SESSION TYPE: Infectious Disease Student/Resident Cases
PRESENTED ON: Tuesday, October 23, 2012 at 11:15 AM - 12:30 PM
INTRODUCTION: Coccidioidomycosis is a fungal infection caused by Coccidioides spp (Coccidioides immitis and Coccidioides posadasii) endemic to the southwestern region of the United States. Immunocompromised patients are at much higher risk of contracting this infection. Sporadic cases may be seen outside the endemic regions. Pneumothorax due to rupture of coccidioidomycosis lung cavities is rare even in the endemic areas.
CASE PRESENTATION: We report a case of a HIV-AIDS patient presenting with spontaneous pneumothorax due to pulmonary coccidioidomycosis. Our patient, a 40 year old African American male with a history of HIV-AIDS presented to the hospital with 6-8 weeks history of dyspnea, pleuritic chest pain, dry cough, fevers and weight loss.Chest X-ray showed a moderate size right apical pneumothorax with fine miliary nodules throughout the lungs. CT scan of the chest showed multiple miliary & cavitary nodules and a moderate size right apical pneumothorax. A right sided chest tube was placed with resulting re-expansion of the involved lung. Extensive workup including sputum for acid fast bacilli, PPD skin test, pneumocystis DFA was negative. Diagnostic BAL cultures grew Coccidioides imitis and trans-bronchial lung biopsy showed spherules of Coccidiodes spp.Patient was treated with amphotericin B in the hospital followed by outpatient oral fluconazole.
DISCUSSION: Symptomatic coccidioidomycosis infections usually present as a self-limiting lower respiratory tract infection accompanied by constitutional symptoms like fever, cough, arthralgia and anorexia. Chest radiographic findings may include infiltrates, a pleural effusion, and hilar lymphadenopathy. On occasions, the pulmonary Coccidioides infection may evolve into a solitary, thin-walled cavity usually located in upper lobes. Rupture of a coccidioidal pulmonary cavity can result in pneumothorax. Demonstration of the organisms in tissue or BAL fluid is necessary to confirm the diagnosis, especially when outside the endemic areas. Treatment of cavitary coccidioidomycosis complicated by pneumothorax includes surgical intervention (closed-chest tube drainage/resection/decortications) and medical management. Delay in treatment can result in chronic fistula & extensive fibrothorax formation. Antifungal therapy with Amphotericin B or fluconazole is suggested for 3 to 6 months.
CONCLUSIONS: Coccidiomycosis can be encountered outside the usual endemic areas and clinicians must be aware of the clinical spectrum. Rupture of a coccidioidal pulmonary cavity is a rare complication and can result in pneumothorax. Treatment of pneumothorax due to Coccidioides requires surgical intervention with antifungal therapy.
1) Jennie Collins, Marisela Dy,Conrad Clemens,Diala Faddoul. Not Just a Simple Pneumothorax. The Pediatric Infectious Disease J. 30-4, April 2011.
2) Gerald Edelstein,Robert G. Levitt. Cavitary Coccidioidomycosis Presenting as Spontaneous Pneumothorax. AJR 141 : 533-534, September 1983
DISCLOSURE: The following authors have nothing to disclose: Himanshu Bhardwaj, Jeremy Moad, Amar Kirti Dadwal, Paul Carlile
No Product/Research Disclosure InformationUniversity of Oklahoma Health Sciences Center, Oklahoma City, OK