation from mean incidence on the basis of past, current, and forecast climate conditions. The models were specified using a backward stepwise procedure, and were most sensitive to key predictor variables in the winter season and variables that were time-lagged 1 year or more prior to the month being predicted. Model accuracy was generally moderate ( r(2) values for the monthly models, tested on independent data, ranged from 0.15 to 0.50), and months with high incidence can be predicted more accurately than months with low incidence.     

Statistical modeling of valley fever data in Kern County,California

Coccidioidomycosis (valley fever) is a fungal infection found in the southwestern US, northern Mexico, and some places in Central and South America. The fungus that causes it (Coccidioides immitis) is normally soil-dwelling but, if disturbed, becomes air-borne and infects the host when its spores are inhaled. It is thus natural to surmise that weather conditions that foster the growth and dispersal of the fungus must have an effect on the number of cases in the endemic areas. We present here an attempt at the modeling of valley fever incidence in Kern County, California, by the implementation of a generalized auto regressive moving average (GARMA) model. We show that the number of valley fever cases can be predicted mainly by considering only the previous history of incidence rates in the county. The inclusion of weather-related time sequences improves the model only to a relatively minor extent. This suggests that fluctuations of incidence rates (about a seasonally varying background value) are related to biological and/or anthropogenic reasons, and not so much to weather anomalies.     

Environmental vVariability and coccidioidomycosis (valley fever)

Coccidioidomycosis (valley fever) is a disease endemic to arid regions in the western hemisphere, and is caused by the soil-dwellingfungus Coccidioides immitis (C. immitis). In this paper, we provide an overview of the current state of knowledge regarding valley fever and C. immitis as related to climatic conditions and habitat requirements. Previous research shows there is a relationship between temperature and precipitation, and outbreaks of coccidioidomycosis. Incidence of the disease varies seasonally as well as annually due to changing climatic conditions. However, the specific environmental conditions that may produce an outbreak of coccidioidomycosis are not well understood in space and time. Previous studies have attempted characterize C. immitis' habitat. Temperature, moisture, salinity, and pH of the soil have all been considered separately in the geographic distribution of the fungus. Medical and proactive intervention are served best, however, by an integrative strategy that folds climate and surface variables into spatially-explicit models. We conclude with recommendations for future research directions.     

Combining Forces - The Use of Landsat TM Satellite Imagery,Soil Parameter Information,and Multiplex PCR to Detect Coccidioides immitis Growth Sites in Kern County,California

Coccidioidomycosis is a fungal disease acquired through the inhalation of spores of Coccidioides spp., which afflicts primarily humans and other mammals. It is endemic to areas in the southwestern United States, including the San Joaquin Valley portion of Kern County, California, our region of interest (ROI). Recently, incidence of coccidioidomycosis, also known as valley fever, has increased significantly, and several factors including climate change have been suggested as possible drivers for this observation. Up to date details about the ecological niche of C. immitis have escaped full characterization. In our project, we chose a three-step approach to investigate this niche: 1) We examined Landsat-5-Thematic-Mapper multispectral images of our ROI by using training pixels at a 750 m×750 m section of Sharktooth Hill, a site confirmed to be a C. immitis growth site, to implement a Maximum Likelihood Classification scheme to map out the locations that could be suitable to support the growth of the pathogen; 2) We used the websoilsurvey database of the US Department of Agriculture to obtain soil parameter data; and 3) We investigated soil samples from 23 sites around Bakersfield, California using a multiplex Polymerase Chain Reaction (PCR) based method to detect the pathogen. Our results indicated that a combination of satellite imagery, soil type information, and multiplex PCR are powerful tools to predict and identify growth sites of C. immitis. This approach can be used as a basis for systematic sampling and investigation of soils to detect Coccidioides spp.     

Airborne pollen characteristics and the influence of temperature and precipitation in Raleigh,North Carolina,USA (1999–2012)

The incidence of allergic diseases has been increasing in recent decades, in part due to increased exposure to aeroallergens, particularly pollen. Allergic diseases have a major burden on the health care system, with annual costs in the USA alone exceeding $30 billion. There is evidence that the production of aeroallergens, including pollen, is increasing in response to environmental and climatic change, which has important implications for the treatment of allergy sufferers. In this study, pollen data from a Rotorod sampler in Raleigh, North Carolina, was used to characterize and examine trends in the atmospheric pollen seasons for trees, grasses, and weeds over the period 1999–2012. The influence of mean monthly antecedent and concurrent temperature and precipitation on the timing, duration, and severity of the pollen seasons was assessed using Pearson’s product-moment correlation coefficients and multiple linear regression models. An increasing trend was noted in seasonal tree pollen concentrations, while seasonal and peak weed pollen concentrations declined over time. The atmospheric pollen seasons for grasses and weeds trended toward earlier start dates and longer durations, while the tree pollen season trended toward an earlier end date. Peak daily tree pollen concentrations were strongly associated with antecedent temperature and precipitation, while peak daily grass pollen concentrations were strongly associated with concurrent precipitation. The strongest relationships between climate and weed pollen were associated with the timing and duration of the pollen season, with drier antecedent and warmer concurrent conditions tied to longer weed pollen seasons.     

THE DISTRIBUTION OF COCCIDIOIDOMYCOSIS IN SOUTHERN CALIFORNIA

In coccidioidin skin test surveys among persons of high school age in Saugus, Canoga Park, Banning and Palm Springs areas the average incidence of positive reaction was 15 per cent. Although considerably less than the 68 per cent incidence reported among high school students of Kern County, it is high enough to indicate pockets of relatively high endemicity in Southern California below the San Joaquin Valley.Histoplasmin tests were performed on most of the persons tested with coccidioidin in this survey. The over-all incidence of positive reaction in the group was 7.6 per cent. Most of the subjects with positive reaction to histoplasmin gave a history of having previously lived in some area in the central United States where histoplasmosis is known to be endemic.A few subjects who had positive reaction to coccidioidin tests and who had lived in areas known to be endemic for coccidioidomycosis but not for histoplasmosis, also had positive reaction to histoplasmin. However, the induration produced was always smaller than that caused by the coccidioidin reaction, and there was minimal confusion in interpreting the tests.     

The epidemiology of coccidioidomycosis in Mexico

Coccidioidomycosis, also known as San Joaquin Valley Fever, is an endemic mycosis restricted to the American deserts, caused by the ascomycete Coccidioides spp. In 2000 it was estimated that more than 100,000 cases of the disease took place in the United States, and that these numbers have been rising over time. The current impact of this disease in Mexico is unknown, but the available data suggest that an increase of the incidence of this mycosis in California and Arizona might have the same impact in Mexican nearby States. These two USA States both have a bioclimatic pattern similar to the nearby Mexican States endemic for coccidioidomycosis. The main objective of this study was to collect the available information on the historical and epidemiological research done in Mexico to assess the impact of the disease and to evaluate whether the disease have a tendency to increase in the endemic areas and if this grow could represent a problem of public health in Mexico. We have conducted an extensive search on this topic in Health institutions and Academic facilities of California, Arizona and Mexico. After analyzing the scarce Mexican records we found that: 1) the main studies conducted in Mexico are limited to the northern desert areas of the country, mainly in the states of Sonora, Coahuila, Nuevo Leon and the Baja California peninsula; 2) until 1994 an increase of coccidioidomycosis in Mexico was noted; and 3) we found that Mexico shares a similar epidemiological data as that reported in the United States. For instance, the most affected groups in Mexico were children under 5 years-old and adults over 45 years-old. The collective information suggests the need to implement joined organized efforts and multi-institutional collaboration to clarify the current situation of this important endemic disease of North America to administer a viable early detection plan of this mycosis in Mexico.     

Coccidioidomycosis: An Update

Coccidioidomycosis is the oldest of the major mycoses. In recent years the incidence of the disease has increased in California and Arizona, which may be partially due to the massive migration to the endemic region. The endemic region for the disease lays exclusively in the Western Hemisphere, between the 40° latitudes north and south. The disease manifests in one of four clinical syndromes: acute pulmonary, chronic pulmonary and acute or chronic disseminated coccidioidomycosis. Serologic tests identifying anticoccidioidal antibodies are the most frequently employed assays for diagnosis. Primary coccidioidomycosis is usually self-limited; therapy of primary disease is recommended when symptoms persist for more than 6 weeks, for severe acute cases and for patients with impaired cellular immunity. Chronic pulmonary coccidioidomycosis and all forms of disseminated coccidioidomycosis require antifungal therapy. The drugs of choice are either fluconazole or itraconazole.     

Coccidioidomycosis incidence in Arizona predicted by seasonal precipitation

The environmental mechanisms that determine the inter-annual and seasonal variability in incidence of coccidioidomycosis are unclear. In this study, we use Arizona coccidioidomycosis case data for 1995–2006 to generate a timeseries of monthly estimates of exposure rates in Maricopa County, AZ and Pima County, AZ. We reveal a seasonal autocorrelation structure for exposure rates in both Maricopa County and Pima County which indicates that exposure rates are strongly related from the fall to the spring. An abrupt end to this autocorrelation relationship occurs near the the onset of the summer precipitation season and increasing exposure rates related to the subsequent season. The identification of the autocorrelation structure enabled us to construct a “primary” exposure season that spans August-March and a “secondary” season that spans April–June which are then used in subsequent analyses. We show that October–December precipitation is positively associated with rates of exposure for the primary exposure season in both Maricopa County (R = 0.72, p = 0.012) and Pima County (R = 0.69, p = 0.019). In addition, exposure rates during the primary exposure seasons are negatively associated with concurrent precipitation in Maricopa (R = −0.79, p = 0.004) and Pima (R = −0.64, p = 0.019), possibly due to reduced spore dispersion. These associations enabled the generation of models to estimate exposure rates for the primary exposure season. The models explain 69% (p = 0.009) and 54% (p = 0.045) of the variance in the study period for Maricopa and Pima counties, respectively. We did not find any significant predictors for exposure rates during the secondary season. This study builds on previous studies examining the causes of temporal fluctuations in coccidioidomycosis, and corroborates the “grow and blow” hypothesis.     

Modeled response of the West Nile virus vector Culex quinquefasciatus to changing climate using the dynamic mosquito simulation model

Climate can strongly influence the population dynamics of disease vectors and is consequently a key component of disease ecology. Future climate change and variability may alter the location and seasonality of many disease vectors, possibly increasing the risk of disease transmission to humans. The mosquito species Culex quinquefasciatus is a concern across the southern United States because of its role as a West Nile virus vector and its affinity for urban environments. Using established relationships between atmospheric variables (temperature and precipitation) and mosquito development, we have created the Dynamic Mosquito Simulation Model (DyMSiM) to simulate Cx. quinquefasciatus population dynamics. The model is driven with climate data and validated against mosquito count data from Pasco County, Florida and Coachella Valley, California. Using 1-week and 2-week filters, mosquito trap data are reproduced well by the model (P < 0.0001). Dry environments in southern California produce different mosquito population trends than moist locations in Florida. Florida and California mosquito populations are generally temperature-limited in winter. In California, locations are water-limited through much of the year. Using future climate projection data generated by the National Center for Atmospheric Research CCSM3 general circulation model, we applied temperature and precipitation offsets to the climate data at each location to evaluate mosquito population sensitivity to possible future climate conditions. We found that temperature and precipitation shifts act interdependently to cause remarkable changes in modeled mosquito population dynamics. Impacts include a summer population decline from drying in California due to loss of immature mosquito habitats, and in Florida a decrease in late-season mosquito populations due to drier late summer conditions.     

The Changing Epidemiology of Coccidioidomycosis in Los Angeles (LA) County,California, 1973–2011

Coccidioidomycosis, also known as Valley Fever, is often thought of as an endemic disease of central California exclusive of Los Angeles County. The fungus that causes Valley Fever, Coccidioides spp., grows in previously undisturbed soil of semi-arid and arid environments of certain areas of the Americas. LA County has a few large areas with such environments, particularly the Antelope Valley which has been having substantial land development. Coccidioidomycosis that is both clinically- and laboratory-confirmed is a mandated reportable disease in LA County. Population surveillance data for 1973–2011 reveals an annual rate increase from 0.87 to 3.2 cases per 100,000 population (n = 61 to 306 annual cases). In 2004, case frequency started substantially increasing with notable epidemiologic changes such as a rising 2.1 to 5.7 male-to-female case ratio stabilizing to 1.4–2.2. Additionally, new building construction in Antelope Valley greatly rose in 2003 and displayed a strong correlation (R = 0.92, Pearson p<0.0001) with overall LA County incidence rates for 1996–2007. Of the 24 LA County health districts, 19 had a 100%-1500% increase in cases when comparing 2000–2003 to 2008–2011. Case residents of endemic areas had stronger odds of local exposures, but cases from areas not known to be endemic had greater mortality (14% versus 9%) with notably more deaths during 2008–2011. Compared to the 57 other California counties during 2001–2011, LA County had the third highest average annual number of cases and Antelope Valley had a higher incidence rate than all but six counties. With the large number of reported coccidioidomycosis cases, multi-agency and community partnering is recommended to develop effective education and prevention strategies to protect residents and travelers.     

CORTISONE IN COCCIDIOIDOMYCOSIS

Cortisone administered orally, in low dosages for brief periods, promptly suppressed the allergic manifestations accompanying primary pulmonary coccidioidomycosis in 19 cases. There was no interference with the coccidioidin skin test reaction or with the usual serologic pattern.Dissemination of the disease as a sequel to the administration of cortisone and/or corticotropin has not been reported. A survey of physicians and of the known instances of disseminated coccidioidomycosis in Kern County failed to reveal any such episode.In none of the cases in which the authors gave cortisone in the presence of coccidioidomycosis was there any complication or undesirable sequel—specifically, no subsequent dissemination of the disease.The data presented are not to be interpreted as a therapeutic recommendation, but as a contribution to the information available concerning the effects of these drugs in infectious diseases.     

Coccidioidomycosis in Northern California—An Outbreak among Archeology Students near Red Bluff

An outbreak of coccidioidomycosis occurred among 39 archeology students in the summer of 1972. The students excavated Indian ruins near Red Bluff in Tehama County, California, 20 miles north of the previously recognized northernmost limit of endemicity. At least 17 persons contracted an illness clinically compatible with a diagnosis of coccidioidomycosis. Coccidioidomycosis was documented by skin test conversion as well as by specific serologic reactions. Coccidioides immitis was also isolated from two soil samples taken at the excavation site. In light of its ecological requirements, it is doubtful that C. immitis will be recovered much farther north than Red Bluff. The occupational hazard of coccidioidomycosis to archeologists and others employed in known endemic areas remains a substantial threat to health.     

Distribution and management of citrus in California: implications for management of glassy-winged sharpshooter

The epidemiology of Pierce's disease of grape (Vitis spp.) in California has changed over the past 10 yr due to the introduction of an exotic vector, Homalodisca vitripennis (Germar), the glassy-winged sharpshooter. Although this insect is highly polyphagous, citrus (Citrus spp.) is considered a preferred host and proximity to citrus has been implicated as a significant risk factor in recent epidemics of Pierce's disease in southern California. Consequently, a detailed knowledge of the distribution and management of citrus in relation to grape is needed to improve insect and disease management. Analysis of data on the area planted to these two commodities indicates that only five counties in California concomitantly grow >1,000 ha of grape and >1,000 ha of citrus: Riverside, Kern, Tulare, Fresno, and Madera counties. Comparison of the distribution of grape and citrus within each of these counties indicates that the percentage of grape that is in proximity to citrus is greatest for Riverside County, but the total area of grape that is in proximity to citrus is greater for Fresno, Kern, and Tulare counties. The use of carbamates, neonicotinoids, organophosphates, and pyrethroids as part of the citrus pest management program for control of key insect pests was compared among the same five counties plus Ventura County from 1995 to 2006. Ventura County was included in this analysis as this county grows >10,000 ha of citrus and has established glassy-winged sharpshooter populations. The use of these broad-spectrum insecticides was lowest in Riverside and Ventura counties compared with the other four counties. Analysis of historical trapping data at the county scale indicates a negative association of broad-spectrum insecticide use with glassy-winged sharpshooter abundance. These results are used to retrospectively analyze the Pierce's disease outbreaks in Kern and Riverside counties.     

Spatiotemporal Trends and Climatic Factors of Hemorrhagic Fever with Renal Syndrome Epidemic in Shandong Province,China

Background

Hemorrhagic fever with renal syndrome (HFRS) is a rodent-borne disease caused by Hantaviruses. It is endemic in all 31 provinces, autonomous regions, and metropolitan areas in mainland China where human cases account for 90% of the total global cases. Shandong Province is among the most serious endemic areas. HFRS cases in Shandong Province were first reported in Yutai County in 1968. Since then, the disease has spread across the province, and as of 2005, all 111 counties were reported to have local human infections. However, causes underlying such rapid spread and wide distribution remain less well understood.

Methods and Findings

Here we report a spatiotemporal analysis of human HFRS cases in Shandong using data spanning 1973 to 2005. Seasonal incidence maps and velocity vector maps were produced to analyze the spread of HFRS over time in Shandong Province, and a panel data analysis was conducted to explore the association between HFRS incidence and climatic factors. Results show a rapid spread of HFRS from its epicenter in Rizhao, Linyi, Weifang Regions in southern Shandong to north, east, and west parts of the province. Based on seasonal shifts of epidemics, three epidemic phases were identified over the 33-year period. The first phase occurred between 1973 and 1982 during which the foci of HFRS was located in the south Shandong and the epidemic peak occurred in the fall and winter, presenting a seasonal characteristic of Hantaan virus (HTNV) transmission. The second phase between 1983 and 1985 was characterized by northward and westward spread of HFRS foci, and increases in incidence of HFRS in both fall-winter and spring seasons. The human infections in the spring reflected a characteristic pattern of Seoul virus (SEOV) transmission. The third phase between 1986 and 2005 was characterized by the northeast spread of the HFRS foci until it covered all counties, and the HFRS incidence in the fall-winter season decreased while it remained high in the spring. In addition, our findings suggest that precipitation, humidity, and temperature are major environmental variables that are associated with the seasonal variation of HFRS incidence in Shandong Province.

Conclusions

The spread of HFRS in Shandong Province may have been accompanied by seasonal shifts of HTNV-dominated transmission to SEOV-dominated transmission over the past three decades. The variations in HFRS incidence were significantly associated with local precipitation, humidity, and temperature.     

California encephalitis virus,a newly described agent

In three cases of encephalitis in humans that occurred in the area where the newly described California virus was isolated from mosquitoes, serological evidence seemed to indict the California virus as the etiological agent. In the case of an infant with very severe disease, the serological evidence was convincing; the evidence was almost as strong in the case of a seven-year-old boy; the results in an adult were equivocal. Inapparent infection in man is quite common as indicated by neutralization tests on the sera of nearly 600 residents of California, but encephalitic manifestations of infection are extremely rare. In Kern County, California, where the virus was discovered, approximately 11 per cent of the population has been infected. Infection rates are higher in adults than in very young children. Absence of neutralizing antibodies from 64 specimens of blood from persons in Japan, Washington, and other states supports the specificity of the neutralization test in man and suggests that this virus is absent or is not being similarly transmitted in some areas. Serological evidence from serial bleedings of two sick horses suggested, but did not definitely establish, that this virus leads to a naturally acquired encephalomyelitis in horses. Serological tests with the viruses of western equine and St. Louis encephalitis did not lead to any other etiological diagnosis in the sick animals studied. Results of neutralization tests on the sera of eight horses and three cows in Kern County suggested extremely high infection rates, and an immunity rate of 18 per cent was noted in rabbits and ground squirrels. In the natural biological cycle rabbits and ground squirrels are suspected as the possible counterpart of birds in the St. Louis and western equine virus cycles. There is no evidence from field or laboratory to indicate that birds become infected with the California virus. Sera from 33 mammals other than man were collected from Northern California and Washington. All were free from neutralizing antibodies, again supporting the specificity of positive findings from Kern County.     

Coccidioidomycosis in a California sea otter (Enhydra lutris).

A weak and emaciated California sea otter (Enhydra lutris) was found stranded on Atascadero Beach in Morro Bay, California. It died three weeks after capture. A diagnosis of coccidioidomycosis was confirmed by histology, serology and culture. This is believed to be the first reported case of this disease from the Morro Bay area of San Luis Obispo County, California as well as the first reported case in a free-ranging marine mammal.     

CALIFORNIA ENCEPHALITIS VIRUS—A Newly Described Agent

In three cases of encephalitis in humans that occurred in the area where the newly described California virus was isolated from mosquitoes, serological evidence seemed to indict the California virus as the etiological agent. In the case of an infant with very severe disease, the serological evidence was convincing; the evidence was almost as strong in the case of a seven-year-old boy; the results in an adult were equivocal.Inapparent infection in man is quite common as indicated by neutralization tests on the sera of nearly 600 residents of California, but encephalitic manifestations of infection are extremely rare. In Kern County, California, where the virus was discovered, approximately 11 per cent of the population has been infected. Infection rates are higher in adults than in very young children.Absence of neutralizing antibodies from 64 specimens of blood from persons in Japan, Washington, and other states supports the specificity of the neutralization test in man and suggests that this virus is absent or is not being similarly transmitted in some areas.Serological evidence from serial bleedings of two sick horses suggested, but did not definitely establish, that this virus leads to a naturally acquired encephalomyelitis in horses. Serological tests with the viruses of western equine and St. Louis encephalitis did not lead to any other etiological diagnosis in the sick animals studied.Results of neutralization tests on the sera of eight horses and three cows in Kern County suggested extremely high infection rates, and an immunity rate of 18 per cent was noted in rabbits and ground squirrels. In the natural biological cycle rabbits and ground squirrels are suspected as the possible counterpart of birds in the St. Louis and western equine virus cycles. There is no evidence from field or laboratory to indicate that birds become infected with the California virus.Sera from 33 mammals other than man were collected from Northern California and Washington. All were free from neutralizing antibodies, again supporting the specificity of positive findings from Kern County.     

Strategies to Combat Coccidioidomycosis: Are We Making Any Progress?

Coccidioidomycosis is caused by the dimorphic fungi Coccidioides immitis and Coccidioides posadasii. One of the endemic mycoses, this organism has been found solely in the semiarid to arid life zones of the southwestern United States, Mexico, and parts of Central America and South America. Clinical manifestations of disease vary greatly between patients and are largely dependent upon both the extent of exposure and the immune status of the host. The incidence of coccidioidomycosis continues to rise within the United States. Primary coccidioidal pneumonia accounts for close to 25% of all community-acquired pneumonia within endemic regions, reflecting the substantial burden of disease and health care costs associated with this infection. Although most patients with coccidioidomycosis resolve their initial infection without long-term complications, a minority of patients develop complications of disease ranging from asymptomatic pulmonary nodules to life-threatening disease such as meningitis. This review focuses on the epidemiology, clinical manifestations, spectrum of disease, and treatment options currently available for coccidioidomycosis.