Disseminated Coccidioidomycosis

Disseminated Coccidioidomycosis To the Editor: Coccidioidomy-cosis, an infection caused by the dimorphic fungus Coccidioides immi-tis, is endemic in the southwestern United States, parts of Mexico, and Central and South America (1). Patients with C. immitis infection may have chronic pneumonia, fungemia, and extrapulmonary dissemination to skin, bones, meninges, and other body sites. The clinical features of coccid-ioidomycosis may mimic those of melioidosis, penicilliosis marneffei, and tuberculosis, which are commonly seen in some southeastern Asian countries, including Taiwan. A previously healthy, 71-year-old retired gynecologist from Taiwan, visited Los Angeles in August 2003 and traveled to the San Joaquin Valley in November 2003. He had smoked 1 package of cigarettes daily for 50 years. He noted fever 5 days before returning to Taiwan on December 1, 2003. He came to a local hospital on December 4 with a temperature of 39°C and a history of 1 month of night sweats, productive cough, and weight loss of 10 kg. Chest radiograph showed diffuse nodular lung lesions bilaterally (Figure, panel A). His leukocyte count was 16.65 x 10 9 /L (neutrophils 85.6%, lymphocytes 6.2%), and C-reactive protein was 21.5 mg/dL (reference value, <0.8 mg/dL). Empiric antimicrobial drugs (amoxicillin/clavulanic acid and ciprofloxacin) and antituberculosis therapy (isoniazid, rifampin, ethamb-utol, and pyrazinamide) were administered. Blood and sputum specimens were negative for bacteria; HIV anti-body test results were negative, but the fever persisted. A follow-up chest film showed a left pleural effusion. The pleural effusion aspirate was exudative with 3.6 x 10 9 /L leukocytes (73% neutrophils). Computed tomo-graphic scan of the patient's chest showed collapse of the left lower lung with central necrosis, bilateral pleural effusions, and mediastinal lym-phadenopathy. Pleural biopsy by video-assisted thoracoscopic surgery showed no evidence of malignancy, but heavy lymphoplasmacytic infiltration and chronic necrotizing granulo-matous inflammation were found (Figure, panel C). On December 17, 2003, 30 mg/day prednisolone orally was prescribed for intermittent fever. Biopsy material and cultures of blood samples taken at admission grew an Figure. A) Chest radiograph shows diffuse nodular lesions in both lungs. B) Chest radi-ographic scan taken 2 months later shows coalescence of nodular shadows and almost complete white-out of bilateral lung fields. C) Hematoxylin and eosin staining of the wound specimen from pleural biopsy site showed spherules of Coccidioides immitis and chronic necrotizing granulomatous inflammation (400x).