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Pulmonology Procedures |

Airway Manifestation of Coccidioidomycosis in an Immunocompromised Host

Jey Chung*, MD; Danielle Acosta, MD; Weicha Chen, MD; Frank Kagawa, MD; Eric Hsiao, MD; Carl Kirsch, MD; Vibha Mohindra, MD; John Wehner, MD; Allison Friedenberg, MD; Sharmila Pramanik, MD
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Stanford University, Stanford, CA


Chest. 2012;142(4_MeetingAbstracts):875A. doi:10.1378/chest.1386564
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Abstract

SESSION TYPE: Bronchology Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Coccidioidomycosis is an endemic fungal infection in the southwestern United States with various clinical presentations. Although infection begins with airway inoculation of arthroconidia, endotracheal and endobronchial manifestations of Coccidioidomycosis are rarely encountered. We report the case of an immunocompromised patient presenting with cough and miliary nodules, subsequently undergoing bronchoscopy notable for cobblestoned mucosa throughout his tracheobronchial tree demonstrating Coccidioides spherules.

CASE PRESENTATION: A 28 year-old gentleman with known AIDS and a history of cervical lymphadenopathy, biopsied and found to have Coccidioidomycosis two years prior, presents complaining of cough, fever, night sweats, and malaise. Six months prior, his CD4 count was noted to be 190/mcL; however, he reports having stopped taking his HAART therapy and antifungal medications soon thereafter. Chest radiograph is suspicious for miliary nodularity, confirmed on further CT scan. Although suspicious for disseminated, pulmonary Coccidioidomycosis, other infectious processes cannot be dismissed. Bronchoscopy is performed on hospital day #3, promptly revealing diffuse, irregular, cobblestoned mucosa throughout the tracheobronchial tree. Endobronchial biopsy of the abnormal mucosa reveals cellular granulomas with the presence of spherical organisms containing intracellular endospores, consistent with Coccidioides.

DISCUSSION: Endotracheal and endobronchial manifestations of Coccidioidomycosis are rarely reported. Two methods of airway inoculation by Coccidioides are generally accepted: direct bronchial infection versus extension of affected lymph nodes into airways. Bronchoscopic descriptions of tracheobronchial appearances range from localized patches of mucosal abnormalities to obstructive masses. Although airway expression of disease has been reported in both immunocompetent and immunocompromised hosts, prior case series have noted a significant number of immunocompromised (specifically HIV/AIDS) hosts with endobronchial disease, likely a function of their higher disease burden and poor immune function. Potential diagnosis via biopsy of abnormal airway findings is particularly important in these cases due to the unreliability of serum antibody testing in immunocompromised patients. In this case, an immunocompromised host demonstrates grossly abnormal mucosa on bronchoscopy, proving on biopsy to be infected with Coccidioides.

CONCLUSIONS: Although rare, disseminated Coccidioidomycosis of the airways can have various manifestations and can be apparent on gross inspection of the tracheobronchial tree with bronchoscopy, particularly in the immunocompromised host. Diagnosis can be made via endobronchial biopsy, showing evidence of Coccidioides.

1) Polesky A. Airway Coccidioidomycosis - Report of Cases and Review. Clin Inf Dis. 1999;28:1273-80.

2) Wallace JM. The Role of Bronchoscopy in Pulmonary Mycoses. J Bronchology. 2001;8:114-122.

DISCLOSURE: The following authors have nothing to disclose: Jey Chung, Danielle Acosta, Weicha Chen, Frank Kagawa, Eric Hsiao, Carl Kirsch, Vibha Mohindra, John Wehner, Allison Friedenberg, Sharmila Pramanik

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Stanford University, Stanford, CA

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