A 21 y.o. avid outdoorsman complains of R pleuritic chest pain

his cxr is shown below

He was treated for RML pneumonia with levofloxacin and symptoms resolve but return in 3 weeks with the xray below.

 What is wrong with this patient?

What is wrong with this patient?

Our patient had coccidiomycosis in a pulmonary form which led to “phantom” infiltrates. These repeated pneumonias are a classic pulmonary presentation for the fungal infection.

Coccicdiomycosis is a fungal disease native to the Americas. It is caused by two fungi: C. immitis and C. posadasii which are endemic to the southwestern US, northern Mexico and central and South America.

 

It was first described in 1892 in a soldier in Argentina.  The illness in the US was found with increasing prevalence when immigrants moved to California after the dustbowl in the 1930’s.  The first effective therapy was not found until 1957 when IV amphotericin was used.

 

Initial infection can occur from inhaling a single spore of the fungus which then rapidly multiplies in the lung over 48-72 hours.  60% of people are asymptomatic with this infection because the fungus is destroyedby macrophages.  It can , however, cause a flu-like illness or pulmonary disease including infiltrates as in our patient, nodules or even cavitary lesions which can rupture into the pleural space causing pneumothoraces or effusions.  Only 1% of healthy individuals go on to develop disseminated coccidiomycosis(although this number is higher in the immunocompromised) .  Disseminated disease can result inosteomyelitis, arthritis, meningitis or transplacental infection in a pregnant woman. Disseminated disease can also present with skin infections including abscesses, granulomas , ulcers or rashes often of the nasolabial folds.  Disseminated infection may require years of antifungal treatment at a cost of $5,000-12,000 per person per year.

Coccidiomycosis is found with increasing frequency in Arizona where 80% of the population who have lived there for five years is positive for coccidiomycosis.

 

 Our patient had been hiking in Arizona and presumably this is where he acquired the disease.  He was treated successfully with antifungals and had no recurrence of the disease.

Amstead GM, Graybell JR. Coccidiomycosis Infect Dis Clinic N AM 2006 20: 621-43.

Gaidici A, Saubolle MA. Transmission of coccidiomycosis to a human via a cat bite. Microbiol Feb47(2):505-6.

CDC From the Centers for Disease Control and Prevention. Coccidiomycosis following the Northridge California Earthquake.  JAMA 1997 March 19 277(11) 904-8.

Increase in reported coccidiomycosis in the United States 1998-2011.  MMWR. Morb Mortal Wkly Rep 2013 March 29 62(12): 217-21.