2019 Research Forum

Coccidioides: A Stealthy Alien Forever Golriz Asefi MD Graduate RA 1, 2 , Tung Trang MD 1 , Royce H. Johnson MD 1, 2 Arash Heidari MD 1, 2 1. Department of Internal Medicine , Kern Medical, Bakersfield , CA 2. Valley Fever Institute, Bakersfield, CA

Treatment

Introduction

Initial Regimen

Discharge Regimen

Disseminated coccidioidomycosis (cocci) to the central nervous system (CNS) is one of the most severe and debilitating forms of this infection. The definitive etiology behind dissemination and chronicity of CNS cocci is unknown but certainly lies in the host immune response. Treatment of cocci meningitis is life-long and experts believe that this form of infection is forever. Here we are presenting a case of CNS cocci with incidental findings of pathognomonic cocci spherules in his cervical lymph nodes six years after continuous treatment with azoles. Case Presentation A 52-year-old Hispanic male field worker with diabetes had presented six years prior to our institute with respiratory failure, headache, night sweats, and 40-pound weight loss. He was diagnosed with severe pulmonary cocci with hypoxemia and placed on liposomal amphotericin B and steroid taper. His serum cocci Complement Fixation (CF) was >1:512. He was also diagnosed with cutaneous cocci with several lesions around his mouth and disseminated cocci meningitis as his CSF result revealed WBC of 615 (40% lymphocytes, 51% neutrophils), a protein of 168, and glucose 22 and cocci (CF) at 1:16. He was also placed on 1000 m of fluconazole.

Liposomal Amphotericin B Fluconazole

Steroid taper Fluconazole

2

3

Figure 2,3: CT Neck did not demonstrate any glossal lesions or cervical lymphadenopathy

Conclusion Experts believe that coccidioidomycosis could remain dormant in chronic forms of infection, even after successful completion of treatment. The clinician should be aware of this form and reactivation particularly in immunocompromising conditions. Figure 4: Cocci spherules. Despite negative CT neck findings, lymph node biopsy was free of cancer but revealed cocci spherules.

Test

Result Tag >1:512 High

Serum Compliment fixation

CSF WBC

615

High

CSF Lymphocytes % 40% CSF Neutrophils % 51% CSF Protein 168

References

High Low

CSF Glucose

22

4

5

CSF Compliment Fixation

>1:16 High

1: D'Assumpcao C, Heidari A, Sabetian K, Johnson RH. Crescendo Transient Ischemic Attacks Due to Basilar Coccidioidal Meningitis With Coccidioma. J Investig Med High Impact Case Rep. 2018 Nov 19;6:2324709618813178. doi: 10.1177/2324709618813178. eCollection 2018 Jan- Dec. PubMed PMID: 30480005; PubMed Central PMCID: PMC6247484.

Figure 4,5: 2-View Chest X-ray demonstrated persistent right middle lobe segmental consolidation.

Figure 1: Admission labs

His cutaneous lesions resolved. His treatment was switched to voriconazole two years later after the failure of response based on his CSF findings. He developed severe side effects and had difficulties with access to voriconazole, therefore, his treatment was changed to isavuconazonium utilizing patient assistance program from the drug company. His serum CF titers remain stable at 1:32 and his CSF CF titers remained around 1:16. Results Six years after being on continuous azole therapy since his diagnosis, he was found to have a 1.5 x1.5 cm ulcer on his tongue. His biopsy showed squamous cell carcinoma and he underwent left partial glossectomy and supraomohyoid neck dissection. Lymph node histology was free of cancer but revealed the presence of cocci spherules with endosporulation. After completion of his amphotericin treatment, he continued on fluconazole and follow up with a serial lumbar puncture as an outpatient.

Acknowledgement

The authors would like to acknowledge the contributions of the patient care team and research support staff for their roles in bringing awareness to this rare condition for the medical community.

1

Figure 2: Right middle lobe alveolar density, pneumonia six years prior to presentation

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