Chest Infections |

Not Your Average Case of Pulmonary Coccidiomycosis FREE TO VIEW

Deborah Dossick, MD; Bhavesh Patel, MD; Joel Larson, MD; Jabraan Pasha, MD; Alyssa Chapital, PhD
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Mayo Clinic, Phoenix, AZ

Chest. 2013;144(4_MeetingAbstracts):233A. doi:10.1378/chest.1703833
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SESSION TITLE: Infectious Disease Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Coccidioides immitis is a common cause of acute respiratory illness in the Southwest. Disseminated coccidiomycosis is less common. We present a case of presumed cutaneous coccidiomycosis that progressed to disseminated infection in an end-stage liver disease (ESLD) patient.

CASE PRESENTATION: A 70 year old woman with autoimmune hepatitis and primary sclerosing cholangitis presented to our facility to discuss liver transplantation. Her MELD score was 26 and she was immunosuppressed on Azathioprine. On physical exam, she had an uncomfortable, erythematous nodule on her right popliteal fossa. This was unroofed and cultured; the culture did not speciate. The following day, the nodule had enlarged and become necrotic. She was admitted, blood and sputum cultures ordered, and broad-spectrum IV antibiotics started. Within 48 hours she developed respiratory distress; an ABG showed that she was acidotic. Laboratory evaluation indicated progressive multi-system organ failure. She was intubated and transferred to the ICU. A CT showed innumerable nodules within both lungs and numerous hypodensities throughout her liver and spleen concerning for septic emboli. The patient’s family decided not to escalate care and she passed away. Two days later, her blood and sputum cultures speciated Coccidioides posadasii/immitis.

DISCUSSION: Coccidioides immitis most commonly produces an influenza-like illness. Transient skin manifestations occur in 10%-50%. Nodular presentation is the most common. A large study of 233 patients with coccidiomycosis demonstrated 18 with cutaneous involvement; 20% of these had negative skin-biopsy cultures. ESLD patients represent a special population. A study performed at a tertiary referral center in Maricopa County showed the incidence of coccidiomycosis in ESLD patients undergoing transplant evaluation was 2.1% (five times higher than the incidence in the general population, 0.04%). This may be due to altered host-defenses, including decreased phagocytosis, opsonization, and synthesis of complement components, as well as immune-suppressive medications, as in this case.

CONCLUSIONS: Empiric fungal coverage should be considered in immunosuppressed patients, particularly ESLD patients, with evidence of sepsis in regions endemic with Coccidioides immitis.

Reference #1: Blair J.E., Balan, V., Douglas D.D., Hentz J.G., Incidence and Prevalence of Coccidiomycosis in Patients with End-Stage Liver Disease. Liver Transplantation. 2003; 9: 843-850.

Reference #2: Crum N.F., Lederman E.R., Stafford C.M., Parrish J.S., Wallace M.R., Coccidioidomycosis: a Descriptive Survey of a Reemerging Disease. Clinical Characteristics and Current Controversies. Medicine. 2004; 83: 149-175.

Reference #3: Galgiani J.N., Ampel N.M., Blair J.E., Catanzaro A., Johnson R.H., Stevens D.A., et. al. Coccidioidomycosis. Clinical Infectious Diseases. 2005; 41: 1217-1223.

DISCLOSURE: The following authors have nothing to disclose: Deborah Dossick, Bhavesh Patel, Joel Larson, Jabraan Pasha, Alyssa Chapital

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