COCCIDIOIDES KILLS: A CASE REPORT

Abstract

SESSION TITLE: Fellows Lung Pathology Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Coccidioidomycosis immitis is a dimorphic fungus that infects the host via inhalation of spores found in the soil of endemic areas such as the southwestern United States. In immunocompetent patients it usually presents as a flu like illness. In patients that are immunocompromised it can lead to disseminated disease affecting numerous organs. CASE PRESENTATION: A 32-year-old male with a history of asthma presented to the ED with fevers, back pain, shaking chills, shortness of breath, and a nonproductive cough for two weeks. A CT chest was performed that revealed diffuse bilateral ground glass opacities (Figure 1). His respiratory status worsened despite treatment for pneumonia and he was subsequently intubated. MRI of the thoracic spine was performed given his back pain, which showed T8-T12 paravertebral abscess (Figure 2). It was also noted while gathering history that he played football in Arizona and lived in that area for some time. Aspiration of the paraspinal abscess was performed. Patient was placed on empiric amphotericin B as he developed worsening acute respiratory distress syndrome (ARDS). Despite being on lung protective strategies, he was difficult to oxygenate and placed on ECMO. Infectious workup for other organisms was also performed including bacterial and viral co-infection in the blood, cerebrospinal fluid (CSF), and bronchial fluids. His spinal cultures and CSF grew Coccidioides immitis along with spherules noted in his bronchial washings. He was also found to have cutaneous disseminated lesions on his upper extremity (Figure 3). Despite best efforts, patient continued to decompensate. Palliative care was consulted and withdrawal of support was performed after patient was noted to have multiple cardiac arrests. DISCUSSION: Symptomatic patients with coccidioidomycosis typically present with community acquired pneumonia. Uncommonly, in about 1% of infections, hematogenous, extra pulmonary dissemination can occur to the spine, meninges, joints, and skin. Coccidioidomycosis is commonly diagnosed in disease-endemic areas but frequently overlooked in disease-nonendemic areas because of a low index of suspicion among physicians. Individuals at risk of dissemination have suppressed cellular immunity, including those with advanced HIV infection, transplantation recipients, and those receiving chronic immunosuppressive medications such as glucocorticoids. Interestingly, this patient had no such risk factors, but the key in his case was obtaining travel/living history as it increased suspicion of coccidioidomycosis infection earlier. Unfortunately, in his case, this did not change his outcome. CONCLUSIONS: Although coccidioidomycosis is rare in non-endemic areas, physicians must keep it in mind when evaluating patients who have traveled or lived in endemic areas even without immunosuppression. Reference #1: Ramanathan D, Sahasrabudhe N, Kim E. Disseminated Coccidioidomycosis to the Spine-Case Series and Review of Literature. Brain Sci. 2019 Jul 7;9(7). doi: 10.3390/brainsci9070160. PubMed PMID: 31284663; PubMed Central PMCID: PMC6680672. DISCLOSURES: No relevant relationships by Alireza Nathani, source=Web Response No relevant relationships by Sean OConnor, source=Web Response No relevant relationships by Chhaya Patel, source=Web Response No relevant relationships by Jorge Velazco, source=Web Response