ACCUSTOMED TO INFECTION J. Hanawi-Heintze MD, N. R. Sells MD Department of Medicine, University Hospital and Clinics, LSU Health, Lafayette, LA
INTRODUCTION: Coccidioides species are known to be endemic to the southwestern United States. Men in endemic areas are disproportionately affected, especially if there is exposure to dust.
CASE: A 68-year-oldmanwith COPD and chronic osteomyelitis of the sacrumpresented after being told of an abnormal lab results. Findings showed an elevated CRP of 20 and a white cell count of 17,000. The patient did not have any major complaints and review of systems was unremarkable other than baseline shortness of breath and dyspnea on exertion. He was found to be hypoxic and noted to have a complicated sacral abscess. The patient was started on broad spectrum antibiotics for his acute infection as well as oxygen for his hypoxia. A CT Thorax revealed increased fibrosis, a 3cm lucent area in the right lung apex consistent with a cavitary lesion, bibasilar consolidation and hilar lymphadenopathy. A full interstitial lung disease workup, gram stain, sputum culture, fungal culture, and acid-fast bacillus testing was unremarkable. Antibiotics were deescalated prior to discharge. One month later, fungal cultures grew Coccidioides immitis. He was in clinic where serology was drawn. The patient did admit to spending time experiencing transient homelessness in Arizona several years prior. Coccidioides IgG and IgM were positive and he was started on a 6 month course of Fluconazole. DISCUSSION: Manifestations of coccidioidomycosis can range from asymptomatic to very mild infections in approximately 50% of cases to clinical illness in 40-50% of cases. The incubation period is usually 1-3 weeks. In this case, it is difficult to determine whether the extent of his disease is secondary only to coccidioidomycosis or to a combination of coccidioides infection and another disease process. Coccidioides infection can manifest similarly to interstitial lung disease, pulmonary fibrosis, TB, or COPD exacerbations. In non-endemic areas, it is easily excluded from the differential. Our patient case most likely a more complicated and chronic course of infection rather than an acute process.
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