OCCULT COCCIDIOIDOMYCOSIS: A CASE OF PLEURAL COCCIDIOIDOMYCOSIS

Abstract

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Coccidioides is a dimorphic fungus found in desert soil, native to parts of southwestern USA. Infection is acquired by inhalation of arthroconidia causing primary pulmonary coccidioidomycosis (Cocci) but patients can also present with unusual manifestations, which makes identifying Coccidioides infection challenging. We present a case of pleural cocci causing isolated right sided pleural effusion. CASE PRESENTATION: A Caucasian male aged 64, residing in Arizona for 40 years, presented with a 2-week history of dyspnea associated with right-sided pleuritic chest pain, anorexia, and 12-lbs weight loss in the past month. Vital signs were stable. Physical exam was significant for dullness to percussion and absent breath sounds on the right lung base. Initial labs were remarkable for a normal leukocyte count with eosinophilia at 6.6%. A chest x-ray showed a large, unilateral right pleural effusion with pleural thickening. CT imaging demonstrated a right-sided pleural effusion and nonspecific, left-sided pulmonary nodules. Thoracentesis was performed, removing 1800 ccs of serous fluid. Fluid studies were consistent with an exudative effusion. Nucleated cell count was 1230cells/mm3 with 40% eosinophils. Gram stain and culture for bacterial, fungal and acid-fast organisms were negative. Cytology was negative for malignant cells. Thoracoscopy showed inflammatory changes along with white studding on the pleural surface. Histopathology demonstrated pleura with granulomatous changes and was negative for organisms or malignancy. Screening antibodies for cocci came back positive and immunodiffusion complement-fixing showed a normal IgG but an elevated IgM level. A diagnosis of pleural cocci was made and fluconazole 400 mg daily was initiated. On a follow up visit after 6 weeks, complete resolution of the effusion and significant symptomatic improvement in the patient were noted. DISCUSSION: Symptomatic coccidioidomycosis commonly presents as community acquired pneumonia. Pleural effusions can be associated in 10% of patients with pulmonary cocci; however, it is unusual for an isolated pleural effusion to present without evidence of ipsilateral parenchymal infection, as was found in this patient. Malignancy should be ruled out in effusions with a high eosinophil count as in our patient and necessitated thoracoscopy. Pleural cocci can be diagnosed with a combination of pleural fluid analysis, blood serology, and thoracoscopy with pleural biopsy. There are no specific recommendations for treatment and our patient was treated with Azole dosed for pulmonary cocci. CONCLUSIONS: This case demonstrates that, rarely, Coccidioidomycosis can present as an isolated pleural effusion, without evidence of parenchymal involvement and requires a high index of suspicion with invasive testing to secure a diagnosis and initiate appropriate treatment. REFERENCE #1: Valdivia L, Nix D, Wright M, et al. Coccidioidomycosis as a common cause of community-acquired pneumonia [published correction appears in Emerg Infect Dis. 2006 Aug;12(8):1307]. Emerg Infect Dis. 2006;12(6):958-962. doi:10.3201/eid1206.060028 REFERENCE #2: John N. Galgiani, Neil M. Ampel, Janis E. Blair, Antonino Catanzaro, Francesca Geertsma, Susan E. Hoover, Royce H. Johnson, Shimon Kusne, Jeffrey Lisse, Joel D. MacDonald, Shari L. Meyerson, Patricia B. Raksin, John Siever, David A. Stevens, Rebecca Sunenshine, Nicholas Theodore, 2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Treatment of Coccidioidomycosis, Clinical Infectious Diseases, Volume 63, Issue 6, 15 September 2016, Pages e112–e146, https://doi.org/10.1093/cid/ciw360 DISCLOSURES: No relevant relationships by Muhammad Arif, source=Web Response No relevant relationships by Arnold Forlemu, source=Web Response No relevant relationships by Abid Khokar, source=Web Response No relevant relationships by Ali Saeed, source=Web Response No relevant relationships by Hursh Sarma, source=Web Response No relevant relationships by Ayushi Sharma, source=Web Response