2019 Research Forum

Kulraj Grewal MS IV 1 , Mandakini Patel MD 1 R3, Simmer Kaur MD 1 R2, Greti Petersen MD 1 , Arman Froush DO 1 , Saad Thara MD 1 R2, Augustine Munoz MD 1,2 , Arash Heidari MD 1,2 1 Department of Internal Medicine - Kern Medical, Bakersfield, CA 2 Valley Fever Institute, Bakersfield, CA A Rare Case of Disseminated Coccidioidomycosis of the Gallbladder

Introduction

Methods

Conclusions

References When comparing the literature, there has been one previous case of dissemination of Coccidioidomycosis to the gallbladder in a child as described by Sydorak et al. The patient in this case report was noted to have an extended history of disseminated Coccidioidomycosis and consequently confirmed to have a reinfection during hospitalization. In correlation with his untreated Diabetes Mellitus and symptoms upon presentation, the immunocompromised state of diabetes ketoacidosis could have possibly tipped the scales for the underlying chronic fungal infection to progress to a more subacute process and flare up in the gallbladder in association with the previous origins of dissemination. In conjunction with the diagnostic workup and the actual findings, it is important to consider that the fistula involving the gallbladder from which the collected turbid, bilious fluid found to contain C. immitis as highly suggestive of perhaps a prior perforation in relation to the dissemination of the gallbladder in a chronic setting. Therefore, careful evaluation by several radiologic techniques can help reveal the extensive spread of Coccidioidomycosis and also assist with the diagnosis of this challenging disease process. This particular case demonstrated an atypical manifestation of disseminated Coccidioidomycosis to the gallbladder amongst other more commonly known sites of dissemination. Such sporadic findings help motivate more investigation into the pathophysiology and current treatment guidelines of Coccidioidomycosis involved in dissemination to the hepatobiliary system. 1. Saubolle MA, McKellar PP, SusslandD. Epidemiologic,clinical, and diagnosticaspectsof coccidioidomycosis.J Clin Microbiol.2007;45(1):26–30 2. Fisher MC, Koening GL, WhiteTJ, & Taylor JW.Molecularand phenotypic descriptionof Coccidioidesposadasii sp. nov., previously recognizedas thenon-Californiapopulationof Coccidioidesimmitis. Mycologia (2002);94(1): 73-84. 3. Johnson,RH, Caldwell, JW,Welch,G, Einstein, HE. The great coccidioidomycosisepidemic:Clinical features. In: Einstein HE, CatanzaroA, eds. Coccidioidomycosis.Proceedingsof the 5th InternationalConference.Washington: National Foundation for InfectiousDiseases;1996:77. 4. Phillips, P, Ford, B. Peritonealcoccidioidomycosis: case reportand review. Clin InfectDis 2000; 30:971. [PubMed] 5. Dooley DP, Reddy RK, Smith CE. Coccidioidomycosispresentingas an omental mass. Clin InfectDis . 1994;19:802-803. 6. Eyer BA, QayyumA, WestphalenAC, et al. Peritonealcoccidioidomycosis:a potentialCTmimic of peritoneal malignancy. Abdom Imaging .2004;29:505-506. 7. Sydorak, R. M.,Albanese,C. T., Chen,Y., Weintraub,P. & Farmer,D. (2001).Coccidioidesimmitis in thegallbladderand biliary tree. J PediatrSurg 36, 1054–1056. 8. CarpenterJB, Feldman JS, Leyva WH, DiCaudo DJ. Clinical and pathologic characteristicsof disseminatedcutaneous coccidioidomycosis.JAmAcadDermatol. 2010;62:831-837. 9.ThomsonC.M., Saad N.E., Quazi R.R., Darcy M.D., Picus D.D., Menias C.O. Managementof iatrogenicbile duct injuries: role of the interventional radiologist.RadioGraphics.2013;33:117–134. 10. Válek V, Kala Z, Kysela P. Biliary tree and cholecyst:post surgery imaging. Eur J Radiol. 2005Mar; 53(3):433–440. 11. KahalehM, WangP, Shami VM, Tokar J,Yeaton P. Drainageof gallbladder fossa fluid collectionswith endoprosthesis placementunderendoscopicultrasoundguidance:a preliminary report of two cases.Endoscopy. 2005 Apr;37(4):393-6. 12. ChavalitdhamrongD, DraganovPV. Endoscopicultrasound-guidedbiliary drainage.World J Gastroenterol.2012 Feb 14;18(6):491-7. 13. Galgiani JN,Ampel NM, Blair JE, CatanzaroA, GeertsmaF, Hoover SE, et al. 2016 InfectiousDiseasesSociety of America (IDSA) Clinical PracticeGuideline for theTreatmentof Coccidioidomycosis.Clin InfectDis. 2016;63:e112–46.

Objectives Coccidioidomycosis is endemic to the southwestern United States, northern Mexico, and Central and South America. Infection is typically self-limiting and most individuals remain asymptomatic; in symptomatic individuals, less than 5% will go on to have dissemination of the fungal infection outside the confines of the chest cavity. Pulmonary Coccidioidomycosis is noted to disseminate through the lymphatic system, which can be visually noted as hilar adenopathy on imaging. Most common sites of dissemination include the nervous system, bones, joints, and skin. Dissemination to the peritoneal cavity is uncommon; however, there are cases reported in the English literature. Dissemination to the hepatobiliary system, particularly the gallbladder is extremely rare, with only one other case reported in the literature. A 60-year-old Hispanic male with Diabetes and history of disseminated osseous Coccidioidomycosis presented with acute onset dyspnea and right upper quadrant (RUQ) pain for two weeks. Patient was admitted for diabetic ketoacidosis. During admission, patient began to deteriorate and developed high grade fevers of unknown origin, as well as hiccups associated with RUQ pain. Chest x-ray (CXR) demonstrated a lingular patchy alveolar density and a 7 millimeter left mid-lung pulmonary nodule seen only on the PA view (Figure 1A).

An ultrasound guided drainage of the pericholecystic fluid collection was performed. Fistulogram was obtained and demonstrated a tract leading to the lumen of the gallbladder and opacification of the gallbladder lumen (Figure 4A). Following catheter placement, spot films exhibited appropriate position of the catheter tip within the gallbladder as it continued to actively drain fluid (Figure 4B).

Results Radiographic imaging of the right hand showed significant degenerative joint disease with osteoporosis and severe cortical erosions with multiple lytic lesions on majority of the carpal bones (Figure 5A). Due to history of dissemination, a right ankle x-ray was also obtained, which showed multiple lytic lesions in the distal tibia and fibula associated with possibility of reinfection (Figure 5B). A whole body bone scan showed increased uptake in the right wrist corresponding to the lytic bone lesions consistent with osteomyelitis and cocci bone lesions (Figure 6) . Serum Coccidioides serology showed complement fixation (CF) of 1:16. Histopathology of pericholecystic fluid revealed fungal hyphae; fungal cultures from the obtained fluid subsequently grew C. immitis (Figure 7) . Treatment plan consisted of weekly liposomal amphotericin B infusions in an outpatient setting, with cholecystostomy tube in place until a delayed cholecystectomy may be performed. Disseminated Coccidioidomycosis to the hepatobiliary system, particularly the gallbladder is extremely rare. In regards to our patient, his symptoms manifested as right upper quadrant pain and persistent hiccups. In order to manage the collection of fluid in the gallbladder fossa in this febrile patient with multiple comorbidities, the options for open surgical and percutaneous intervention were discussed. The decision was made to evaluate the presumed abscess formation via percutaneous modalities in treating the abdominal symptoms and possible underlying origin of the patient’s unexplained

Despite initiation of empirical broad spectrum antibiotics, the patient remained febrile. Abdominal radiographic image was obtained and was non-revealing. Subsequently, a Computed Tomography (CT) of the chest, abdomen, and pelvis with contrast was obtained, which demonstrated numerous cavitary pulmonary nodules in the chest (Figure 1B) . CT further showed a mildly distended gallbladder containing stones with minimal wall thickening with no noticeable adenopathy or organomegaly (Figure 2). Further, pertinent findings from the abdominal ultrasound most notably revealed that there was a sizable area of fluid collection adjacent to the gallbladder measuring 5.6 cm x 3.5 cm in size which was deemed suspicious of a probable abscess (Figure 3).

fevers. US-guided percutaneous interventional procedures have become more feasible for biliary drainage and internal biliary decompression because such procedures are minimally invasive and can also be performed as an adjunctive treatment that tend to have an excellent long-term outcome with lower complication rates in comparison to open surgical procedures. Dissemination to the hepatobiliary system was confirmed via serum cocci serology as well as positive histopathology and fungal cultures of the pericholecystic fluid.

Acknowledgements

We thank Royce H. Johnson, MD for valuable discussions, feedback, and for sharing his expertise of Coccidioidomycosis.

This study was conducted after approval from the Institutional Review Board.

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