A CURIOUS CASE OF COCCIDIOIDOMYCOSIS

SESSION TITLE: Chest Infections 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Coccidioidomycosis is a fungal disease endemic to the southwest United States and northern Mexico, often affecting the respiratory tract. Latent infection or reactivation years after prior exposure is reported in immunocompromised individuals, but rare in those with intact immune systems. CASE PRESENTATION: A 40-year-old African American male veteran from northeast Texas was referred to The Michael E. DeBakey VA Medical Center for chest CT findings concerning for malignancy. He had originally presented with 2-3 months of non-productive cough, 20-pound weight loss, anorexia, headache, subjective fevers, and fatigue. A CT of the chest was performed which showed a spiculated left perihilar mass measuring 3.9 x2.4 cm with associated necrotic aortopulmonary lymph nodes, interpreted as highly suspicious for malignancy (figure 1). He was a never-smoker and did not have significant past medical comorbidities. His most recent travel had been to Virginia one year prior to presentation; three years prior to presentation he had been stationed in San Diego, California. Flexible bronchoscopy was performed and demonstrated 60% narrowing of the airway of the left upper lobe upper division by a mucosal mass (figure 2). Endobronchial ultrasound and transbronchial needle aspiration of the mass and lymph nodes was performed. Intraoperative pathology demonstrated necrosis and granulomatous reaction without malignant cells. Spherules were noted on PAS and GMS stain (figure 3), consistent with a diagnosis of coccidioidomycosis. Tissue culture was positive for Coccidioides immitis and confirmed by genetic sequencing. Given headache and elevated risk factors for disseminated disease, a lumbar puncture and CT of the head was performed. CT head was normal. The LP was notable for an elevated opening pressure (350 mm water), concerning for central nervous system involvement. Cytology noted non-specific debris; cultures are pending. He was treated with long term fluconazole 800mg by mouth daily, and is still undergoing treatment. DISCUSSION: Careful history taking revealed risk factors, namely a young, otherwise healthy African American man without smoking history who had been stationed in southern California, that pointed to Coccidioides infection over lung cancer, and this was verified by classic pathology findings of spherules on tissue biopsy. Such delayed onset of symptoms is unusual in immunocompetent individuals. CONCLUSIONS: This case demonstrates the ability of pulmonary coccidioidomycosis to masquerade as malignancy by both symptomatology and on imaging, even years after travel to endemic regions. Reference #1: Brown J, Benedict K, Park BJ, Thompson GR. Coccidioidomycosis: epidemiology. Clinical Epidemiology. 2013;5:185-197. https://doi.org/10.2147/CLEP.S34434. Reference #2: Kotton, C.N., Marconi, V.C., Fishman, J.A., Chung, R.T., Elias, N., and Hertl, M. (2006). Coccidioidal meningitis after liver transplantation in a nonendemic region: a case report. Transplantation 81, 132–134. DISCLOSURES: No relevant relationships by Venkata Bandi, source=Web Response No relevant relationships by Linda Green, source=Web Response No relevant relationships by Daniel Hyman, source=Web Response No relevant relationships by Harman Kular, source=Web Response no disclosure on file for Donald Lazarus; No relevant relationships by Katherine Moeller, source=Web Response