2019 Research Forum

Carlos D’Assumpcao MD R1, Amit Sah MS IV, Charles Clark MD R1, Matthew Gilbert MS III, Serghei Burcovschii MD R1, Emily Gunz MS IV, Jessica McFarland MS IV, Leila Moosavi MD R3, Manasa Kalluri MD R1, Janushe Patel MD MPH, Arash Heidari MD Valley Fever Institute | Department of Medicine Kern Medical | Bakersfield, CA Extrapulmonary Coccidioidomycosis Presenting As Abdominal Distension

One week later at a second hospital, he presented with abdominal distension, persistent pain, decreased appetite and right testicular pain for two days. He had palpable tender cervical lymphadenopathy, diffuse abdominal guarding with “doughy” feeling without shifting dullness. No testicular swelling or inguinal lymphadenopathy was appreciated. He was found to have leukocytosis (11.7 mg/dl) without bandemia nor eosinophils. Basic chemistries were within normal limits. Liver panel was normal except for alkaline phosphatase at 154 IU/L and albumin at 2.8 g/dL. Erythrocyte sedimentary rate was 81 millimeters per hour. Lipase, lactic acid, lactic dehydrogenase, uric acid and tumor markers alpha-fetoprotein and carcinoembryonic antigen were all within normal limits. Imaging found diffuse supraclavicular [B] and mediastinal lymphadenopathy [C], small bronchopulmonary fistula [D], loculated left sided effusion with volume loss [E], recurrent abdominal ascites with omental caking and splenomegaly [F]. He underwent diagnostic and therapeutic paracentesis that removed 2100 milliliters cloudy amber fluid. Cell count revealed 3463 red blood cells, 738 white blood cells of which 42% were segmented (310 total neutrophil count). Of note, eosinophils were 1%. Serum to ascites albumin gradient was 0.6. Gram stain only showed white blood cells and red blood cells and cultures had no growth through day 6. Out of concern for lymphoma, a cervical lymph node biopsy was performed, which instead revealed spherules with endosporulation . Coccidioides serum immunodiffusion detected only immunoglobulin G with compliment fixation titers reportedly as high as 1:4096 by a commercial laboratory. QuantiFERON GOLD was negative. Intravenous liposomal amphotericin B was started three times a week.

Lab Test

Result

B

HIV DNA PCR

Negative Negative Negative Negative Negative Negative

Introduction

Hepatitis B Surface Antigen

Hepatitis C PCR

Case Report While coccidioidomycosis most commonly presents as a pulmonary infection, dissemination can occur in rare number of cases. Intraabdominal dissemination have been reported but very few cases had peritoneal involvement. This is a case of disseminated coccidioidomycosis presenting as peritonitis. This is a 23 year old Latino college student who works in a restaurant and had an inguinal hernia repair at age 8. He presented to the first hospital emergency department with left knee pain and swelling without trauma history. The patient suspected it was a weight lifting injury. X-rays did not show any fractures. He was discharged with codeine/acetaminophen 5/325mg tablets and methylprednisolone 4mg tablets . One week later, he developed generalized swelling all over his body, subjective fevers, nausea, vomiting, severe abdominal pain.

QuantiFERON GOLD

Bone Scan [J]

Abscess AFB smear and culture

Coccidioides immitis

MIC

Amphotericin B Natamycin Fluconazole Itraconazole Posaconazole Voriconazole Isavuconazole

<0.03

2

16

0.125

0.06 0.25

Discussion References Coccidioidal peritonitis has been reported in about 20 cases worldwide so far. Common presenting symptoms include abdominal pain and distension, hernia and fever. It has been incidentally diagnosed during hernia repair, ascites evaluation with and without eosinophila, pelvic pain with suspicion for tubo- ovarian abscess, and may present similar to carcinomatosis like the patient in this case. It has even been cultured from peritoneal dialysis. Coccidioidal peritonitis can be isolated to the peritonitis or become extraperitoneal. It has been found in both the immunocompetent and immunocompromised. This patient may have had a subclinical infection of systemic coccidioidomycosis that became uncontrolled after steroid administration for knee pain. SidhuR, LashDB,HeidariA, NatarajanP, Johnson RH. EvaluationofAmphotericin B Lipid Formulations forTreatment of Severe Coccidioidomycosis.AntimicrobAgentsChemother. 2018:26;62(7). MalikU, CheemaH, KandikatlaR,AhmedY,ChakralaK.DisseminatedCoccidioidomycosisPresenting asCarcinomatosisPeritoneiand Intestinal Coccidioidomycosisin a PatientwithHIV. Case RepGastroenterol. 2017Mar 3;11(1):114-119. BækO,AstvadK, SerizawaR, Wheat LJ, BrenøePT, HansenAE. Peritoneal and genital coccidioidomycosisin an otherwise healthyDanish female: a case report.BMC InfectDis. 2017 Jan 31;17(1):105. StorageTR, Segal J, Brown J. PeritonealCoccidioidomycosis: a RareCaseReport andReview of the Literature. J GastrointestinLiverDis. 2015 Dec;24(4):527-30. AlaviK,Atla PR, HaqT, SheikhMY.CoccidioidomycosisMasquerading as EosinophilicAscites.Case RepGastrointestMed. 2015;2015:891910. Zhou S,MaY, ChandrasomaP. Small bowel dissemination of coccidioidomycosis.Case Rep Pathol. 2015;2015:403671. McGwire B,Marr B, Zhou XP,Ayers L. Iliopsoas coccidioidomycoticabscesswith associated intra-abdominalextension in an immunocompetent patient. BMJCaseRep. 2012Nov 27;2012. KoksengSL, Blair JE. Subclinicaldisseminationof coccidioidomycosisin a liver transplant recipient.Mycopathologia. 2011 Sep;172(3):223-6. SmithG, Hoover S, SobonyaR, Klotz SA.Abdominal and pelvic coccidioidomycosis.Am J Med Sci. 2011Apr;341(4):308-11. ChungCR, LeeYC, RheeYK,ChungMJ, HongYK, KweonEY, Park SJ. Pulmonary coccidioidomycosiswith peritoneal involvementmimicking lung cancerwith peritoneal carcinomatosis.Am J RespirCritCareMed. 2011 Jan 1;183(1):135-6. Micha JP, GoldsteinBH, Robinson PA, RettenmaierMA, Brown JV.Abdominal/pelvicCoccidioidomycosis. EllisMW, DooleyDP, SundborgMJ, Joiner LL, Kost ER.Coccidioidomycosismimickingovarian cancer.ObstetGynecol. 2004 Nov;104(5 Pt 2):1177- 9. EyerBA,QayyumA, WestphalenAC,YehBM, Joe BN,Coakley FV. Peritoneal coccidioidomycosis: a potentialCTmimic of peritonealmalignancy. AbdomImaging. 2004 Jul-Aug;29(4):505-6. Buchmiller-CrairTL. Initialpresentationof coccidioidomycosisduring inguinal herniorrhaphy.Hernia. 2003 Jun;7(2):92-4. PhillipsP, Ford B. Peritoneal coccidioidomycosis: case report and review.ClinInfectDis. 2000 Jun;30(6):971-6. DooleyDP, ReddyRK, SmithCE.Coccidioidomycosispresenting as an omentalmass. ClinInfectDis. 1994Oct;19(4):802-3. Perez JA Jr,ArsuraEL. Peritoneal coccidioidomycosisdiagnosed incidentally at herniorrhaphy.West J Med. 1993Apr;158(4):406. JamidarPA, CampbellDR, FishbackJL, Klotz SA. Peritoneal coccidioidomycosisassociatedwith human immunodeficiency virus infection. Gastroenterology. 1992 Mar;102(3):1054-8. AmpelNM,White JD, VaranasiUR, LarwoodTR, VanWyck DB,GalgianiJN.Coccidioidalperitonitis associatedwith continuous ambulatory peritonealdialysis.Am J KidneyDis. 1988 Jun;11(6):512-4. 1 He remained in hospital for 9 days. He received 14 days of ceftriaxone, 14 days of daily IV liposomal amphotericin B 5 mg/kg followed by 12 weeks of IV liposomal amphotericin B 5 mg/kg three times a week. He is now on suppressive antifungal therapy with isavuconazole. Most recent serum coccidioidal antibody immunodiffusion detected both IgM and IgG with compliment fixation titers of 1:256. Left ventricular ejection fraction improved to 40-45%.

Three weeks later, he developed rigid painful abdomen with guarding and distension with suspicious fluid collection around the bladder [G]. He was transferred to our institution for higher level of care. Upon arrival his coccidioidal compliment fixation titers were greater than 1:512. He developed bowel obstruction with large pelvic abscess [H], progression of ascites, and heart failure with reduced ejection fraction 30-35%. Catheter placed into pelvic abscess [I] drained purulent fluid that grew Coccidioides immitis , Escherichia coli , and Bacteroides ovatus . Bowel obstruction improved with abscess drainage and antibiotics.

A

G

C D

F

E

H I

[ A]: Initial CT abdomen from the first hospital showed peripherally enhancing rim engulfing the central mesentery without free flowing ascites. The thickening and nodularity of omentum rose initial concern for peritoneal carcinomatosis.

He was discharged after paracentesis without any further treatment.

ChenKT. Coccidioidalperitonitis.Am J ClinPathol. 1983Oct;80(4):514-6. CRUMRB. Peritoneal coccidioidomycosis.AMAArch Surg. 1959 Jan;78(1):91-5.

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