2019 Research Forum

Applicant: Golriz Asefi MD Graduate RA Principal Investigator & Faculty Sponsor: Arash Heidari MD

A Devastating Case of Disseminated Coccidioidomycosis in a Previously Undiagnosed AIDS Patient

Golriz Asefi MD Graduate RA, Jeffrey J Jolliff PharmD, Arash Heidari MD

INTRODUCTION Disseminated coccidioidomycosis (cocci) is a condition that most commonly presents in immunocompromised patients. While it is a severe infection, adequate and early treatment can have a fair prognosis in the absence of other comorbidities or if comorbidities are treated early. PURPOSE We are presenting the management of a patient with disseminated cocci complicated by hepatic and kidney failure secondary to advanced previously undiagnosed AIDS. HIPAA/IRB review and approval for the case report was obtained. DISCUSSION A 47-year-old Hispanic male with a history of pulmonary cocci presented to the ED at Kern Medical with two weeks of progressive shortness of breath. Review of records indicated that patient was diagnosed with pulmonary cocci two years prior, but was never tested for HIV. He was started on fluconazole, but his condition worsened one year later. He was then diagnosed with Tuberculosis in Mexico but after 5 days of treatment presented to our facility with worsening of productive cough, vomiting 10 times per night, and a 45-pound weight loss. He was found to be septic with multiorgan failure. Labs revealed WBC of 23.3, neutrophil count of 22.1 with 26% band, BUN of 92, creatinine of 6.47, total bilirubin 5.2, and INR 4.67. Viral hepatitis panel was negative. HIV viral load was over 600,000 copies/ml with absolute CD4 cells <20. Cocci complement fixation titer was 1:256. Imaging showed bilateral diffuse miliary pulmonary infiltrations. Empirical antibiotics, antituberculosis medication, liposomal amphotericin B, prednisone, and hemodialysis were initiated. Blood and Bronchoalveolar lavage grew coccidioidomycosis immitis. TB was ruled out and medication was adjusted accordingly. Patient was intubated due to hypoxia. Initiation of HIV treatment was a challenge due to his ChildPugh Score of 11, Class C, and HIV-associated nephropathy. Lamivudine, enfuvirtide, zidovudine, and etravirine were started. Patient continued to deteriorate and passed away in comfort care on hospital day 16. CONCLUSION In cases of combined liver and kidney failure the management of either coccidioidomycosis or HIV is perplexing. In the case of coinfection, this complexity becomes a real ordeal. Early diagnosis and suppression of HIV could prevent organ failure as a limiting factor for selection of appropriate treatment for other conditions.

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