2019 Research Forum

Golriz Asefi MD Graduate RA, Monica Kumar MD R1, Tana Parker MD, Arash Heidari MD Valley Fever Institute | Rio Bravo Family Medicine | Department of Medicine Kern Medical First Reported Case of Osteopoikilosis Mimicking Disseminated Osseous Coccidioidomycosis

Introduction T he clinical

Outcome

Serology confirmed the diagnosis of cocci with complement fixation (CF) of 1:4. Her sputum and bronchoscopy samples grew MRSA and Coccidioides immitis simultaneously. Blood cultures remained sterile. She was placed on liposomal amphotericin B and Linezolid. Her chest CT also showed diffuse medullary sclerotic lesions in the sternum, and bilateral clavicles and humerus bones. She had a high protein albumin gap above 6gm/dl suspicious for gammopathy. The bone survey showed similar findings in bilateral acetabulum, ischium, femurs, and tibias without lytic lesions and sparing spine. Technetium 99m bone scan also did not show any increased in uptake. She was diagnosed with osteopoikilosis. The patient continued to improve and was discharged home to complete 4 weeks of linezolid and will be continued on liposomal amphotericin B infusion. Her titers increased to 1:16 despite clinical improvement suggesting immune reconstitution syndrome.

Case Report manifestation of coccidioidomycosis (cocci) infection ranges from asymptomatic disease to severe dissemination forms such as to bones. Diabetes a known risk factor in severity and dissemination. In the presence of coexistence of other osseous conditions, the diagnosis of dissemination becomes a difficult task. Here we are presenting a case of a severe form of pulmonary coccidioidomycosis co-infected with Methicillin-Resistant Staphylococcus Aurous (MRSA) with cavitation in the presence of underlying uncontrolled diabetes and congenital osteopoikilosis mimicking osseous dissemination. 40-year-old Hispanic woman with poorly controlled diabetes, previous history of MRSA bacteremia and amphetamine abuse presented to our facility with significant weight loss and glucose of 835 mg/dL. Imaging showed bilateral diffuse alveolar and nodular densities with a large cavitary lesion in the lingula.

The patient continued to improve and was discharged home to complete 4 weeks of linezolid and will be continued on liposomal amphotericin B infusion. Her titers increased to 1:16 despite clinical improvement suggesting immune reconstitution syndrome.

Conclusions

Osseous

dissemination

of

coccidioidomycosis should be suspected in the right clinical setting. However, the coexistence of other bone involvement such as hereditary disease, prior fractures, and metastasis makes the proper diagnosis difficult. A combination of different complementary imaging modalities should be used, and biopsies will remain the last resort.

Figs 3, 4, 5: Technetium 99m bone scan showed markedly increased uptake in both kidneys, decreased uptake in both femurs indicating osteopoikilosis.

References

Al-Bourini O, Lotz J, Wienbeck S. Radiological Findings in Osteopoikilosis. Rofo. 2018 Jun;190(6):499-502. doi: 10.1055/a-0577-5399. Epub 2018 May 15. German. Ye C, Lai Q, Zhang S, Gao T, Zeng J, Dai M. Osteopoikilosis found incidentally in a 17-year-old adolescent with femoral shaft fracture: A case report. Medicine(Baltimore). 2017 Nov;96(47):e8650.

Acknowledgments

The authors would like to acknowledge the contributions of the patient care team and research support staff for their roles in bringing awareness to this rare condition for the medical community.

Figs 1, 2; Her chest CT bilateral diffuse alveolar and nodular densities with a large cavitary lesion in the lingula

Fig. 6, 7, 8: Bone survey showed multiple symmetric foci of meducallary bone sclerotic lesions consistent with osteopoikoilosis with no evidence of infection .

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