Skip to main content

Main menu

  • Home
  • Our journals
    • Clinical Medicine
    • Future Healthcare Journal
  • Subject collections
  • About the RCP
  • Contact us

Clinical Medicine Journal

  • ClinMed Home
  • Content
    • Current
    • Ahead of print
    • Archive
  • Author guidance
    • Instructions for authors
    • Submit online
  • About ClinMed
    • Scope
    • Editorial board
    • Policies
    • Information for reviewers
    • Advertising

User menu

  • Log in

Search

  • Advanced search
RCP Journals
Home
  • Log in
  • Home
  • Our journals
    • Clinical Medicine
    • Future Healthcare Journal
  • Subject collections
  • About the RCP
  • Contact us
Advanced

Clinical Medicine Journal

clinmedicine Logo
  • ClinMed Home
  • Content
    • Current
    • Ahead of print
    • Archive
  • Author guidance
    • Instructions for authors
    • Submit online
  • About ClinMed
    • Scope
    • Editorial board
    • Policies
    • Information for reviewers
    • Advertising

Images of the month: The conundrum of chronic coccidioidomycosis

Oluwabusola M Bolaji, Nurul I Zainudin, Susan Snape, Gauri Saini and Vadsala Baskaran
Download PDF
DOI: https://doi.org/10.7861/clinmed.2020-0815
Clin Med January 2021
Oluwabusola M Bolaji
ANottingham University Hospital NHS Trust, Nottingham, UK
Roles: foundation year doctor
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: busolabolaji@hotmail.co.uk
Nurul I Zainudin
ANottingham University Hospital NHS Trust, Nottingham, UK
Roles: foundation year doctor
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Susan Snape
BNottingham University Hospital NHS Trust, Nottingham, UK
Roles: consultant in microbiology
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Gauri Saini
CNottingham University Hospital NHS Trust, Nottingham, UK
Roles: consultant in respiratory medicine
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Vadsala Baskaran
DNottingham University Hospital NHS Trust, Nottingham, UK
Roles: clinical research fellow in respiratory medicine
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info & Metrics
Loading
KEYWORDS:
  • respiratory infection
  • histology
  • imaging

Case presentation

A 68-year old woman was admitted to a tertiary hospital for an elective removal of a right spheno-orbital tumour. She had a 2-month history of increasing unsteadiness, recurrent falls, right-sided headache, diplopia and increasing confusion. It is noteworthy that she had been on high-dose steroids pre-operatively to reduce the significant tumour-associated oedema, predisposing her to an immunocompromised state. There were no intraoperative complications; histology showed grade II atypical meningioma with extensive soft tissue invasion. Postoperatively, the patient desaturated and became tachypnoeic. Computed tomography (CT) pulmonary angiography revealed large bilateral, peripheral cavitating lung lesions and confirmed the presence of a subsegmental pulmonary embolism in the right upper lobe upstream to one of the lesions (Fig 1). The patient underwent bronchoscopy to investigate for possible underlying infective versus malignant pathology. Bronchoalveolar lavage showed evidence of pneumocystis pneumonia (PCP; deoxyribonucleic acid (DNA) positive) and she was treated with a 2-week course of co-trimoxazole. Despite treatment, symptoms of general malaise, dry cough and intermittent confusion ensued with raised inflammatory markers. Due to ongoing concerns of differential diagnoses of vasculitis and malignancy, the patient had a CT-guided lung biopsy. Histology and extended culture of the lung biopsy showed features of fungal involvement with associated tissue necrosis and histolytic reaction. Haematoxylin and eosin stain showed multiple large thick-walled spherules consistent with Coccidioides immites (Fig 2). Pan-fungal polymerase chain reaction performed on the tissues rapidly detected Coccidioides DNA. Serology tests further confirmed the diagnosis; both Coccidioides mycelial antigen using complement fixation test and Coccidioides immunodiffusion were positive. In light of these findings, upon direct questioning, the patient reported travelling to Phoenix, Arizona, in the USA annually for over 15 years. The patient was diagnosed with chronic coccidioidomycosis, and started on a 1-week course of AmBisome (amphotericin B) before switching to oral fluconazole which will be continued for a year and possibly life-long.

Fig 1.
  • Download figure
  • Open in new tab
  • Download powerpoint
Fig 1.

Computed tomography pulmonary angiography showing large bilateral, peripheral cavitating lung lesions with bilateral lower lobe atelectasis, worse on the left. a) Lung window showing coronal planes. b) Mediastinal window showing coronal planes. c) and d) Axial planes.

Fig 2.
  • Download figure
  • Open in new tab
  • Download powerpoint
Fig 2.

Haematoxylin and eosin stain, from computed tomography-guided lung biopsy, showing multiple large thick-walled spherules consistent with Coccidioides immites.

Discussion

Coccidioidomycosis, also known as valley fever, is a systemic fungal infection caused by C immites or C posadasii. These fungal species are endemic in southwestern USA (particularly Arizona and California), Mexico, Central America and South America. Most infected people are asymptomatic, however, symptomatic individuals present with pulmonary sequelae (self-limiting influenza-like illness or community-acquired pneumonia) as the most common initial syndrome.1 As the prevalence of coccidioidomycosis in the UK is entirely due to imported cases or laboratory acquisition, suspicion of coccidioidomycosis in our patient was only noted after the provisional histology report showing pathognomonic features of this fungal infection and targeted travel history confirmed the exposure. The indication of whether to treat in complex chronic cases, such as this, is rarely clear. Immunosuppressive medications including corticosteroids have been associated with increased risks of complications from coccidioidal illness.2 Therefore, despite having relatively few symptoms, the patient's history of high-dose steroid use, combined with PCP co-infection meant the benefits of therapy outweighed the risks. Although there is a relatively small incidence of the disease in the UK, it is inevitable we will continue to see coccidioidomycosis cases due to the globalisation of travel in the modern world.

  • © Royal College of Physicians 2021. All rights reserved.

References

  1. ↵
    California Department of Public Health Infectious Diseases Branch. Coccidioidomycosis (valley fever). CDPH, 2018. www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/IDBGuidanceforCALHJs-Cocci.pdf
  2. ↵
    1. Galgiani JN
    , Ampel NM, Blair JE, et al. 2016 Infectious Diseases Society of America (IDSA) clinical practice guideline for the treatment of coccidioidomycosis. Clin Infect Dis 2016;63:e112–46.
    OpenUrlCrossRefPubMed
Back to top
Previous articleNext article

Article Tools

Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Citation Tools
Images of the month: The conundrum of chronic coccidioidomycosis
Oluwabusola M Bolaji, Nurul I Zainudin, Susan Snape, Gauri Saini, Vadsala Baskaran
Clinical Medicine Jan 2021, 21 (1) e110-e111; DOI: 10.7861/clinmed.2020-0815

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Images of the month: The conundrum of chronic coccidioidomycosis
Oluwabusola M Bolaji, Nurul I Zainudin, Susan Snape, Gauri Saini, Vadsala Baskaran
Clinical Medicine Jan 2021, 21 (1) e110-e111; DOI: 10.7861/clinmed.2020-0815
del.icio.us logo Digg logo Reddit logo Twitter logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Case presentation
    • Discussion
    • References
  • Figures & Data
  • Info & Metrics

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • Images of the month 1: Ischaemic stroke due to pulmonary arteriovenous fistula
  • Images of the month 1: Histoacryl glue embolisation to the right ventricle following treatment for gastric varices
  • Images of the month 2: Disseminated nocardiosis in a 60-year-old woman with sarcoidosis
Show more Image of the month

Similar Articles

FAQs

  • Difficulty logging in.

There is currently no login required to access the journals. Please go to the home page and simply click on the edition that you wish to read. If you are still unable to access the content you require, please let us know through the 'Contact us' page.

  • Can't find the CME questionnaire.

The read-only self-assessment questionnaire (SAQ) can be found after the CME section in each edition of Clinical Medicine. RCP members and fellows (using their login details for the main RCP website) are able to access the full SAQ with answers and are awarded 2 CPD points upon successful (8/10) completion from:  https://cme.rcplondon.ac.uk

Navigate this Journal

  • Journal Home
  • Current Issue
  • Ahead of Print
  • Archive

Related Links

  • ClinMed - Home
  • FHJ - Home
clinmedicine Footer Logo
  • Home
  • Journals
  • Contact us
  • Advertise
HighWire Press, Inc.

Follow Us:

  • Follow HighWire Origins on Twitter
  • Visit HighWire Origins on Facebook

Copyright © 2021 by the Royal College of Physicians