Coccidioides Mycetoma? A Rare Cause of Hemoptysis

Abstract

SESSION TITLE: Fungal Infections 1 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Pulmonary cavities are a common cause of hemoptysis. Here we present a case of Coccidiomycosis as a casuse of hemoptysis due to mycetoma formation. CASE PRESENTATION: A 27 year-old man presented for two years of intermittent hemoptysis. His hemoptysis occurred 1-2x weekly, increasing in frequency to daily with 2-3 teaspoons in quantity three weeks prior to presentation. He denied any sick contacts, infectious symptoms, or B symptoms. He was initially born in El Salvador and lived in a rural community around livestock; he moved to the USA in 2009 where he worked in construction. He briefly lived in Tuscon, Arizona before moving to Washington DC in 2010. He has no smoking history or illicit drug use. A chest x-ray demonstrated a 2.7x3.7cm cavity in the right mid-lung field. A subsequent CT chest showed a thick-walled air-filled cavity in the superior segment of the right lower lobe with a soft-tissue mass resembling a fungal ball at the periphery. A bronchoscopy with BAL returned as Coccidiomycosis immitus/posadasii on PCR. He was initiated on fluconazole for a prolonged duration of therapy. DISCUSSION: Pulmonary cavities are frequently caused by infection, including typical bacterial organisms, anaerobes, and Mycobacterial species. Primary invasive can cause cavities but typically do so in immunocompromised individuals. In immunocompetent patients, Coccidiomycosis may cause thin- or thick-walled cavities. Due to either local invasion into pulmonary arterial branches or bronchial artery branch proliferation as a consequence of indolent cavity formation, hemoptysis may ensue. However, only a handful of cases report fungal ball formation as a consequence of Coccidiomycosis infection. Definitive therapy is with azoles, with surgical resection reserved for severe or refractory cases. CONCLUSIONS: This case demonstrates hemoptysis as a result of invasive Coccidiomycosis infection with pulmonary cavity formation and complicated by a fungal ball. Hemoptysis is a relatively common presentation in these with cavities; however, the vast minority with exposure to Coccidiomycosis will develop cavities and only a rare few will develop a fungal ball, which may have an impact on prognosis and response to antifungal therapy. This case highlights the need for close attention to Coccidiomycosis as a causative agent of hemoptysis, cavities, and mycetoma formation in immunocompetent individuals. Reference #1: Winn R, et al. Cavitary Coccidiomycosis With Fungus Ball Formation. Chest, 1994; 105(2): 412-416. DISCLOSURE: The following authors have nothing to disclose: Michael Bergman, Ryan Richard No Product/Research Disclosure Information