Coccidioides: a Stealthy Alien Forever
Golriz Asefi1, 2, Tung T. Trang1, Royce Johnson1, 2, Arash Heidari1, 2. 1Internal Medicine, Kern Medical-UCLA, Bakersfield, California, United States, 2Valley Fever Institute, Bakersfield, California, United States
Purpose of Study 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. Treatment of cocci meningitis is life-long. Here we are presenting a case of CNS cocci with incidental findings of pathognomonic cocci spherules in his cervical lymph nodes six years after continuous treatment with azoles.
Methods Used Case report
Summary of Results A 52-year-old Hispanic male field worker with diabetes had presented six years prior to our institute 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 also initiated. 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 therapy since his diagnosis, 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.
Conclusions 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.
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