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

All That Is Miliary Is Not TB: A Case of Disseminated Pulmonary Coccidioidomycosis FREE TO VIEW

Madhu Kalyan Pendurthi, MBBS; Pralay Sarkar, MD; Kalpalatha Guntupalli, MD
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Baylor College of Medicine, Houston, TX

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

Chest. 2016;150(4_S):127A. doi:10.1016/j.chest.2016.08.136
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SESSION TITLE: Fellow Case Report Poster - Chest Infections II

SESSION TYPE: Affiliate Case Report Poster

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

INTRODUCTION: Miliary nodular pattern on lung imaging is commonly associated with miliary tuberculosis. Disseminated pulmonary coccidioidomycosis is a close mimicker.

CASE PRESENTATION: 30 year old construction worker presented with 3 weeks of dry cough and low grade fever. He coughed a small amount of blood 2 days prior to the clinic visit. Clinical exam was unremarkable. 1 month ago he returned from a trip to Queretaro, Mexico. Patient was a life time non-smoker, no history of illicit drug use, inhalational exposure and sick contacts. Patient was admitted to air borne isolation, 3 serial sputum specimens were negative for acid fast bacilli. CT scan of chest showed diffuse pulmonary nodules in random distribution.HIV was negative. Considering the recent trip to a highly endemic area of tuberculosis patient was started on a four drug regimen anti-tubercular therapy. Flexible fibre-optic bronchoscopy showed multiple fleshy pale yellow nodules in the right tracheobronchial tree. Endobronchial biopsies were obtained from involved areas and trans-bronchial biopsies from the right lower lobe. Bronchial alveolar lavage was lymphocyte and eosinophil predominant. Bacterial, fungal and mycobacterial cultures were negative. Histopathology of bronchial biopsies showed abundant chronic inflammatory cells and scattered coccidioidomycosis spherules with endospores. Serum coccidioidomycosis antibodies were elevated at 1:8. Anti-tubercular therapy was stopped and patient was treated with flucanozole.

DISCUSSION: Miliary nodular pattern is well described in disseminated tuberculosis. It is also seen histoplasmosis and varicella pneumonia. The pattern is uncommon for disseminated coccidioidomycosis. The disease is endemic to the desert regions of the southwestern United States, Mexico and Central America. It is caused by inhalation of spores of Coccidioides species in soil dust. Asymptomatic disease mainly involves lungs. Disseminated disease is rare and occurs in less than 1% of patients and is extremely rare in immunocompetent patients.

CONCLUSIONS: Early recognition of miliary spread of coccidioidomycosis and prompt treatment is crucial to avoid morbidity and mortality. Endobronchial biopsies should be considered in suspicious cases.

Reference #1: Arsura EL, Kilgore WB. Miliary coccidioidomycosis in the immunocompetent. Chest. 2000;117(2):404-9

Reference #2: Jude CM, Nayak NB, Patel MK, Deshmukh M, Batra P. Pulmonary coccidioidomycosis: pictorial review of chest radiographic and CT findings. Radiographics. 2014;34(4):912-25.

DISCLOSURE: The following authors have nothing to disclose: Madhu Kalyan Pendurthi, Pralay Sarkar, Kalpalatha Guntupalli

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