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Primary Pleural Coccidiodomycosis
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A5409 - Primary Pleural Coccidiodomycosis
Author Block: H. Khudayar; Memorial hospital of Rhode Island/Brown University, Pawtucket, RI, United States.
Coccidioidomycosis is commonly associated with pulmonary parenchymal infection and associated secondary pleural effusion in 10% of cases. It is rarely presents as pleural-predominant disease with minimal or no evidence of parenchymal involvement. CASE DESCRIPTION:36 year old immunocompetent man presented with persistent fever, dry cough and recurrent hospital admissions for one month duration. His travel history was significant for a trip to Philippines three months prior to the onset of symptoms and a recent road trip during which he spent a few hours in California. His initial hospital admissions revealed left sided pleural effusion for which diagnostic and therapeutic thoracentesis were done twice, revealing exudative effusion. Chest computerized tomography (CT) scan showed minimal atelectasis. He was admitted for the third time with worsening symptoms. Physical examination was significant for high grade fever and tachycardia. Chest examination was significant for diminished breath sounds at left base. Work up showed mild leukocytosis and anemia of chronic disease. Aerobic and anaerobic bacterial, mycobacterial and fungal blood cultures were negative. A therapeutic and diagnostic left sided thoracentesis was done which was consistent with exudative pleural effusion with lymphocytic predominance. Cytology was negative for malignant cells. Pleural fluid cultures were negative.Sputum gram stain was negative for acid fast bacilli. Video-assisted thoracoscopic surgery (VATS) was significant for extensive adhesions between the left lung and left chest wall with a collection of fibrinous exudate and thickening of parietal pleura.Partial left sided parietal pleurectomy was performed. Pleural biopsy revealed granulomatous inflammation. Silver stain and PAS stain was positive for spherules with multiple endospores . Tissue culture showed a growth of coccidioides immitis by DNA probe. He was subsequently started on oral fluconazole with clinical improvement. DISCUSSION: Coccidioides spp are two fungal organisms (C immitis and C posadasii) endemic to deserts in the southwest USA, Mexico and Central America. Infection may occur following inhalation of airborne arthroconidia. Risk factors included immunodeficiency, smoking, and occupational exposure to soil. Pleural effusions occur more commonly as a consequence of underlying pulmonary parenchymal infection. Isolated pleural predominant disease with milder parenchymal involvement is rarely reported. The diagnosis can be missed made by thoracentesis and pleural biopsy is necessary for definitive diagnosis. Recurrent pleural effusion in absence of underlying pulmonary parenchymal disease is a rare presentation of coccidioidomycosis and pleural tissue culture is warranted to establish the diagnosis in setting of inconclusive pleural fluid studies. Treatment includes lobectomy or decortication and antifungal medications
Author Block: H. Khudayar; Memorial hospital of Rhode Island/Brown University, Pawtucket, RI, United States.
Coccidioidomycosis is commonly associated with pulmonary parenchymal infection and associated secondary pleural effusion in 10% of cases. It is rarely presents as pleural-predominant disease with minimal or no evidence of parenchymal involvement. CASE DESCRIPTION:36 year old immunocompetent man presented with persistent fever, dry cough and recurrent hospital admissions for one month duration. His travel history was significant for a trip to Philippines three months prior to the onset of symptoms and a recent road trip during which he spent a few hours in California. His initial hospital admissions revealed left sided pleural effusion for which diagnostic and therapeutic thoracentesis were done twice, revealing exudative effusion. Chest computerized tomography (CT) scan showed minimal atelectasis. He was admitted for the third time with worsening symptoms. Physical examination was significant for high grade fever and tachycardia. Chest examination was significant for diminished breath sounds at left base. Work up showed mild leukocytosis and anemia of chronic disease. Aerobic and anaerobic bacterial, mycobacterial and fungal blood cultures were negative. A therapeutic and diagnostic left sided thoracentesis was done which was consistent with exudative pleural effusion with lymphocytic predominance. Cytology was negative for malignant cells. Pleural fluid cultures were negative.Sputum gram stain was negative for acid fast bacilli. Video-assisted thoracoscopic surgery (VATS) was significant for extensive adhesions between the left lung and left chest wall with a collection of fibrinous exudate and thickening of parietal pleura.Partial left sided parietal pleurectomy was performed. Pleural biopsy revealed granulomatous inflammation. Silver stain and PAS stain was positive for spherules with multiple endospores . Tissue culture showed a growth of coccidioides immitis by DNA probe. He was subsequently started on oral fluconazole with clinical improvement. DISCUSSION: Coccidioides spp are two fungal organisms (C immitis and C posadasii) endemic to deserts in the southwest USA, Mexico and Central America. Infection may occur following inhalation of airborne arthroconidia. Risk factors included immunodeficiency, smoking, and occupational exposure to soil. Pleural effusions occur more commonly as a consequence of underlying pulmonary parenchymal infection. Isolated pleural predominant disease with milder parenchymal involvement is rarely reported. The diagnosis can be missed made by thoracentesis and pleural biopsy is necessary for definitive diagnosis. Recurrent pleural effusion in absence of underlying pulmonary parenchymal disease is a rare presentation of coccidioidomycosis and pleural tissue culture is warranted to establish the diagnosis in setting of inconclusive pleural fluid studies. Treatment includes lobectomy or decortication and antifungal medications
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