Coccidioidomycosis where you least expect it

Background

Coccidioidomycosis is a fungal infection which is predominantly found in the hot arid states of Texas, Nevada, New Mexico, Arizona and large parts of central and southern California in the southwestern United States. Risk factors include residency or travel in endemic areas, immunocompromised state secondary to uncontrolled diabetes, HIV, cancer, advanced age, organ transplantation and taking immunosuppressive drugs for any cause. In India, three cases of pulmonary coccidioidomycosis have been reported from different parts of the country, namely Verghese et al in Chennai, Savio et al in Andhra Pradesh and Oberoi et al in New Delhi. In all three cases, the patient had a history of travel to or from endemic areas in the USA. Common clinical presentations include fever, cough, fatigue, breathlessness, night sweats, muscle or join pains and headache. This case reports outlines an Indian patient with absolutely no travel history to any endemic area, get diagnosed with coccidioidomycosis.

Case presentation

An elderly man, farmer with no known comorbidities with no significant travel history, presented to the pulmonary medicine out-patient unit with complaints of intermittent episodes of fever for 2 months and cough with scanty expectoration for 15 days. It was associated with an evening rise in temperature. Cough was associated with scanty, thick, mucoid expectoration. Patient also had history of weight loss of about 5 kg in the last 1 year. There was no history of haemoptysis, foul-smelling sputum, breathlessness or orthopnea. He was referred to a local hospital, where radiography in the form of chest X-ray (figure 1) and CT scan of the thorax was done and showed ‘centrilobular nodules in all the lobes of both the lungs, patchy consolidation in subpleural location of right upper lobe, right middle lobe and bilateral lower lobes and mediastinal lymphadenopathy’ (figure 2). The patient underwent bronchoscopy and bronchoalveolar lavage (BAL) was sent for further analysis. BAL culture grew pseudomonas aeruginosa but did not detect mycobacterium tuberculosis (MTb) in the cartridge based nucleic acid amplification test (CBNAAT). He was prescribed tablet ciprofloxacin 500 mg two times per day for a week based on culture sensitivity pattern; however, the patient continued to have symptoms. The patient was hence referred to us for further evaluation and management. All relevant blood investigations were done and were found to be within normal limits. The patient was planned for image-guided biopsy of the right lung lesion. However, during the procedure, it was observed that there was clearing of the radio-opacities, which were present in the initial CT scan and appearance of fresh lesions in different locations. Since there was a 3-week lag between the initial CT and the current one, migratory shadows were suspected. Fine-needle aspiration cytology (FNAC) showed features suggestive of coccidioidomycosis (figures 3 and 4). The patient was started on tablet fluconazole 400 mg once a day and has since shown improvement in the form of reduction in symptoms as well as clearance of shadows on repeat chest X-ray after 1 month (figure 5).

Figure 1

Chest X-ray shows bilateral mid-zone hazy opacities.

Figure 2

CT thorax shows consolidation and surrounding ground-glass opacities in the left lower lobe.

Figure 3

Microphotograph of CT-guided fine-needle aspiration cytology showing thick-walled yeast-like fungal structures measuring around 75–100 microns (morphologically mimicking coccidioidomycosis) against the background of mixed inflammatory cells and haemorrhage (MGG stain × 45×).

Figure 4

Microphotograph of CT-guided fine-needle aspiration cytology showing thick-walled yeast-like fungal structures measuring around 75–100 microns (morphologically mimicking coccidioidomycosis) with ruptured endospores (MGG stain × 45×).

Figure 5

Chest X-ray shows clearing of the patches 1 month after starting treatment.

Investigations

CT scan of the thorax showed ‘Centrilobular nodules in all the lobes of both the lungs, patchy consolidation in subpleural location of right upper lobe, right middle lobe and bilateral lower lobes and mediastinal lymphadenopathy’ (figure 2).

BAL culture grew pseudomonas aeruginosa but did not detect mycobacterium tuberculosis in the CBNAAT.

All relevant blood investigations were done and were found to be within normal limits.

CT-guided FNAC of the lesion showed features suggestive of coccidioidomycosis (figures 3 and 4).

Differential diagnosis

Possibility of lung malignancy was considered on presentation in view of fever of 2 months, cough with scanty expectoration of 15 days associated with weight loss. CT did not show any lesions suggestive of malignancy; however, centrilobular nodules were seen and possibility of tuberculosis was considered. BAL CBNAAT for MTb was found to be negative. FNAC of the lung lesion was done and showed features suggestive of coccidioidomycosis. The patient showed improvement in both symptoms and chest X-ray after 1 month of treatment with antifungals, hence supporting the diagnosis of pulmonary coccidioidomycosis.

Treatment

Patient was treated with ciprofloxacin at an outside hospital after which he did not show much improvement. He was started on fluconazole after acquiring the diagnosis of coccidioidomycosis and has shown improvement after a month.

Outcome and follow-up

Patient showed clinical improvement as well as improvement of shadows on repeat chest X-ray after a month following fluconazole therapy (figure 5). He is now able to go to work as well as do his daily activities without much difficulty.