THE DILEMMA OF MILIARY COCCIDIODOMYCOSIS

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Coccidioidomycosis, a fungal infection endemic to the Southwest United States, can take on many appearances on chest imaging. A miliary pattern is seen less frequently. In the immunocompromised patient, this can be a quandary for physicians as it may mimic tuberculosis. CASE PRESENTATION: A 34-year-old woman with systemic lupus erythematosus, on immunosuppressive therapy, presented with two months of fevers, fatigue, and 25-pound weight loss. Additional symptoms included dry cough, pleuritic chest pain, and vision changes. Other history was notable for birthplace in a developing country and immigration to Arizona in early childhood. On presentation, a computed tomography of the chest revealed diffuse miliary nodules with confluent necrotizing pneumonia in the left lower lobe. Ophthalmology was consulted for her vision disturbances and found creamy chorioretinal lesions bilaterally on fundoscopic exam. Quantiferon testing was indeterminate. Beta-D glucan was elevated, as were coccidioidomycosis IgM and IgG antibodies. Bronchoscopy with bronchoalveolar lavage was subsequently performed, as the patient was unable to provide satisfactory sputum samples. These cultures were negative for tuberculosis, and the initiation of antitubercular therapy was avoided. Intravenous Amphotericin and oral Fluconazole was initiated during her hospitalization, followed by a prolonged course of Fluconazole at discharge. DISCUSSION: There was concern for disseminated tuberculosis, given the patient's miliary pattern on imaging, chorioretinitis, and history of birth place. As coccidioidomycosis is endemic to Arizona, the patient was empirically started on antifungal treatment, but precautions and workup of active tuberculosis were still taken. Antitubercular therapy was to be held until the appropriate respiratory samples were collected. The patient afforded this delay as she remained hemodynamically stable without oxygen requirements. This decision also minimized the risk of building resistance and subjecting the patient to potentially harmful side effects. Cultures resulted negative for tuberculosis, and the patient's rapid clinical improvement on antifungal therapy supported her diagnosis of pulmonary coccidioidomycosis. She was placed on oral fluconazole and prednisolone eye drops at discharge; her follow up with Infectious Diseases nine months later found the patient to be asymptomatic with near complete resolution of the nodules on chest imaging. CONCLUSIONS: Coccidioidomycosis can have acute to subacute presentations of pneumonia with imaging findings ranging from focal infiltrates and nodular opacities to cavitary lesions. A miliary pattern can also occur, which should prompt a thorough infectious history and consideration for more invasive testing prior to empiric treatment of tuberculosis in a stable patient. REFERENCE #1: Adam RD, Elliott SP, Taljanovic MS. The Spectrum and Presentation of Disseminated Coccidioidomycosis. The American Journal of Medicine. 2009;122(8):770-777. doi:10.1016/j.amjmed.2008.12.024 REFERENCE #2: Sotello D, Rivas M, Fuller A, Mahmood T, Orellana-Barrios M, Nugent K. Coccidioidomycosis with diffuse miliary pneumonia. Proc (Bayl Univ Med Cent). 2016 Jan;29(1):39-41. doi: 10.1080/08998280.2016.11929351. PMID: 26722164; PMCID: PMC4677849. DISCLOSURES: No relevant relationships by Nicholas Schlund, source=Web Response No relevant relationships by Aishan Shi, source=Web Response No relevant relationships by Ashley Thomas, source=Web Response