LUNG NODULES: VALLEY FEVER OR CANCER IN HIV

Abstract

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease 3 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: The Human Immunodeficiency Virus (HIV) epidemic has vastly changed the prevalence and epidemiological burden of fungal infections. With worldwide travel, diseases such as coccidioidomycosis, while rare in non endemic parts of the United States of America, <1%, have been increasing in incidence. Coccidioidomycosis may present with a constellation of clinical and radiological findings that often confound diagnosticians, further emphasizing the need for more sensitive risk calculators. CASE PRESENTATION: A 45 year old caucasian male with HIV, last CD4 845, on highly active antiretroviral therapy (HAART) presents with a six week history of cough. He reports a persistent dry cough associated with right-sided chest pain now resolved and constitutional symptoms. He also has shortness of breath, treated with Albuterol inhaler. He is a current smoker with 16 pack years. Prior to onset of his symptoms, he completed a cross-country road trip from California to the east coast. He denied any ill-contacts or limitations in activity. On exam, he is afebrile in no respiratory distress with an unremarkable exam. His white blood cell count was 9.7 (13% eosinophils) along with positive coccidioidomycosis antibody complement fixation 1:4 and elevated IgG and IgM. Notably tuberculosis quantiferon gold, histoplasmosis antibodies and urine antigen were within normal limits. Computerized Tomography chest with contrast revealed 1.9x1.4x1.1 cm spiculated solid upper lobe nodule along with scattered subcentimeter, noncalcified solid round nodules in all lobes bilaterally and mediastinal lymphadenopathy. He was commenced on oral fluconazole for pulmonary coccidioidomycosis and scheduled for follow-up. DISCUSSION: Numerous advances have been made in the management of HIV, however aspects of the pathophysiology still remain unknown. ATS (2010) recommended treatment of coccidioidomycosis in all immunocompromised patients e.g. HIV AIDS as well as treatment in immunocompetent patients with HIV (BII). Nathan et al, later highlighted not only the role of a decreased number of CD4 cells as a component of immunosuppression in HIV patients but also the progressive loss of T cell function due to neutrophil immunosuppression in chronic HIV infection. As HIV places patients at higher risk for disseminated disease, it further confounds differentiating lung nodules due to coccidioidomycosis from lung cancer. Ronaghi et al, found significant radiographic overlap between the aforementioned. A study by Peterson et al, evaluated three existing online risk calculators and found they performed well in patients with lung cancer but poorly in patients with coccidioidomycosis. No serological marker has been validated. CONCLUSIONS: The increasing prevalence of HIV along with worldwide travel will mandate the need for more reliable risk assessment tools to prevent unnecessary invasive procedures and treatment for decades to come. Reference #1: Nathan L. Bowers, E. Scott Helton, Richard P. H. Huijbregts, Paul A. Goepfert, Sonya L. Heath, Zdenek Hel. Immune Suppression by Neutrophils in HIV-1 Infection: Role of PD-L1/PD-1 Pathway. PLOS Pathogens. 2014 March; 10(3). E10003993 Reference #2: Reza Ronaghi, MD; Ali Rashidian, MD; Paul Mills, PhD; Kurt Hildebrandt, MD; Keith Carson, MD; Michael Peterson, MD. Radiographic Features Differentiating Lung Nodules Caused by Coccidioidomycosis From Lung Cancer. CHEST. 2015 October; 148(4_MeetingAbstracts): 509A. https://doi.org/10.1378/chest.2248593 Reference #3: Michael Peterson, Reza Ronagi, Paul Mills. Differentiating incidental lung nodules due to lung cancer from those due to coccidioidomycosis. European Respiratory Journal. 2015; 46. https://doi.org/10.1183/13993003.congress-2015.PA2996 DISCLOSURES: No relevant relationships by Sahai Donaldson, source=Web Response No relevant relationships by Karlene Williams, source=Web Response