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A5427 - A Strange Case of Coccidioidomycosis: Utilization of Bronchoscopy to Diagnose a Chronic Cavitary Lesion
Author Block: M. Nayeemuddin1, M. D. Jankowich2, A. Noska3, E. J. Gartman2; 1Pulmonary and Critical Care, Rhode Island Hospital - Warren Alpert Medical School of Brown University, Providence, RI, United States, 2Pulmonary and Critical Care, Providence VA Medical Center, Providence, RI, United States, 3Infectious Disease, Providence VA Medical Center, Providence, RI, United States.
Introduction: Coccidioidomycosis is a common respiratory pathogen in endemic regions of the United States. Most infections in immunocompetent adults are transient with 5-10% of cases resulting in pulmonary sequelae; chronic complications are rare. Case Presentation: A 60 year old female veteran presented to the Providence VA Medical Center for evaluation of angina. Cardiac CT performed for workup of angina discovered an incidental right upper lobe cavitary lesion interpreted as “consistent with pneumatocele.” Her only significant pulmonary history was a pneumonia treated as an outpatient while residing in California eight years prior to presentation. She moved to the Northeast four years later and has remained asymptomatic and very physically active. Follow-up imaging over three years demonstrated stability in the size of the cavity with surrounding infiltrates that waxed and waned - atypical for a pneumatocele. Interval increase in both size and wall thickness of the cavity was noted on most recent CT and subsequent noninvasive workup, including fungal antibody panel, was negative. She underwent bronchoscopy for further evaluation and tolerated the procedure well but developed fevers to 101.2 and rigors the following day requiring hospitalization for a febrile illness associated with multifocal airspace disease concerning for post-bronchoscopy pneumonia. Bronchoalveolar lavage culture grew 1+ Coccidioides immitis and subsequent Coccidioides antibody complement fixation was also positive. Long-term high-dose fluconazole therapy was initiated (400 mg daily) and she has recovered with a full return to her highly active lifestyle. Discussion: In the United States, most Coccidioidomycosis infections in immunocompetent adults are transient and confined to the endemic regions of the Southwest. Less than 10% of patients develop sequelae of pulmonary disease with peripheral thin-walled cavities and nodules being the most common. Complicated infections usually elicit severe fatigue and dyspnea thus undiagnosed chronic infections are rare. Our patient’s cavitary lesion was discovered incidentally following a relatively long period of time since endemic exposure and required invasive evaluation. Use of bronchoscopy for cavitary lesions is controversial due to potential complications but was essential to the diagnosis in this unique case. She experienced short term complications after bronchoscopy but has returned to her baseline activity level while on high-dose fluconazole therapy. Conclusion: A broad differential is essential when considering chronic cavitary lesions; coccidioidomycosis should remain a consideration even if exposure to endemic areas was remote. Bronchoscopy is a useful tool to obtain a diagnosis but complications may ensue post-bronchoscopy from infectious causes of cavitary lung disease.