Chest Infections: Fellow Case Report Poster - Chest Infections I |

Corticosteroids in the Management of Severe Pulmonary Coccidioidomycosis FREE TO VIEW

Melisa Chang, MD; Neha Chopra, MD; David Beenhouwer, MD; Matthew Goetz, MD; Guy Soo Hoo, MD
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VA Greater Los Angeles Healthcare System and Geffen School of Medicine at UCLA, Los Angeles, CA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):123A. doi:10.1016/j.chest.2016.08.132
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SESSION TITLE: Fellow Case Report Poster - Chest Infections I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Coccidioidomycosis can be slow to resolve despite appropriate anti-fungal therapy. Recovery from severe pulmonary disease may be hastened by systemic corticosteroids1. We report a patient with severe coccidioidal pneumonia whose recovery was facilitated by systemic corticosteroids.

CASE PRESENTATION: A 69 year-old Hispanic man with diabetes mellitus (HgbA1c 6.8) was admitted to an outside hospital with severe LLL pneumonia. He required intubation on hospital day (HD) 4. Coccidioidomycosis was diagnosed by positive IgM titers and growth of Coccidioides immitis from bronchoscopy. He started fluconazole and liposomal amphotericin (5 mg/kg/d). Anuric renal failure was attributed to sepsis and contrast nephropathy. Lumbar puncture, brain MRI and bone scan were negative. He required tracheostomy and gastrostomy tube placement with transfer to our hospital on HD 30. He completed 28 days of amphotericin and continued high dose fluconazole. Dialysis was discontinued on HD 38, but daily fevers continued. CT imaging demonstrated dense LLL > RLL consolidation and moderate pleural fluid. Thoracentesis on HD 46 was lymphocytic and exudative, with negative cultures. Intravascular catheters were removed, but fevers persisted. He transitioned to trach collar oxygen, but remained weak with evidence of critical illness polyneuropathy. Coccidioides continued to grow from sputum. On HD 48, methylprednisolone (40 mg/d decreasing 10 mg every three days to complete a 12 day course) was started. He quickly deferversced, cleared sputum Coddidioides, with radiographic and functional improvement. He transferred to a medical ward on HD 54, improved with physical therapy, and was discharged to a nursing home.

DISCUSSION: Addition of corticosteroids to antimicrobial therapy has been effective in some infectious conditions. By controlling the destructive effects of inflammation, benefits as seen in severe Pneumocystis, outweigh concerns for immunosuppression. This patient has persistent infection despite several weeks of effective antimicrobials, before corticosteroid therapy appeared to accelerate recovery.

CONCLUSIONS: Systemic corticosteroids may enhance recovery from severe pulmonary infection with C. immitis. The optimal dosing and duration of therapy are not established. In this case, an approximate two week course was effective and associated with resolution of disease.

Reference #1: Shibili M et al. Adjunctive corticosteroids therapy in acute respiratory distress syndrome owing to disseminated coccidioidomycosis. Crit Car Med 2002;30:1896.

DISCLOSURE: The following authors have nothing to disclose: Melisa Chang, Neha Chopra, David Beenhouwer, Matthew Goetz, Guy Soo Hoo

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