Ahad Azeem, MD
Creighton University Medical Center-Bergan Mercy
Omaha, NE
Disclosure information not submitted.
David Quimby, MD
Assistant Professor, Infectious diseases
Creighton University Medical Center-Bergan Mercy, United States
Disclosure information not submitted.
John Horne, MD
Assistant Professor, Infectious diseases
Creighton University Medical Center-Bergan Mercy, United States
Disclosure information not submitted.
Bryan Krajicek, MD
Assistant Professor, Pulmonary and critical care medicine
Creighton University Medical Center-Bergan Mercy, United States
Disclosure information not submitted.
Title: An (Ig)Easy Diagnosis: A Case of Disseminated Coccidioidomycosis
Case Report Body:
Introduction:
Coccidioidomycosis is a fungal disease that is usually caused by either Coccidiodes immitis or Coccidiodes posadasii. The former is found in California and the latter is endemic to other parts of the United States and Mexico. After inhalation, pneumonia is often the primary infection, but it may disseminate to involve the reticuloendothelial system, bones, and central nervous system.
Description:
A 24-year-old African American male was admitted for shortness of breath, fevers, and acute on chronic back pain with paraspinal tenderness in the lumbar area. He had traveled to Arizona three months prior to presentation. On presentation, he was hemodynamically stable and noted an unintentional 20 lbs. weight loss within the last 30 days. CT angiogram of his chest revealed mediastinal and hilar lymphadenopathy with diffuse pneumonitis; abdominal imaging showed an abscess of 8.2 cm with osteomyelitis in the sacrum and right iliac bone. Laboratory evaluation showed a white blood cell count 25.2 k/ul (normal range, 4.0-12.0 k/ul), serum 1,3 beta-d-glucan 249 (reference range, < 80) and IgE 4500 IU/ml (reference range, 0-158 IU/ml). Based on his travel history, serum Coccidiodes antibodies were ordered. Due to worsening respiratory status, he was transferred to intensive care unit where bronchoscopy was performed. He also underwent CT-guided right sacroiliac (SI) joint fluid aspiration. Based on high clinical suspicion and elevated serum IgE, liposomal amphotericin B (5 mg/kg/day) was initiated. Later his antibodies against Coccidiodes resulted elevated - IgM 6.0 (reference range, < 1.0) and IgG 8.8 (reference range < 1.0). Fungal cultures from the bronchoalveolar lavage and SI joint grew mold, consistent with Coccidiodes. Neurosurgery recommended conservative management since his symptoms improved with medical therapy. After two weeks of liposomal amphotericin B, he was started on high-dose oral fluconazole 800 mg daily at the time of discharge.
Discussion:
Disseminated coccidioidomycosis, more common in immunodeficient patients, can also be seen rarely in the immunocompetent. Like our case, elevated serum IgE can hint towards the diagnosis while serology tests and cultures are pending. Antifungals coupled with surgical intervention for vertebral osteomyelitis have been associated with improved outcomes.