CAVITARY PULMONARY COCCIDIOIDOMYCOSIS IN A PATIENT WITH A REMOTE HISTORY OF LIVING IN CALIFORNIA

Abstract

SESSION TITLE: Infections SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/08/2018 03:15 PM - 04:15 PM INTRODUCTION: Lower lobe pulmonary cavitation is a rare presentation of coccidioidomycosis. Coccidioidomycosis is endemic to the southwestern United States, but incidence in other areas has increased due to travel, and the ability of an infection to become latent and then later reactivate. We present a case of lower lobe cavitary pulmonary coccidioidomycosis (PC) in a patient living in the West Texas Panhandle who moved from California eight years ago. CASE PRESENTATION: A 64 year old African American female with uncontrolled diabetes and hypertension presented with a three-week history of fatigue, malaise, non-productive cough, subjective fevers, occasional night sweats, loss of appetite, and several days of left-sided chest pain. Computed tomography (CT) of the chest showed a low-density collection within the posterior and lateral left lung base measuring 2.1 cm x 1.4 cm and reactive lymph nodes. Given the absence of exposure risk factors, negative tuberculosis (TB) test and blood cultures, the initial diagnosis was anaerobic lung abscess due to poor dentition. The patient was discharged on oral clindamycin and then lost to follow-up. One year later, she returned with similar symptoms and hemoptysis. CT of the chest revealed an enlarged 3.9 cm x 4 cm left lower lobe cavitary mass, with a second cavitary lesion and small satellite lesions. Bronchoalveolar lavage was inconclusive. TB test and all cultures were negative. Left lower lobe wedge resection was performed. Microscopic examination of the specimen found variably sized PAS-positive and silver stain-positive structures suggestive of PC. The patient is being treated with long-term oral fluconazole and is improving. DISCUSSION: Approximately 95% of symptomatic coccidioidomycosis patients develop pulmonary manifestations. Up to 15% of patients with PC will develop a pulmonary cavity. Risk factors for cavitation include smoking-related pulmonary fibrosis and uncontrolled diabetes mellitus. Cavitary PC is one of the most challenging presentations of coccidioidomycosis to diagnose. Serological testing has low sensitivity and sputum cultures are often negative. Tissue pathology is not always diagnostic, since cavitary PC can have varied histological presentations. PC cavities occur most frequently in the upper lobes and can be either thin-walled, if developing in an area of prior consolidation (more common), or thick-walled, if developing from the excavation of a nodule. Pulmonary resection is recommended for patients with hemoptysis, mycetoma, or a peripherally enlarging cavity at risk for rupture. CONCLUSIONS: Cavitary PC can mimic other illnesses such as bacterial pneumonia, TB, abscess, and malignancy. Clinicians should be aware that cavitary PC can develop in patients with uncontrolled diabetes who have moved from an endemic area, even many years after the initial exposure. Reference #1: Brown J, Benedict K, Park BJ, Thompson III GR. Coccidioidomycosis: epidemiology. Clin Epidemiol. 2013; 5:185-97. Reference #2: Sobonya RE, Yanes J, Klotz SA. Cavitary pulmonary coccidioidomycosis: pathologic and clinical correlates of disease. Hum Pathol. 2014; 45(1): 153-9. Reference #3: Jude CM, Nayak NB, Patel MK et al. Pulmonary coccidioidomycosis: pictoral review of chest radiographic and CT findings. Radiographics. 2014; 34(4): 912-25. DISCLOSURES: No relevant relationships by Joshua Crane, source=Web Response No relevant relationships by Manish Patel, source=Web Response No relevant relationships by Thien Vo, source=Web Response No relevant relationships by Grace Wang, source=Web Response