Abstract Background Miliary coccidioidomycosis is a rare, disseminated form of Coccidioides infection characterized by numerous tiny granulomas throughout the lungs and, in some cases, other organs via hematogenous or lymphatic spread. Pulmonary disease is the most common manifestation of coccidioidomycosis, with presentations ranging from asymptomatic infection to fulminant respiratory failure. Miliary coccidioidomycosis represents one of the most severe forms of infection, often associated with acute hypoxemic respiratory failure. Although traditionally described in immunocompromised patients, miliary coccidioidomycosis can occur in immunocompetent individuals, as illustrated in the following case. Case Presentation A 61-year-old male veteran with non-ischemic cardiomyopathy, heart failure with reduced ejection fraction (LVEF 19%), methamphetamine use disorder, and post-traumatic stress disorder was transferred to the Palo Alto Veterans Affairs Medical Center (PAVA) for management of heart failure exacerbation. He had initially presented to an outside hospital one day prior with shortness of breath, abdominal distension, leg swelling, and weight gain. Four days before transfer, he visited the PAVA emergency department with fever, cough, dyspnea, nausea, and vomiting. Chest CT angiography showed no pulmonary abnormality. He tested positive for COVID-19 and was discharged on nirmatrelvir/ritonavir (Paxlovid). During his hospitalization, he developed fevers, rising leukocytosis with peripheral eosinophilia, persistent cough, and acute hypoxemic respiratory failure requiring 3-4 L/min oxygen. On hospital day 9, repeat chest CT unexpectedly revealed new diffuse randomly distributed nodules (Figure 1a), prompting pulmonology consultation. At evaluation, he was febrile (102 °F), tachycardic (130 bpm), normotensive, tachypneic (20 breaths/min), and saturating 92% on 4 L/min nasal cannula. He reported dyspnea and ongoing cough. Bronchoscopy On hospital day 16, bronchoscopy with BAL of both upper lobes showed 35% neutrophils, 11% lymphocytes, 9% monocytes, and 45% eosinophils. BAL dimorphic fungi PCR was positive for Coccidioides immitis/posadasii. BAL cytology revealed eosinophils and spherical structures consistent with Coccidioides (Figure 1b). Pathology PET-CT demonstrated hypermetabolic diffuse lymphadenopathy. On hospital day 23, the patient underwent left supraclavicular lymph node biopsy. Tissue culture grew Coccidioides, and pathology showed numerous thick-walled spherules with endospores in a background of granulomatous inflammation. Conclusion We describe the case of a 61-year-old male admitted for acute decompensated heart failure and developed miliary pulmonary nodules on CT scan, ultimately resulting in an unexpected diagnosis of disseminated coccidioidomycosis. This case is remarkable for the rapid development of miliary nodules on CT imaging, occurrence of disseminated coccidioidomycosis in a non-immunocompromised host, and the suspected association between the patient’s recent COVID-19 and coccidioidomycosis infection. This abstract is funded by: None
Chai et al. (Fri,) studied this question.