INTRAPLEURAL AMPHOTERICIN B INSTILLATION: A NOVEL APPROACH TO THE TREATMENT OF CHRONIC PULMONARY COCCIDIOIDOMYCOSIS

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Coccidioidomycosis is transmitted by inhalation of fungal spores commonly found in southwestern border of United States and South America. Most primary coccidioidomycosis cases are asymptomatic and do not require treatment. Symptomatic progressive coccidioidomycosis affect people with certain risk factors: ethnic origin, advanced age, pregnancy, and immunosuppressive state. Most cases are effectively treated with oral triazoles. Intravenous (IV) amphotericin B (AMB) is reserved for severe cases. Although intrapleural instillation of AMB has been reported in cases for aspergillus empyema, it has not been reported for other diseases (1). We are reporting the first known case of successful novel use of intrapleural instillation of amphotericin B in the treatment of chronic progressive pulmonary coccidioidomycosis. CASE PRESENTATION: A 48-year-old Hawaiian man with diabetes mellitus type 2 presented with 10 days of epigastric pain, anorexia, constipation, chills, progressive shortness of breath, and low-grade fever. He had a 9-month nonproductive cough after returning from Las Vegas. He was admitted to another facility where he was diagnosed with cryptogenic organizing pneumonia and treated with moderate dose prednisone for over 6 months. Initial chest x-ray here revealed a large left pneumothorax. Chest tube insertion did not provide significant improvement. Subsequent chest computerized tomography (CT) revealed a large hydropneumothorax with lingular and left lung base consolidation. Transbronchial biopsy showed coccidioides. After 7 days of hospitalization, patient was discharged home with fluconazole. He was readmitted 2 weeks later due to recurrence of same set of symptoms. Chest CT scan now revealed progression of multifocal necrotizing pneumonia. Based on continued deterioration despite IV AMB, there was a high suspicion of persisting intrapleural infection with coccidioides. A left pneumonectomy with placement of a special drainage catheter for intrapleural instillation was performed, in addition to continued IV AMB. He tolerated 7 days of intrapleural AMB well and discharged home 9 days afterward with continued fluconazole. One year later he was able to resume all normal activities. DISCUSSION: Our patient developed progressive coccidioidomycosis due to uncontrolled diabetes mellitus from prednisone prolonged use. He has progressive pneumonia, pulmonary nodules and cavities, fever, cough, chills, hemoptysis, abdominal pain, anorexia, weight loss, and weakness. Due to the many adverse reactions of AMB, it is generally reserved for severe cases; in our case, the addition of intrapleural instillation was successful in conjunction with his pneumonectomy and IV antifungal therapy. CONCLUSIONS: This is the first known reported case of intrapleural amphotericin B instillation, in combination with conventional therapy, in the successful treatment of chronic progressive coccidioidomycosis. REFERENCE #1: Almuhareb, A., & Habib, Z. (2018). Management of Aspergillus Pleural Empyema with Combined Systemic and Intrapleural Antifungal Therapy in a Pediatric Patient: Case Report. Journal of Infection and Public Health, 11(2), 280-282. DISCLOSURES: No relevant relationships by Angelica Guzman Paz, source=Web Response No relevant relationships by Takkin Lo, source=Web Response