2019 Research Forum

Applicant: Mandakini Patel MD R3 Principal Investigator & Faculty Sponsor: Arash Heidari MD

Disseminated Coccidioidomycosis (cocci) of the Gallbladder is an Extremely Rare Entity, with Only One Other Case Reported in the Literature

Kulraj Grewal MS IV, Mandakini Patel MD R3, Simmer Deep Kaur MD R2, Greti Petersen MD, Augustine Munoz MD, Arman Froush MD, Saad Thara MD R2, Arash Heidari MD

INTRODUCTION Disseminatedcoccidioidomycosisoccurswhencocci departs theoriginal infectedsiteandestablishes lesions indistantpartsof thebody. The incidenceofdisseminationdependsonhost immunosuppression, general health and immunity factors. Cell-mediated immunity can become further impaired with dissemination.

PURPOSE The rarity of dissemination to the gall bladder and the challenges of medical management are worthy of sharing with the larger medical community.

DISCUSSION A 60-year-old Hispanic male with diabetes mellitus type 2 and previous right wrist disseminated osseous cocci noted in medical history presented with acute onset of dyspnea, right upper quadrant (RUQ) pain. Notable progressive worsening fatigue over a two-week period was reported. Laboratory studies initially revealed diabetic ketoacidosis, which was corrected. Soon after admission, the patient became febrile with hiccups, non-productive cough, worsening RUQ pain and failure to respond to broad spectrum antibiotics. Chest imaging showed a lingular patchy alveolar density with a 7 mm left mid-lung pulmonary nodule. Computed tomography revealed numerous cavitary pulmonary nodules in the chest, a mildly distended gallbladder containing stones and minimal wall thickening. Gallbladder sonography showed sludge, calcified stones and a 5.6 X 3.4 cm multi-loculated pericholecystic fluid collection. Transcutaneous drainage of the pericholecystic fluid collection showed discordance between the volume of fluid obtained and the size of the lesion seen on imaging. Subsequently, a fistulogram demonstrated that a sinus tract had formed secondary to a chronic underlying infection. A cholecystostomy drain was placed into the gallbladder; 10 cc of turbid bilious fluid was evacuated. Fungal culture grew coccidioidomycosis immitis; Cocci serology complement fixation was 1:16. The whole bone scan showed increased dissemination uptake at the right wrist. The patient was started on liposomal amphoteric B and received infusions as an outpatient for 12 additional weeks. The cholecystostomy tube remained in place until the subsequent cholecystectomy. CONCLUSION Dissemination of coccidioidomycosis to the gallbladder is extremely rare. With the rate of coccidioidal infection in Kern County endemic area, our infectious disease team has identified dissemination to additional rare sites: testes, tongue, myocardium, thyroid, liver, an infant’s subglottic area, and mimicking multiple myeloma to confound the differential diagnosis, just within the past year. For physicians with patients who have lived or traveled to endemic areas, presenting with initial or disseminated symptoms, it is essential to consider Coccidioides immitis or Coccidioides posadasii as a pathological causative organism.

58