Duration of neurological deficit and outcomes in the surgical treatment of spinal coccidioidomycosis

OBJECTIVE

Vertebral osteomyelitis is a rare complication of coccidioidomycosis infection. Surgical intervention is indicated when there is failure of medical management or presence of neurological deficit, epidural abscess, or spinal instability. The relationship between timing of surgical intervention and recovery of neurological function has not been previously described. The purpose of this study was to investigate if the duration of neurological deficits at presentation affects neurological recovery after surgical intervention.

METHODS

This was a retrospective study of all patients diagnosed with coccidioidomycosis involving the spine at a single tertiary care center between 2012 and 2021. Data collected included patient demographics, clinical presentation, radiographic information, and surgical intervention. The primary outcome was change in neurological examination after surgical intervention, quantified according to the American Spinal Injury Association Impairment Scale. The secondary outcome was the complication rate. Logistic regression was used to test if the duration of neurological deficits was associated with improvement in the neurological examination after surgery.

RESULTS

Twenty-seven patients presented with spinal coccidioidomycosis between 2012 and 2021; 20 of these patients had vertebral involvement on spinal imaging with a median follow-up of 8.7 months (IQR 1.7-71.2 months). Of the 20 patients with vertebral involvement, 12 (60.0%) presented with a neurological deficit with a median duration of 20 days (range 1-61 days). Most patients presenting with neurological deficit (11/12, 91.7%) underwent surgical intervention. Nine (81.2%) of these 11 patients had an improved neurological examination after surgery and the other 2 had stable deficits. Seven patients had improved recovery sufficient to improve by 1 grade according to the AIS. The duration of neurological deficits on presentation was not significantly associated with neurological improvement after surgery (p = 0.49, Fisher's exact test).

CONCLUSIONS

The duration of neurological deficits on presentation should not deter surgeons from operative intervention in cases of spinal coccidioidomycosis.

Endemic mycoses in children in North America: a review of radiologic findings

Clinically significant endemic mycoses (fungal infections) in the United States (U.S.) include Blastomyces dermatitidis, Histoplasma capsulatum, and Coccidioides immitis/posadasii. While the majority of infections go clinically unnoticed, symptomatic disease can occur in immunocompromised or hospitalized patients, and occasionally in immune-competent individuals. Clinical manifestations vary widely and their diagnosis may require fungal culture, making the rapid diagnosis a challenge. Imaging can be helpful in making a clinical diagnosis prior to laboratory confirmation, as well as assist in characterizing disease extent and severity. In this review, we discuss the three major endemic fungal infections that occur in the U.S., including mycology, epidemiology, clinical presentations, and typical imaging features with an emphasis on the pediatric population.

Disseminated Coccidioidomycosis: Cutaneous, Soft Tissue, Osseous, and "Shotgun Intraparenchymal" Brain Disease

Coccidioidomycosis is a disease found in the southwestern United States and caused by inhalation of arthroconidia of Coccidioides immitis and posadasii. Although the disease is most commonly asymptomatic or respiratory, it has a propensity to disseminate to any tissue in the body with the most common being skin, bone, joints, and central nervous system. This case demonstrates the dissemination of coccidioidomycosis to several foci along with a rare form of parenchymal dissemination with an unusual neuroradiological finding.

Application of laser capture microdissection and PCR sequencing in the diagnosis of Coccidioides spp. infection: A case report and literature review in China

Coccidioidomycosis is endemic to California, Arizona, and Mexico. In recent years, the reported cases of coccidioidomycosis have increased in nonendemic regions. Here, we reported a case of imported pulmonary coccidioidomycosis in a Chinese patient. A 63-year-old man presented with dry cough and fatigue for 6 months, and a computed tomography scan revealed a solitary nodule in the right lower lung and small nodules in both lungs. The diagnosis of coccidioidomycosis was initially confirmed by histopathologic examination. The pathogen Coccidioides spp. was identified by laser capture microdissection (LCM) combined with subsequent molecular techniques based on the positive histopathologic features. Additionally, we reviewed 47 reported cases of coccidioidomycosis in China. The number of reported cases is increasing, and the incidence of disseminated infection has exhibited a trend of shifting towards healthy young adults in China. Since clinical presentations and imaging findings lack specificity, a majority of domestic cases of coccidioidomycosis were initially misdiagnosed as tumours or tuberculosis. Moreover, the diagnosis of endemic mycoses may be challenging because of their rarity and the limited availability of diagnostic tests. The diagnosis was mainly confirmed by histopathological examination. The species involved were identified based on positive cultures in only 4 cases. To our knowledge, this is the first study to use LCM and molecular techniques to identify Coccidioides spp. in the histopathologically positive but uncultivable specimen. Comparing with previous reported studies, LCM combined with nucleic acid amplification techniques improve the ability of species identification for the timely diagnosis of coccidioidomycosis.

Suspected Locally Acquired Coccidioidomycosis in Human, Spokane, Washington, USA

The full geographic range of coccidioidomycosis is unknown, although it is most likely expanding with environmental change. We report an apparently autochthonous coccidioidomycosis patient from Spokane, Washington, USA, a location to which Coccidioides spp. are not known to be endemic.

Coccidioidomycosis: Surgical Issues and Implications

BACKGROUND

Coccidioidomycosis, commonly called "valley fever," "San Joaquin fever," "desert fever," or "desert rheumatism," is a multi-system illness caused by infection with Coccidioides fungi (C. immitis or C. posadasii). This organism is endemic to the desert Southwest regions of the United States and Mexico and to parts of South America. The manifestations of infection occur along a spectrum from asymptomatic to mild self-limited fever to severe disseminated disease.

METHODS

Review of the English-language literature.

RESULTS

There are five broad indications for surgical intervention in patients with coccidioidomycosis: Tissue diagnosis in patients at risk for co-existing pathology, perforation, bleeding, impingement on critical organs, and failure to resolve with medical management. As part of a multidisciplinary team, surgeons may be responsible for the care of infected patients, particularly those with severe disease.

CONCLUSION

This review discusses the history, microbiology, epidemiology, pathology, diagnosis, and treatment of coccidioidomycosis, focusing on situations that may be encountered by surgeons.

PULMONARY COCCIDIODOMYCOSIS PRESENTING AS A MASS, AN UNCOMMON DISEASE ENTITY IN ETHIOPIA

Coccidiodomycosis is a disease caused by the spores of the fungi coccidiodes immitis and pulmonary coccidiodomycosis comes after inhalation of the spores which are mainly found in desert areas of the United States, central and South America. Reported cases from outside the endemic areas have always history of travel to these areas. There are no reports so far from Ethiopia or the whole Africa. We report here a case of pulmonary coccidodomycosis with no history of travel to such areas. A 24 years old female patient from Samre, South-Eastern Tigray, presented with right side chest pain and productive cough of yellowish sputum which sometimes is blood streaked. She had completed anti-tuberculosis treatment without any improvement. With a preliminary diagnosis of pulmonary mass, surgical exploration was made and histology of the excised tissue showed appedrances consistent with pulmonary coccidioidomycosis. There was marked clinical and radiological improvement after three weeks of treatment with ketoconazole. Though there are no reported cases from Ethiopia and Africa as a whole, Coccidiodomycosis should be considered as differential diagnosis especially for patients from arid areas like that of our patient before any empirical treatment.

Granuloma annulare arising in association with pulmonary coccidioidomycosis

Granuloma annulare (GA) is a reactive process in the dermis, related to degeneration of collagen. It may occur as an idiopathic phenomenon or in conjunction with a myriad of systemic conditions, including infectious disease. We report an interesting case of GA precipitated by pulmonary coccidioidomycosis.

[Spontaneous pneumothorax due to pulmonary coccidioidomycosis]

Coccidioidomycosis is a systemic infection caused by the soil fungus Coccidioides immitis. It is endemic in northern Mexico and the southwest part of the United States. Radiologic manifestations are varied. Rupture of a coccidioidal pulmonary cavity with subsequent pneumothorax is a rare clinical event, even in endemic areas. We present a case with a brief review of this rare condition.

Coccidioides immitis and Mycobacterium tuberculosis diagnosed by endoscopic ultrasound

The use of endoscopic ultrasound in staging non-small cell lung cancer is well known. Its role in diagnosing non-malignant conditions that cause mediastinal adenopathy is still not well established. We diagnosed Coccidioides immitis and Mycobacterium tuberculosis in two patients using endoscopic ultrasound. To our knowledge this is the first case of Coccidioidomycosis to be diagnosed by endoscopic ultrasound.

Coccidioidomycosis in a 38-year-old man: a case report

The present article describes a case of acute pulmonary coccidioidomycosis in a 38-year-old man, a research worker. The disease started during the patient stay in Arizona, USA, and clinical symptoms persisted after his return to Poland. Acute coccidioidomycosis is one the clinical manifestations of Coccidioides immitis strain endemic infections occurring in the south-western regions of USA including California (mainly San Joaquin Valley), Western Texas, New Mexico and the desert areas of Arizona, and Central and South America. The native environment of Coccidioides immitis is soil penetrated by rodents. People, domestic and wild animals suffer from coccidioidomycosis. The infection rate in endemic areas is about 2-4% a year in the healthy population. Coccidioidomycosis can be observed in non-endemic areas due to population mobility and in immunocompromised patients. The Coccidioides immitis infection is caused by inhaled airborne fungal spores and it may occur as primary pulmonary (acute or chronic) asymptomatic form, meningitis, or disseminated disease. The clinical symptoms of coccidioidomycotis like acute pulmonary manifestations may resemble typical, resistant to empiric antibiotic treatment of bacterial pneumonia. In healthy subjects, pulmonary coccidioidomycosis may occur as asymptomatic infection, which resolves spontaneously without medication. Sometimes, slight shadows like local fibrosis and cavities may be visible on the chest X-ray. The Coccidioides immitis infection in people with immunological deficiency syndromes, e.g. HIV/AIDS, manifests itself as disseminated disease and may lead to severe complications including death.

Imaging of Bacterial Pulmonary Infection in the Immunocompetent Patient

Pulmonary infection is a common reason for imaging of the lung and a common incidental finding in immunocompetent patients. Findings on chest radiography are nonspecific in defining acute infection; however, the radiologist should be aware of classically described patterns of infection, including air space, bronchopneumonia, and interstitial patterns. The radiologist must also be aware of potential limitations of the sensitivity of chest radiography. Imaging findings at computed tomography in acute infection have been poorly studied but may be more specific. Aspiration and septic emboli are additional potential radiographic patterns of infection that may be very characteristic in appearance. In the setting of nonresolving pneumonia, the differential diagnosis includes noninfectious causes as well as a variety of atypical infectious agents, specifically, mycobacterial and fungal agents, which have overlapping but distinctive clinical and radiographic presentations.

Deep solitary brain mass in a four-month-old male with disseminated coccidioidomycosis: case report

Parenchymal brain involvement from disseminated coccidioidomycosis occurs rarely and there are few documented pediatric cases. We report a four-month-old male infant with a cerebellar lesion seen in the brain on computed tomography (CT). Coccidioides immitis (C. immitis) grew on bronchoscopic fluid samples and serum titers to C. immitis were 1:1024. Antifungal treatment was initiated and after 3 months, CT scans demonstrated brain mass resolution and serum titers were decreased.

[A case of pulmonary coccidioidomycosis]

A 32-year-old Japanese woman who had been living in Arizona, United States since two years previously was admitted to our hospital because of an abnormal shadow. Her chest X-ray films revealed a small cavity in the right middle lung field which had not been identified two years ago. The chest CT showed that it was 15 mm in diameter and located in the right S6, and open lung biopsy was performed. Histological examination revealed caseous lesion of the epithelioid granulomas, that contained spherulitic forms of endospores. Fungal cultures demonstrated barrel-shaped arthroconidia. A diagnosis of pulmonary coccidioidomycosis was made.

Thoracic Radiology of Infections Emerging After Natural Disasters

When natural disasters demolish shelter, destroy sources of clean drinking water, and disrupt the availability of medical care, vast numbers of people are placed at increased risk of disease. The infectious diseases that propagate under these conditions are usually common ones. Occasionally, a natural disaster alters the local environment in ways that markedly increase the prevalence of a disease that is endemic to a geographic region, occurring only as isolated cases under normal conditions. Many of these infections may affect the thorax. In this article, we discuss the radiologic findings of 4 infectious diseases, coccidioidomycosis, leptospirosis, melioidosis, and Chagas disease, which may flourish after natural disasters strike areas where they are endemic.

Neuroimaging as a Guide to Predict Outcomes for Patients with Coccidioidal Meningitis

Sixty-two patients with coccidioidal meningitis underwent neuroimaging. Magnetic resonance imaging detected neuroimaging abnormalities in 76% of patients, and computed tomography scanning detected neuroimaging abnormalities in 41.6%. The most common abnormal neuroimaging findings were hydrocephalus (51.6%), basilar meningitis (46.8%), and cerebral infarction (38.7%). Significantly elevated mortality rates were associated with hydrocephalus and hydrocephalus coexisting with infarction. Basilar meningitis did not influence outcome. Patients without neuroimaging abnormalities had a mortality rate of 7.7%.

Increased risk of coccidioidomycosis in patients treated with tumor necrosis factor ? antagonists

OBJECTIVE

To describe a group of patients who were treated with tumor necrosis factor alpha (TNF alpha) antagonists and who developed coccidioidomycosis, and to test the hypothesis that patients with inflammatory arthritis receiving TNF alpha antagonist therapy are at higher risk for developing symptomatic coccidioidomycosis.

METHODS

Cases of coccidioidomycosis were identified and reviewed from among patients receiving TNF alpha antagonist therapy from May 1998 through February 2003 in 5 practices within the areas endemic for coccidioidomycosis (Arizona, California, and Nevada). In addition, the relative risk of developing symptomatic coccidioidomycosis was calculated in patients with inflammatory arthritis who were receiving treatment with infliximab, in comparison with patients with inflammatory arthritis who were not receiving infliximab, from January 2000 to February 2003 in a single medical center.

RESULTS

Thirteen cases of documented coccidioidomycosis were associated with TNF alpha antagonist therapy. Twelve cases were associated with the use of infliximab and 1 case with etanercept. Among the cohort of patients from a single medical center, 7 of the 247 patients receiving infliximab and 4 of the 738 patients receiving other therapies developed symptomatic coccidioidomycosis (relative risk 5.23, 95% confidence interval 1.54-17.71; P < 0.01).

CONCLUSION

Patients with inflammatory arthritis who are undergoing treatment with infliximab appear to be at higher risk for developing symptomatic coccidioidomycosis as compared with those not receiving infliximab.

Clinical, clinicopathologic, and radiographic findings in dogs with coccidioidomycosis: 24 cases (1995-2000)

OBJECTIVE

To determine clinical, clinicopathologic, and radiographic abnormalities in dogs with coccidioidomycosis.

DESIGN

Retrospective case series.

ANIMALS

24 dogs.

PROCEDURE

Clinical information and results of clinicopathologic testing were obtained from medical records. Thoracic radiographs were reviewed to characterize abnormalities.

RESULTS

Dogs ranged from 1 to 10 years old at the time of diagnosis, with 12 dogs being between 1 and 3 years old. Historical complaints included cough, lameness, signs of head or neck pain, and difficulty breathing. Mild anemia, neutrophilia, and monocytosis were common. All dogs had hypoalbuminemia, and 8 of 15 had hyperglobulinemia. Thoracic radiographs of 19 dogs were reviewed. Pulmonary infiltrates were seen in 13 dogs, with an interstitial pattern of infiltration being most common. Hilar lymphadenopathy was seen radiographically in 10 dogs. Serum from 20 dogs was tested for antibodies against Coccidioides immitis. One dog was positive for IgM antibodies, 5 were positive for IgM and IgG antibodies, and 14 were positive for IgG antibodies. Quantitative IgG titers measured in 14 dogs ranged from 1:2 to 1:128 (median and mode, 1:32). In 6 dogs, histologic examination of biopsy samples revealed fungal spherules ranging from 8 to 70 microm in diameter.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that in dogs, coccidioidomycosis may be associated with a wide spectrum of nonspecific respiratory and musculoskeletal abnormalities. The chronic nature of the disease makes diagnosis difficult, even in regions in which the organism is endemic.

Coccidioidomycosis presenting as liver abscess

A 26-year-old man presented with pain in the right upper abdomen. Ultrasonography revealed a large solitary right lobe liver abscess, which was treated by aspiration and antiamebic treatment. The patient continued to be symptomatic with the abscess increasing in size. Repeat aspiration revealed a pure growth of coccidioidomycosis, which was confirmed on culture. He was treated with amphotericin-B; the abscess resolved completely and the patient has remained asymptomatic at one-year follow up.

Coccidioidomycosis meningitis with massive dural and cerebral venous thrombosis and tissue arthroconidia

To our knowledge we report the first case of meningitis from Coccidioides immitis associated with massive dural and cerebral venous thrombosis and with mycelial forms of the organism in brain tissue. The patient was a 43-year-old man with late-stage acquired immunodeficiency syndrome (AIDS) whose premortem and postmortem cultures confirmed C immitis as the only central nervous system pathogenic organism. Death was attributable to multiple hemorrhagic venous infarctions with cerebral edema and herniation. Although phlebitis has been noted parenthetically to occur in C immitis meningitis in the past, it has been overshadowed by the arteritic complications of the disease. This patient's severe C immitis ventriculitis with adjacent venulitis appeared to be the cause of the widespread venous thrombosis. AIDS-related coagulation defects may have contributed to his thrombotic tendency.

Disseminated coccidioidomycosis. The role of cytology in multidisciplinary clinical approach and diagnosis

A case of clinically unsuspected disseminated coccidioidomycosis diagnosed by different cytologic approaches and confirmed by mycological culture is reported. An African-American man presented with a clinical picture of pneumonia not responding to antibiotics. He subsequently developed a large neck mass and was found to have mediastinal and hilar adenopathy highly suspicious of a neoplastic process. Fine needle aspiration biopsy of the neck mass, followed by flexible bronchoscopy, was performed. Various cytologic approaches and techniques in rapid diagnosis of suspicious masses are discussed.

A fluffy white traveller: imported Coccidiodes immitis infection in an Australian tourist

Pulmonary coccidioidomycosis is a rare cause of pulmonary nodules and respiratory infection in travellers to endemic areas. An Australian tourist suffered an acute respiratory illness while on holiday in Mexico. She subsequently developed erythema nodosum and was noted to have a left pulmonary nodule on chest X-ray after return to Australia. The diagnosis of Coccidioides immitis infection was established by histology and culture of the resected lung lesion. The patient made an uneventful recovery and received one month of therapy with ketoconazole. Culture of the fungus took place under controlled Class 3 conditions. An unusual fungal infection in Australia, coccidioidomycosis poses special risks to staff of microbiology laboratories.

Chronic pulmonary coccidioidomycosis: computed tomographic and pathologic findings in 18 patients

OBJECTIVE

To review the computed tomographic (CT) findings in pathologically proven chronic pulmonary coccidioidomycosis.

PATIENTS AND METHOD

The study included 19 pulmonary lesions caused by mycologically and pathologically proven chronic coccidioidomycosis in 18 immunocompetent patients (aged 22 to 75 years, mean 57 years) who had a chest CT scan. Thirteen patients were Canadians who had travelled to an endemic area, and 5 were inhabitants of an endemic area in southern California and Arizona. The CT findings were assessed to determine the type, size, margin, internal architecture and location of parenchymal abnormalities.

RESULTS

The CT findings included solitary nodules of 1.0 to 2.0 cm (mean 1.7 cm) in diameter in 17 patients, a focal area of ground-glass attenuation in 1 patient, and focal consolidation in 1 patient. Ten of the nodules had homogeneous attenuation on CT, 2 had central areas of low attenuation, 2 showed cavitation, 2 had foci of calcifications and 1 had bubble lucency. The nodules were located peripherally (in 14 patients) and centrally (in 3 patients). The predominant histologic finding in these nodules was a necrotizing granuloma. Three nodules were surrounded by halos of ground-glass attenuation, which were shown on histologic examination to represent granulomatous inflammation (in 2 cases) and pulmonary hemorrhage due to a pulmonary artery-bronchial fistula (in 1 case). Two nodules had adjacent consolidation, which was due to granulomatous inflammation surrounding a necrotizing granuloma.

CONCLUSION

Necrotizing granulomas in chronic coccidioidomycosis appear as a well-defined nodule on CT, while granulomatous inflammation may appear as areas of ground-glass attenuation or consolidation.

Pulmonary coccidioidomycosis in Kentucky

Coccidioidomycosis is a highly infectious disease caused by the dimorphic fungus, Coccidioides immitis that is endemic to the arid and semiarid regions of the southwestern United States, Mexico, Central America, and South America. The majority of infections from C immitis are asymptomatic; however, approximately 40% of infected individuals present with symptoms ranging from a mild flu-like respiratory infection to acute pneumonia that may lead to chronic progressive pulmonary infection or occasionally disseminated disease. Due to the mobility of the population, increasing numbers of cases are being recognized outside endemic areas. We report five patients with coccidioidomycosis diagnosed at the University of Kentucky Medical Center during the period from 1984 to 1993 in order to illustrate the clinical and radiographic spectrum of findings that may be encountered with the disease. In a patient with unexplained pulmonary symptoms, a history of recent travel to or immigration from an endemic area may be an early clue to the diagnosis of coccidioidomycosis.

Skeletal coccidioidomycosis: imaging findings in 19 patients

OBJECTIVE

The objective of this study was to describe the distribution and radiologic appearance of skeletal coccidioidomycosis in 19 documented cases.

DESIGN AND PATIENTS

Medical records of 19 patients (17 men, 2 women; age range 17-62 years, mean age 34 years) with clinically confirmed skeletal coccidioidomycosis were retrospectively reviewed. The patients were studied with plain radiography (n = 19), skeletal scintigraphy (n = 6), computed tomography (CT) (n = 5), and magnetic resonance imaging (MRI) (n = 1).

RESULTS

Multiple lesions were seen in 11 of 19 patients (58%). Of a total of 46 lesions, 27 (59%) were described as punched-out lytic, 10 (22%) as permeative/destructive, and 9 (17%) as involving a joint and/or disk space. Lesions were identified in almost every bone (with the exception of the facial bones, ulna, carpus, and fibula) and were most commonly found in the axial skeleton (20 of 46; 43%).

CONCLUSION

Skeletal coccidioidomycosis is frequently multicentric and may involve almost any bone. The axial skeleton is the most common site of involvement. Lesions are usually well demarcated but may present with an ill-defined border and permeative type of bone destruction, especially in the spine. Joint involvement is not uncommon. Plain radiographs are effective in the initial evaluation of bones and joints, scintigraphic studies can identify disseminated disease, and CT and MRI are effective in determining soft tissue involvement and spinal abnormalities.

Orbital coccidioidomyosis presenting as a lacrimal gland fossa mass

Images

Thoracic mycoses from endemic fungi: radiologic-pathologic correlation

The endemic fungi Histoplasma capsulatum, Blastomyces dermatitidis, and Coccidioides immitis are primary human pathogens whose major portal of entry is the respiratory tract. Their clinical manifestations are categorized as acute, chronic or chronic progressive, or disseminated fungal disease. Most acute pulmonary infections are self-limited, and many are asymptomatic. Chronic, progressive, or disseminated disease is much less common and most often occurs in immunocompromised patients. The radiologic manifestations of these disorders are protean. They include interstitial or air-space opacities, solitary or multiple pulmonary nodules, parenchymal masses, cavities, and hilar or mediastinal adenopathy. The diagnosis of a thoracic mycosis requires familiarity with the epidemiology of the fungus in question, the various modes of clinical presentation, and the full spectrum of radiologic manifestations. Although skin and serologic tests can be useful, definitive diagnosis requires culture of the fungus from infected tissue or demonstration of the organism at microscopic examination.

Diabetic ketoacidosis associated with pulmonary coccidioidomycosis

We describe three patients who developed diabetic ketoacidosis in association with pulmonary coccidioidomycosis and review the literature concerning the influence of diabetes on coccidioidomycosis. Our cases demonstrate that coccidioidomycosis is an infection that can be associated with diabetic ketoacidosis and that should be considered in the differential diagnosis of pneumonia in patients who live in a region in which Coccidioides immitis is endemic.

Primary diagnosis of disseminated coccidioidomycosis by fine needle aspiration of a neck mass. A case report

Coccidioidomycosis is a pulmonary fungal infection endemic to the southwestern United States and northern Mexico. Disseminated coccidioidomycosis occurs in 0.1-0.5% of cases and is a life-threatening condition. We report a case of disseminated coccidioidomycosis in an immunocompetent black male with cutaneous lesions, a flocculent neck mass, bilateral hilar adenopathy, persistent fever, night sweats and malaise. The clinical suspicion was lymphoma with cutaneous involvement. Fine needle aspiration (FNA) of the neck mass provided the primary diagnosis of coccidioidomycosis. It was confirmed by culture of FNA-obtained fluid and a subsequent biopsy of a cutaneous lesion. As shown in this case, FNA of soft tissue masses may provide rapid identification of the responsible organism and allow early initiation of therapy for this potentially life-threatening infection.

An unusual case of coccidioidomycosis

Dissemination of coccidioidomycosis is rare. The skin, musculoskeletal system, and central nervous system have been described as the most common sites of extrapulmonary disease. We present a case of an asymptomatic patient in whom the diagnosis of coccidioidomycosis was made on a lymph node biopsy. The biopsy was performed because of an abnormal mammogram and physical findings suggestive of malignancy.

Pulmonary coccidioidomycosis

Coccidioidomycosis is a fungal disease endemic in the southwestern desert area of the United States. The infection is acquired by inhalation of arthrospores, and 60% of the infections are asymptomatic. Chest radiographic abnormalities are common and may even be seen in asymptomatic cases. In patients with acute infection, segmental or lobar consolidation and nodular or patchy pulmonary opacities are frequent. Hilar and mediastinal adenopathy may be present in 20% of cases, usually with parenchymal findings. A small pleural effusion may occur in 20% of cases. Approximately 5% of patients with primary disease are left with chronic, residual lesions of the lung. These consist of nodules, cavities, pneumonia, adenopathy, pleural effusion, fibrosis, bronchiectasis, and calcification. Rarely, in about 0.5% of cases, the infection may disseminate to any organ. The chest radiograph demonstrates a miliary or reticulonodular pattern and mediastinal adenopathy. Overall the disease is benign in nature; but patients with severe, progressive pulmonary or disseminated disease often require medical and occasionally surgical management.

Pulmonary coccidioidal pseudomycetoma

Coccidiomycosis is rarely associated with a pulmonary mycetoma. We report a patient with progressive cavitary coccidiomycosis, whose initial radiographic and clinical appearance simulated a mycetoma. Examination of the surgically resected lung showed necrotizing Coccidioides immitis granulomas with spherules and arthroconidialike structures, but no evidence of a mycetoma. We propose the term pulmonary coccidioidal pseudomycetoma as the best descriptor for this patient's clinical, radiographic, pathologic, and microbiologic presentation.

Cases from the aerospace medicine residents' teaching file. Case #47. Primary pulmonary coccidioidomycosis

This case report on primary pulmonary coccidioidomycosis outlines a typical presentation in an individual at high risk and the pitfalls that can occur to practitioners unfamiliar with this disease. The patient was a 36-year-old black male who presented with an initial abnormal chest X-ray and who eventually was correctly diagnosed and improved on a 30-day course of ketoconazole. This patient showed no signs of dissemination.

[A case of pulmonary coccidioidomycosis]

A 55-year-old Japanese woman was admitted to our hospital, complaining of flu-like symptoms and left-sided chest pain. Her chest X-ray films revealed a solitary coin lesion in the left middle lung field. She had traveled to California and Arizona 3 months before being taken ill. Because of negative result in sputum cytology and trans-bronchial lung biopsy examination, open lung biopsy and wedge resection was performed. Histological examination revealed endosporulating spherules in a caseous lesion of the epithelioid granulomas, and fungal cultures demonstrated barrel-shaped arthropores. Pulmonary coccidioidomycosis was diagnosed. Coccidioidomycosis is a rare fungal disease found in certain endemic areas in the southwestern region of the United States. She had been infected during her travels in America, and this is the second case in Japan who had taken surgical intervention for pulmonary coccidioidomycosis.

[Interpretation of clinical and serologic findings--1 1/2 years after a long-term coccidioidomycosis]

A 46-year-old soldier of the German airforce stayed in Texas/USA for 6 months. Without clinical complaints the patient revealed nodular lung infiltration and a cavern on a routine-chest-X-ray examination after his return. Serological, cytological, and histological examinations excluded a sarcoidosis, tuberculosis of the lungs and a neoplasm. The finding of precipitating antibodies and a positive skin reaction against coccidioidin led to the diagnosis of a primary pulmonary, spontaneously healed coccidioidomycosis, which did not need any antimycotic therapy.

Solitary pulmonary nodule: high-resolution CT and radiologic-pathologic correlation

Edge and internal characteristics of pulmonary nodules evaluated with high-resolution computed tomography (HRCT) were correlated with the pathologic specimens in 93 patients. Speculation correlated pathologically with irregular fibrosis, localized lymphatic spread of tumor, or an infiltrative tumor growth pattern and was observed in six of 11 benign nodules (55%) and 74 of 85 malignant nodules (87%). Pleural tags were observed in three benign nodules (27%) and 49 malignant lesions (58%); pathologically, these represented fibrotic bands usually associated with juxta-cicatricial pleural retraction. Bubblelike areas of low attenuation within the nodule were observed in 21 malignant lesions (25%) and only one benign nodule (9%). They were observed most commonly in bronchioloalveolar carcinomas (seven of 14) and were due either to patent small bronchi or small, cystic spaces within neoplastic glands. Malignant nodules as a group were larger than benign lesions (P = .02) and more commonly demonstrated a spiculated contour (P less than .05), lobulation (P less than .001), and inhomogeneous attenuation (P less than .05).

Laryngeal involvement in disseminated coccidioidomycosis

Coccidioidomycosis is a pulmonary fungal infection endemic to the desert southwest of the United States and northern Mexico. Rarely (0.5% of cases), the fungus disseminates widely, causing life-threatening complications. Seven percent of these cases will involve the head and neck. We report a case of disseminated coccidioidomycosis that involved the larynx and cervical lymph nodes in a 40-year-old white woman who presented with hoarseness and unsuspected airway compromise. Review of the 12 reported cases of laryngeal coccidioidomycosis showed a predominance of male and dark-skinned patients; seven were children, and nine presented with airway compromise. Other reported sites of head and neck involvement include the skin, mucosa, bones of the skull, and meninges, and there have been reports of abscesses of the soft tissues and fascial spaces of the neck.

Fluconazole in the treatment of persistent coccidioidomycosis

Fluconazole is one of the new antifungal triazoles undergoing clinical trials. We used fluconazole at a dose of 50 or 100 mg/day in an open trial for the treatment of patients with persistent coccidioidomycosis. Fourteen patients were enrolled and treated for a mean of 13 +/- 7 months. Two failed to respond. Of the 12 who responded, one reactivated while being treated, and one died of myocardial infarction after successful treatment of his fungal infection; six had relapses from nine days to 15 months after treatment was stopped. Only four patients are asymptomatic at a mean of 14 +/- 3 months after cessation of treatment. Fluconazole is well tolerated at this dose. In view of its low toxicity, the partial clinical efficacy observed, and the high recurrence rate of chronic coccidioidal infection, it would be justified to try higher doses.

Solitary pulmonary granuloma with marked enhancement on dynamic CT scanning

A patient is described who presented with a vividly enhancing solitary pulmonary nodule during dynamic CT scanning. This mass proved to represent a granuloma due to coccidioidomycosis. The presumptive mechanism of enhancement as well as the differential diagnosis are discussed.