Coccidioidomycosis With Uncommon Extrapulmonary Manifestations: A Case Report

To the Editors: Coccidioidomycosis is an endemic mycosis present in certain geographic areas.1 Northern Mexico is considered an endemic region, in which Coccidioides posadasii is the most common species. Most patients do not have previous risk exposure, and Coccidioides infections are asymptomatic in 60% of children. Pulmonary involvement is the most common clinical presentation, manifesting as an influenza-like illness. Less than 1% of cases are disseminated to the skin, soft tissues, lymph nodes, or the skeletal system. Pericardial involvement is uncommon. We present the case of a previously healthy, fully immunized 14-year-old boy from Mexico who presented with a 14-day history of abdominal pain and fever. On physical examination at the emergency room admission, he was febrile and tachycardic, with respiratory distress (89% O2 Sat), basal lung hypoventilation and dull percussion, muffled heart sounds and generalized pallor. Initial workup revealed anemia, leukocytosis, and neutrophilia (complete blood count: Hgb 11.8 g/dL, Hct 36.2%, white blood cells 14.4 µ/L (10.3 poly, 2.5 lymph), platelets 346,000). D-dimer (17.845 ng/mL), C reactive protein (14.4 mg/mL), and ferritin (535 ng/dL) levels were elevated. A CT scan was performed and revealed bilateral pleural effusion with multiple areas of consolidation and pericardial effusion. An echocardiography confirmed the pericardial effusion with normal cardiac function. Pericardial and thoracic aspiration and testing were negative for potassium hydroxide, gram, and Ziehl-Neelsen stains as well as GeneXpert mycobacterium tuberculosis complex and resistance to rifampin. Empiric antibiotic and antituberculosis treatments were initiated. The immunologic assessment results were normal. Continuing the workup, the tuberculine skin test and interferon-gamma release assay test results were negative. Thoracoscopy with pleural and pericardial biopsies was performed because of persistent fever, despite antimicrobial treatment (Fig. 1A,B). Periodic acid shiff staining of the pleural tissue and pleural fluid revealed the presence of granulomas and spherules; however, no microbiological or molecular identification was obtained (Fig. 1C,D).FIGURE 1.: A,B: Thoracoscopy images of pleural implantations and effusion. C,D: Periodic acid shiff stain on pleural biopsy and pleural effusion with granulomas and spherules.Amphotericin B was initiated because of a high suspicion of endemic mycosis. Clinically, the fever ceased, but pleural and pericardial effusions persisted. Follow-up echocardiography revealed effusive constrictive pericarditis. A pericardial window for both treatment and histopathological workup was performed, which revealed a significant increase in pericardial thickness and pericardial calcifications. Corticosteroid treatment for constrictive pericarditis was initiated, with no improvement in cardiac function. Cultures from the tissue samples identified Coccidioides immitis. The patient had persistent pericardial effusion, constrictive pericarditis and diastolic dysfunction, which ultimately caused his death. Cardiac and pericardial involvement in coccidioidomycosis is uncommon (<1% of cases). High mortality rates have been reported among pediatric patients. To our knowledge, this is the first report of pericardial coccidioidomycosis in Latin America. Diagnosis is challenging because of the high rates of negative cultures in pericardial effusion samples, which usually require pericardial tissue biopsy.2,3 In endemic areas, extrapulmonary involvement and the need for biopsy must be considered in patients with a nonfavorable response to conventional treatment.