Abstract Introduction Coccidioides is a dimorphic fungus that causes Coccidioidomycosis. Around 20,000 cases of Coccidioidomycosis are reported in the United States of America every year but estimated burden is 10-18 times more than reported. Coccidioidomycosis that is outside the thoracic cavity is considered as disseminated Coccidioidomycosis. The risk of dissemination is around 0.2% of all Coccidioidal infections. Case Report This is a 26 year old woman with history of lobar holoprosencephaly presented with an episode of fever, vomiting and dark colored urine of one day duration. Vital signs were temperature 38.7 degrees Celsius, heart rate 126 per minute, blood pressure 123/82, and saturation 90% on 6 liters per minute of oxygen. Laboratory work up showed hemoglobin of 7.7 g/dl, white blood cell count of 11,500 /ul and sodium of 129. Chest X ray showed diffuse bilateral opacities left more than right and also enlarged left hilar mass. Patient was started on Intra Venous (IV) Vancomycin, Cefepime and Fluconazole. CT scan chest showed 7 cm left anterolateral chest wall mass with adjacent destruction of the left sixth rib, paraspinal mass around the T9 level and enlargement and low density attenuation centrally in the left paraspinal musculature measuring 3.5 x 2 cm with adjacent destruction of the T7 spinous process. Coccidioides immunodiffusion IgM and IgG antibodies came as positive. Patient underwent CT guided biopsy of left chest wall mass and pathology showed necrotizing granulomatous inflammation with spherules consistent with Coccidioides species. Antifungal coverage was changed to IV Amphotericin B liposomal and IV Fluconazole. Cultures grew Coccidioides immitis. Neurosurgery was consulted. MRI of the spine showed osteomyelitis of the T7-T10, L3, L4 and S1 vertebral bodies and a 2.7 cm right paravertebral abscess at the level of T8-T9. Significantly increased left posterior paraspinal musculature abscess extending from the level of T5-T11. Patient underwent CT guided drainage of paraspinal fluid collection and posterior thorax soft tissue fluid collection. Cultures once again grew Coccidioides immitis. Patient received 6 weeks of IV Amphotericin B liposomal and IV Fluconazole. Patient clinically improved over the time and hypoxia was resolved. Plan is to continue oral Fluconazole lifelong or as long as patient tolerates with no adverse effects. Discussion Immunocompromised patients are at higher risk for disseminated infection and mortality. Combined Amphotericin B and Azole therapy is the treatment of choice. Early diagnosis and treatment are very important to decrease morbidity and mortality. This abstract is funded by: None
Loya et al. (Fri,) studied this question.