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Complicated Pulmonary Coccidioidomycosis Infecting Sarcoid Nodules and Presenting With Knee Arthritis FREE TO VIEW

Navin Kaini, MD; Rachel Foot, MD; Alan Smulian, MD; Sadia Benzaquen, MD
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University of Cincinnati, Cincinnati, OH

Chest. 2014;146(4_MeetingAbstracts):144A. doi:10.1378/chest.1990573
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SESSION TITLE: Infectious Disease Cases II

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Wednesday, October 29, 2014 at 11:00 AM - 12:15 PM

INTRODUCTION: Coccidioidomycosis is a spectrum of disease caused by dimorphic fungi C. immitis and C. posadasii. It commonly involves lung, but could affect multiple systems including joints. Sarcoid nodules could be infected with fungus like coccidiodes, especially in patients on chronic immunosuppressive therapy. It could present as unresolving pneumonia and respiratory failure.

CASE PRESENTATION: 54 years old male with biopsy proven sarcoid lung nodules on chronic prednisone developed cavitary pneumonia. Sputum culture grew Pseudomonas aeroginosa and was treated with appropriate antibiotics. However, he had respiratory failure requiring prolonged mechanical ventilation. Computed tomography of the chest showed worsening consolidation and cavitations. Endobronchial ultrasound guided transbronchial biopsies showed fungal elements, with possible mucor Vs aspergillus. He lived in arizona for two years in past. When voriconazole was started, he had significant improvement and was weaned off the ventilator. During follow-up he had right knee swelling and warmth. Arthroscopy with aspiration culture and PCR gene sequencing confirmed Coccidioides posadasii. On review of his original bronchoscopic biopsies, fungal elements appeared to have endospores, due to infection of sarcoid nodules with coccidiodomycosis. . Antifungal was switched to Itraconazole. He returned to baseline functional status and had resolution of cavitations and consolidation.

DISCUSSION: Rare occurance of fungal infections, mainly with histoplasma, blastomyces or crytococcus has been reported in treated patients with sarcoidosis. Our case had complicated pulmonary coccidiodomycosis infecting sarcoid nodules and fungal arthritis of the knee. Clinical deterioration and worsening infiltrate on imaging study in patients with sarcoidosis on treatment warrants investigation. Endospores seen on tissue biopsy of this patient are rarely how coccidiomycosis grow in human, but can be seen in cavitary lung lesions.

CONCLUSIONS: Clinicians should be vigilant about possible fungal infection with unresolving pneumonia in patients with sarcoidosis on immunosuppresive therapy. Complicated pulmonary coccidiodomycosis is rare but has been reported to coexist with sarcoidosis. Travel history is also an important clue in diagnosis.

Reference #1: Baughman RP, Lower EE. Fungal infections as a complication of therapy for sarcoidosis. QJM (June 2005) 98 (6): 451-456.

Reference #2: Sharma OP, Arora A. Coccidiodomycosis and sarcoidosis. Multiple recurrences.West J Med. May 1997; 166(5): 345-347.

DISCLOSURE: The following authors have nothing to disclose: Navin Kaini, Rachel Foot, Alan Smulian, Sadia Benzaquen

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