OUT OF THE VALLEY: COCCIDIOIDOMYCOSIS AS AN ETIOLOGY OF PRIMARY COMMUNITY-ACQUIRED PNEUMONIA IN A PATIENT WITH LIMITED TRAVEL HISTORY

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Coccidioidomycosis is well-established community acquired pneumonia in the Southwestern United States.Herein is described a patient presenting with common pneumonia symptoms and a limited environmental exposure history after recent travel to an endemic region complicated by diagnostic testing suggestive of eosinophilic granulomatosis with polyangiitis. CASE PRESENTATION: A 41-year-old woman with a 2-week history of cough, fever, night sweats, and chills presented with increasing shortness of breath and productive cough after failing outpatient treatment for community-acquired pneumonia.She had no past medical, family, or smoking history, sick contacts, or influenza vaccination.She recently traveled to southern California without outdoor activities 2 weeks prior to symptom onset.She was admitted in acute hypoxic respiratory failure with hemodynamic instability and treated with broad-spectrum antibiotics and systemic steroids.Imaging revealed multifocal pneumonia and right-sided effusion.A repeat CT showed improving atypical pneumonia.Steroids were stopped and she acutely worsened.Bronchoalveolar lavage revealed oropharyngeal flora and transbronchial biopsy showed necrotizing granulomatous inflammation and eosinophilia.Her course of illness and bronchoscopy posed a differential diagnosis including acute eosinophilic pneumonia, eosinophilic granulomatosis with polyangiitis, or fungal pneumonia.ANA and ANCA studies were negative, and fungus cultures eventually grew Coccidioides.She started fluconazole and clinically improved. DISCUSSION: Coccidioides species are a common cause of acute pneumonia in the Southwestern United States typically presenting 1-3 weeks after spore inhalation and is clinically indistinguishable from other etiologies of community-acquired pneumonia [1].60% of patients are asymptomatic and 95% of symptomatic patients may have self-resolution of symptoms after several weeks [2].Diffuse pneumonia is an uncommon manifestation due to large inoculation burden or hematogenous spread and may feature severe illness with cavitary lung lesions and granulomas.The diagnosis of coccidial pneumonia in non-endemic regions is reliant on serologic testing performed in reference laboratories taking several days to result [1,3].The steroid responsive symptoms, eosinophilia, and necrotizing granulomas made eosinophilic granulomatosis with polyangiitis a potent alternative diagnosis in this patient.Steroid induced immunosuppression may have permitted hematogenous spread of Coccidoides infection and manifestation of diffuse pneumonia.The management of this patient relied heavily on an adequate history and clinical suspicions while awaiting confirmatory results. CONCLUSIONS: Fungal pneumonia may mimic a number of concerning pathologies and should be considered highly on the differential in patients with recent travel history to endemic areas and present with non-specific symptoms. Reference #1: Parish JM, Blair JE.Coccidioidomycosis.Mayo Clin Proc.2008;83(3):343-349.https://doi.org/10.4065/83.3.343. Reference #2: Hage CA, Knox KS, Wheat LJ.Endemic mycoses: overlooked causes of community acquired pneumonia.Respir Med.2012;106(6):769-776.https://doi.org/10.1016/j.rmed.2012.02.004. Reference #3: Sotello D, Rivas M, Fuller A, Mahmood T, Orellana-Barrios M, Nugent K.Coccidioidomycosis with diffuse miliary pneumonia.Proc (Bayl Univ Med Cent).2016;29(1):39-41.http://www.ncbi.nlm.nih.gov/pubmed/26722164.Accessed March 2, 2019. DISCLOSURES: No relevant relationships by Vikas Pathak, source=Web Response No relevant relationships by Christopher Walker, source=Web Response