2019 Research Forum

Applicant: Carlos D’Assumpcao MD R1 Principal Investigator Arash Heidari MD

Extrapulmonary Coccidioidomycosis Presenting as Abdominal Distension

Carlos D’Assumpcao MD R1, Charles Clark MD R1, Serghei Burcovschii MD R1, Amit Sah MS IV, Cheng-Ying Wu MS IV, Emily Gunz MS IV, Jessica McFarland MS IV, Matthew Gilbert MS IV, Leila Moosavi MD R3, Manasa Kalluri MD R1, Janushe Patel MD MPH, Arash Heidari MD

INTRODUCTION Coccidioidomycosis is a fungal infection causedbyCoccidoides immitis or posadasii. Whilemost commonly presentingas pulmonary infection, dissemination can occur in 0.4-0.7%of cases. Intraabdominal dissemination have been reported but very few cases had peritoneal involvement.

PURPOSE This is a case of disseminated coccidioidomycosis presenting as peritonitis. HIPPA and IRB review and approval for the case report was obtained.

DISCUSSION A 23-year-old Hispanic male presented to an outside hospital with one-month history of fever, weight loss, blood in stool, abdominal pain and distension. He was discharged after paracentesis without any further treatment. He presented to another hospital with more severe abdominal pain and distension. Imaging found a small bronchopulmonary fistula with extension into left chest wall with associated left lung volume loss and a left loculated pleural effusion, diffuse mediastinal lymphadenopathy, splenomegaly and abdominal ascites with omental caking. A cervical lymph node biopsy originally performed to rule out lymphoma instead showed coccidioidomycosis spherules with endosporulation. Intravenous liposomal amphotericin B was started and he was transferred to our institution for higher level of care. Upon arrival his coccidioidal complement fixation (CF) titers were greater than 1:512. He developed small bowel obstruction with progression of ascites and a large pelvic abscess. Catheters placed into pelvic abscess drained purulent fluid that grew C. immitis, Escherichia coli, and Bacteroides ovatus. Small bowel obstruction improved with abscess drainage and antibiotic therapy. After seven hospital days he was discharged with daily outpatient treatment at our infusion center, ambulating and tolerating a regular diet. His amphotericin treatment was tapered to 5 times a week for 2 weeks and then to 3 times a week aiming to finish a 12-week course. His most recent CF titers improved to 1:256. CONCLUSION Physicians in areas endemic to coccidioidomycosis should be aware of the possibility of abdominal and peritoneal dissemination as the presenting symptom of disseminated coccidioidomycosis. Surgical intervention should be avoided by all means.

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