2019 Research Forum

Applicant: Golriz Asefi MD Graduate RA Principal Investigator & Faculty Sponsor: Arash Heidari MD

Coccidioides: A Stealthy Alien Forever

Golriz Asefi MD Graduate RA, Tung Trang MD, Royce Johnson MD, Arash Heidari MD

INTRODUCTION 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 and treatment of cocci meningitis is life-long. PURPOSE Here we are presenting a rare case of CNS cocci with incidental findings of pathognomonic cocci spherules in the cervical lymph nodes six years after continuous treatment with azoles. HIPAA/IRB review and approval for the case report was obtained. DISCUSSION A 52-year-old Hispanic male field worker with diabetes had presented six years prior to Kern Medical 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. Fluconazole 1000 mg was initiated at that time. After completion of his amphotericin treatment, he continued on fluconazole and follow up with a serial lumbar puncture as an outpatient. 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 two years later utilizing patient assistance program from the drug company. His serum and CSF CF titers remain stable at 1:32 and 1:16 respectively. Six years after being on continuous azole, 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. 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.

78