SESSION TYPE: Infectious Disease Cases III
PRESENTED ON: Wednesday, October 24, 2012 at 11:15 AM - 12:30 PM
INTRODUCTION: Coccidioidomycosis is caused by the soil-dwelling dimorphic fungi Coccidioides immitis and Coccidioides posadasii, which are endemic in southwestern United States, as well as northwestern Mexico. The most typical clinical manifestation is asymptomatic pulmonary disease. However, a subset may develop complications, such as cavitary disease.
CASE PRESENTATION: A 53-year-old Mexican man with a history of diabetes mellitus and tobacco use presented with three months of hemoptysis (one teaspoon daily), unintentional weight loss and fatigue. He denied prior tuberculosis exposure or infection. His physical exam was unremarkable. His relevant laboratory studies were a hemoglobin A1c of 11.9 and a negative rapid HIV test. A CT of the chest revealed a 3 x 3 cm cavitary lesion in the superior segment of the right lower lobe containing several dependent nodules. In addition, there were satellite lesions throughout the right lower lobe. Given his persistent hemoptysis, he underwent a right lower lobectomy. On gross pathologic exam, there was a 2.5 x 2.5 x 2.5 cm cavity. Inside the cavity there was gray-white, tan-brown friable, partially necrotic tissue. Histologically, the cavity contained noninvasive Pseudallescheria boydii (P. boydii). The fungal culture of the cavity grew Coccidioides immitis confirmed by DNA probe and the coccidioides antibody complement fixation was 1:8. Additional sections of the right lower lobe demonstrated Coccidioides immitis. Post-operatively, the patient is asymptomatic.
DISCUSSION: Initially, the patient was thought to have a cavity due to prior tuberculosis infection with intracavitary fungus balls due to Aspergillus. While Coccidioides immitis is known to cause pulmonary disease, coccidiodal fungus balls have only been described in case reports. Although there are no data to guide therapy, the primary treatment in this case was surgical resection given his symptoms. He was treated post-operatively with Fluconazole as he had evidence of infection outside the cavity and his uncontrolled diabetes increased his risk for other complications. In this case, P. boydii presented in a typical fashion. It is a septated, filamentous fungus that commonly forms fungal balls in preexisting lung cavities in immunocompetent patients. The patient may be asymptomatic or have constitutional symptoms. Surgical resection is the mainstay of treatment in symptomatic patients. Antifungals are not required if the disease is localized.
CONCLUSIONS: Fungal balls secondary to Coccidioides immitis are a rare entity, but should be included in the differential diagnosis. Surgical resection is typically required for symptomatic patients.
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DISCLOSURE: The following authors have nothing to disclose: Caroline Kim, Amy Mehta
No Product/Research Disclosure InformationHarbor-UCLA Medical Center, Torrance, CA