2019 Research Forum

Manasa Kalluri MD R1, Carlos D’Assumpcao MD R1, Matthew Gilbert MS III, Amit Sah MS IV, Emily Gunz MD IV, Jessica McFarland MS IV, Leila Moosavi MD R3, Janushe Patel MD MPH, Arash Heidari MD Valley Fever Institute | Department of Medicine, Kern Medical| Bakersfield, CA Multifocal Osseous Coccidioidomycosis Masquerading as Multiple Myeloma

Coccidioidomycosis is a fungal infection of Coccidioides immitis or posidosii endemic to the southwest United States that commonly manifests in the lung but can disseminate to bone and other tissues. Multiple myeloma is a cancer of plasma cells that present as lytic bone lesions in the spine and skull. We present a case of osseous coccidioidomycosis that initially presented with lytic bone lesions. Introduction Case Report 35-year-old homeless, cachectic male with a history of cannabis, crystal methamphetamine and PCP abuse presented after an assault to the head and neck.

Table 1: Laboratory tests support coccidioidomycosis without meningeal dissemination rather than multiple myeloma.

Two days after discharge he represented with neck pain.

Image 3

Image 4

Laboratory Test

Initial Results

1 month later Normal Range

CSF Opening Pressure 30 mmH2O

5-25 cmH2O 40-75 mg/dl 15-45 mg/dl 0-5 cells/cm 2

CSF Glucose CSF Protein

45 mg/dl 55 mg/dl 1 cell/cm 2

CSF WBC

CSF Gram stain

No organisms

CSF Fungal culture CSF Cocci IgM CSF Cocci IgG CSF Cocci CF Serum Cocci IgM Serum Cocci IgG Serum Cocci CF Erythrocyte SED rate

No growth

Very weak reactive

Non-reactive Non-reactive

Non-reactive

<1:1

<1:1

Reactive Reactive

Reactive Non-reactive Reactive Non-reactive

1:256

1:64

<1:2

66 mm/hr

>100 mm/hr

0-15 mm/hr 45-117 U/L

Image 1

Alkaline phosphatase 139 U/L

159 U/L

HIV Ab/Ag

Negative

Negative Negative

QuantiFERON-TB Gold Indeterminate

CT cervical spine without IV contrast sagittal imaging

MRI cervical spine without gadolinium T2 weighted sagittal imaging

SPEP UPEP

Chronic inflammation

Initial chest x-ray was benign (image 5) except for a distal clavicular lesion. CT imaging found a thin walled cavitary lesion in the right upper lobe (image 6).

No abnormal protein bands

Discussion CT and MRI neuroimaging (above) found pathological fractures of C5 and bilateral perched facet of C5 to C6. He underwent C5 corpectomy and C4 to C6 spinal fusion where pathology redemonstrated endosporulating spherules . Postoperatively, patient left against medical advice again and has been lost to follow up ever since. lytic bone lesions are typically pathognomonic for bone or bone marrow related malignancies or metastasis with age-related differential diagnoses. Axial lytic bone lesions with anemia and weight loss in the middle aged may initially suggest multiple myeloma. Osseous coccidioidomycosis is an uncommon site of dissemination for C occidioides. Untreated it can be debilitating with pathological fractures in critical regions such as the cervical spine. Lesion proximity to the meninges should prompt evaluation for meningitis, one of the most devastating sites of dissemination. Risk factors for dissemination are not yet established. Thorough aggressive investigation with multiple imaging and laboratory modalities can guide treatment aggressiveness and estimate prognosis. Unfortunately, social determinants of health such as homelessness, drug abuse, and financial constraints may hamper even the best intended interventions. Physicians in areas endemic for coccidioidomycosis should be aware of atypical presentation of dissemination that may masquerade as other more commonly described diseases. Galgiani JN, Ampel NM, Blair JE, et al. 2016 IDSA Clinical Practice Guideline for the Treatment of Coccidioidomycosis. Clin Infect Dis . 2016;63:e112-e146. Sidhu R. Lash DB, Heidari A, Natarajan P, Johnson RH. Evaluation of Amphotericin B Lipid Formulation for Treatment of Severe Coccidioiomycosis. Antimicrob Agents Chemother . 2018 Jul; 62(7): e02293- 17. Incidental References

Lambda Light chains Kappa Light chains

319 mg/dl 487 mg/dl

91-240 mg/dl 176-443 mg/dl

Kappa/Lambda ratio 1.53

1.29-2.55

Further history was obtained, revealing that one week prior, he was at another hospital where a bone biopsy found endosporulating spherules without evidence of malignancy . At the time, patient was started on fluconazole 600mg PO BID and liposomal amphotericin B, but subsequently left against medical advice.

Image 5

Initial CT neuroimaging per trauma activation protocol incidentally revealed multiple destructive lytic lesions (not shown). Follow up T1 weighted MR neuroimaging demonstrated multiple gadolinium enhancing destructive calvarial (image 1), cervical (image 2), thoracic (image 3), and lumbar spine (image 4) lesions.

Image 6

Image 2

Lytic lesions in right distal clavicle and acromicoclavicular joint (top right) and left proximal phalanx of 2 nd toe (right).

At this point, lytic bone lesions, mild microcystic anemia and cachexia raised concern for plasma cell dyscrasia such as multiple myeloma in addition to coccidioidomycosis. Urine and serum were sent for protein electrophoresis and light chain analysis.

NM bone imaging (above left) suggested further dissemination and was confirmed on x-ray. He was treated with daily liposomal amphotericin B 5mg/kg for 18 days with plan for three weekly infusions for 12 weeks as an outpatient.

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