2019 Research Forum

Applicant: Michael Valdez MS IV Principal Investigator & Investigator Sponsor: Arash Heidari MD

Concomitant Central Nervous System Toxoplasmosis and Seronegative Disseminated Coccidioidomycosis in a Newly Diagnosed Acquired Immune Deficiency Syndrome Patient

Michael Valdez MS IV, Leila Moosavi MD R3, Arash Heidari MD

INTRODUCTION Opportunistic infections are a major cause of morbidity and mortality in acquired immune deficiency syndrome (AIDS). We describe a fatal case of seronegative disseminated coccidioidomycosis (Cocci) and central nervous system (CNS) toxoplasmosis in a newly diagnosed AIDS patient. PURPOSE IRB review was performed and approval was obtained for this single patient case report documenting the presentation, diagnosis, management, and outcome of concomitant CNS toxoplasmosis and diffuse miliary pneumonia with fungemia due to seronegative Coccidioides immitis (C. immitis). DISCUSSION A 33 year-old Hispanic male with no significant medical history presented to an outside hospital with headaches and was diagnosed with a 2.7cm ring enhancing intracranial lesion in the right temporal lobe. He was transferred to our facility for neurosurgical intervention. Post-operatively, he became febrile and was transferred to the medicine team. He was screened and diagnosed with AIDS with a CD4 count of <20cells/microL. Antiretroviral and CNS toxoplasmosis treatments were started. Comprehensive screening in this AIDS host, including cocci serology, was negative except high IgG titers for toxoplasmosis. Histopathology of the brain lesion confirmed the diagnosis of toxoplasmosis. Further investigation revealed that the patient was made aware of HIV diagnosis two years prior but remained in denial. He was discharged after fever had resolved but was readmitted one week later with persistent fevers and was found to have a new left upper lobe infiltration. Broad-spectrum antibiotics plus fluconazole were started and he was placed on airborne precautions until tuberculosis could be ruled out. Cocci serology was again negative. His condition deteriorated with hypoxemia and development of diffuse miliary pattern revealed by CT of the chest. Bronchoscopy was arranged but hypoxemia worsened which prompted intubation. Bronchoalveolar lavage after intubation showed spherules and blood culture grew fungus resembling C. immitis. Antifungal treatment was changed to liposomal amphotericin B but he developed severe acute respiratory distress syndrome (ARDS), went into cardiac arrest, and passed away. CONCLUSION Impaired immune functions, such as defects in the IL-12/IFN-γ pathway and T-helper 17-mediated response, are associated with increased severity of coccidioidomycosis. In HIV hosts, negative cocci serology can be seen in up to 25% of cases. Therefore, other diagnostic modalities shouldbe initiated promptly and simultaneously. Fungemia and ARDS are both associated with very high mortality in coccidioidomycosis.

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