Beyond the Valley: The Challenge of Chronic Coccidioidomycosis in a Mobile World.

SESSION TYPE: Infectious Disease Case Report Posters IIPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PMINTRODUCTION: Coccidioides immitis is a dimorphic fungus endemic to the San Joaquin Valley and Southwestern United States. Lung infections typically occur after inhalation of arthroconidia. Patients are usually asymptomatic but may present with upper respiratory infection or pneumonia. If symptoms persist greater than 6 weeks or are severe, 3-6 months of anti-fungal therapy is recommended. Patients may develop chronic cavitary coccidioidomycosis if symptoms persist greater than 3 months. Although uncommon, it can be a diagnostically and therapeutically challenging dilemma.CASE PRESENTATION: A 36 year old previously healthy male, originally a resident of Arizona, presented in 2006 with several weeks of cough, hemoptysis, and chest discomfort. Chest computed tomography revealed a 2 by 3 centimeter left upper lobe cavitary lesion abutting the pleura. Broncho-alveolar lavage (BAL) was non-diagnostic, and serology for HIV, vasculitis, and connective tissue diseases were negative. Coccidioidomycosis was diagnosed by positive serum antibody titers. He received 6 months of oral fluconazole with resolution of symptoms. He moved across country, and was evaluated approximately 18 months later for recurrent hemoptysis. Over the next 2 years, he was evaluated at 3 different facilities across the United States and treated with 3-6 month courses of fluconazole and itraconazole with initial improvement, but with return of symptoms after cessation of therapy. On presentation to our facility on the East Coast, 6 years following his initial presentation, BAL was negative, but serum titers for coccidioidomycosis were positive at 1:64. He underwent a left upper lobe segmentectomy with pathologic specimens consistent with coccidioides. His symptoms resolved, and he currently remains on fluconazole.DISCUSSION: Chronic cavitary coccidioidomycosis can be debilitating and life threatening. Our patient's frequent transfers made his medical care challenging. Clinicians should be aware that chronic cavitary coccidioides can develop in immunocompetent patients who have demonstrated an initial response, but may relapse after cessation of therapy.CONCLUSIONS: Currently no guidelines exist regarding the duration of serologic and radiographic follow-up after completion of definitive therapy. Clinicians should be aware, and patients should be counseled, that continued follow-up with serology and radiography may be necessary to avoid protracted disease and recurrence.1) Limper AH, Knox KS, Sarosi GA: An Official American Thoracic Society Statement: Treatment of Fungal Infections in Adult Pulmonary and Critical Care Patients, American Journal of Respiratory and Critical Care Medicine, 2011; 183: 96-1282) Thompson GR: Pulmonary Coccidioidomycosis, Seminars in Respiratory and Critical Care Medicine, 2011; 32:6: 754-7623) Parish JM, Blair JE: Coccidioidomycosis, Mayo Clinic Proceedings, 2008; 83:3: 343-349DISCLOSURE: The following authors have nothing to disclose: Christopher Nelson, Janet MyersNo Product/Research Disclosure InformationWalter Reed National Military Medical Center, Bethesda, MD.