Imported human Coccidioidomycosis in Germany 2011-2023
Coccidioidomycosis (cocci) is a deep fungal infection endemic to semiarid regions in the Americas. Data from non-endemic areas are rare, although it is among the most prevalent respiratory infections after travel to endemic regions. We review cases of proven cocci diagnosed in Germany between 2011 and 2023 in order to describe epidemiology, clinical presentation and diagnostic practice in Germany.  Cocci was proven in 15 cases by cultivation (C. immitis: 2, C. posadasii: 9), typical histopathology (n=4) or both (n=5). Infection was diagnosed in 5 females and 10 males aging 23-82 years in 80% without underlying conditions. Clinical presentation included pulmonary (n=8), central nervous system (n=2) or disseminated infection (n=3). Detection of specific antibodies by immunodiffusion (ID) in 82% or lateral flow assay (lfa) in 100% with available serum 3-36 months after stay in endemic areas.  In vitro resistance using the Yeastone microdilution assay confirmed activity oy Amphotericin B and azoles. Phylogenetic analysis of whole genome sequences demonstrating clustering with previously described clades of C. posadasii (Tucson, Phoenix, TX/MX/SA)  Coccidioidomycosis is rarely diagnosed in Germany in previously healthy individuals months to years after travel to Arizona and other US states. Antibody detection appears to be a useful screening test for patients with potential exposure.