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Clinical Meetings at RH Year 2004

2004 - A Special Souvenir

Drs WL Wong, Henry Kwok, CW Lam; Department of Respiratory Medicine, Ruttonjee Hospital

Case history
Mr Leung, a 50 years old ex-smoker with good past health, was admitted to Ruttonjee and Tang Shiu Kin Hospital on 23rdNov 2003 for 2 weeks history of cough, fever of 38°C and weight loss of 6 Ibs. Cough was non-productive. He had no chest pain, shortness of breath and haemoptysis. Physical examination was unremarkable except a right supraclavicular LN enlargement. He travelled frequently to China for business. Detailed travel history also revealed that the patient went to southwestern USA in late Oct 2003, visiting LA, San Francisco, Las Vegas, Grand Canyon area. He was a hawker selling jade and jewellery.

Chest radiograph (CXR) after admission showed left hilar shadow with left B6 consolidation (Fig 1). He was given 2 courses of antibiotic, namely Augmentin and Klacid, with no improvements. Complete blood picture: Hb 14.6, WCC 7.7 (PMN 4.7, Lym 1.3, Eos 1.08), PIt 174. Liver and renal function test: Na 145, K 4.0, Urea 5.1, Cr 101, Alb 44, Glob 35, Bil6 ALP 78, ALT 22, sugar(spot) 6.1. Blood for HIV serology was negative. Patient was started on anti TB drug on 2ndDec 2003. However, he did not respond to the anti-tuberculosis (TB) treatment and fever was persistent.



Computed tomograph (CT) scan of thorax was then performed on 10thDec 2003 which showed atelectasis of medial portion of left lower lobe with air bronchogram. Lung nodules in left and right lower lobes and multiple enlarged lymph nodes in mediastinum were also noted. No pleural effusion and no other masses were found (Fig 2). Bronchoscopy was performed on 11thDec 2003 which showed left main bronchus mucosal infiltration with mild narrowing, also mucosal swelling at left lower lobe. Bronchoalveolar lavage was negative for malignancy and acid-fast bacilli. TB drugs were stopped on loth Dec 2003 as CT and bronchoscopy findings were not suggestive of TB. Eventually, right supraclavicular lymph node biopsy revealed spherules in the specimen which was pathonomonic for coccidioidomycosis (Fig 3).





Patient's condition improved after bronchoscopy despite no specific therapy was initiated. He was discharged on 23rd Dec 2003. Serial CXR in outpatient clinic showed resolving left hilar shadow. In Mar 2004, patient presented with right groin and left cervical lymph node enlargement. Biopsy and culture confirmed disseminated disease. Fluconazole was started in view of disseminated disease.
Patient was admitted again in April 2004 for drainage of left neck lymph node abscess. Fluconazole was continued after incision and drainage of the abscess. His subsequent clinical course had been stable, and it was planned that the antifungal therapy be continued for at least 6 months with regular clinical and radiological assessment for progress.

Discussion
Coccidioidomycosis is a systemic infection through inhalation of airborne spores from Coccidioides immitis. It is found in soil in southwestern USA- Arizona, Texas, California, Mexico, Central and South America. Infection occurs following activities or natural events that disrupt the soil- earthquakes, sandstorms, landslides. At risk occupation and activities include military personnel, archeological worker, and participation in activities surrounded by dusty environment. Sporadic cases exported to other parts of USA and other countries included New York, Hungary, Sweden, Korea, Japan and Hong Kong. Length of exposure ranges from days to years. Our patient stayed in southwestern USA for only 10 days. Coccidioidomycosis was classified by CDC as an emerging infectious disease. I Incidence in Arizona rise from 7.0 per 100000 population in 19902 to 43 per 100000 population in 2001. 3 It is the only fungal agent requiring level 3 bio-safety in laboratories and some regards it as a potential biological weapon.

The infectious particle is the arthroconidium. Infection is established via inhalational route. Typical symptoms included lower respiratory tract infection accompanied with systemic symptoms like fever, sweating, anorexia, weakness, arthralgia, cough, sputum and chest pain. Erythema nodosum and multiforme are possible manifestations. Acute respiratory infection usually subsides without specific therapy, 5% has residua in lungs.

Independent risk factors for severe pulmonary disease include diabetes mellitus, recent history of cigarette smoking, income
Coccidioidomycosis can present as septic shock. A retrospective review involving 8 patients presenting with septic shock due to coccidioidomycosis, all developed ARDS and all had pulmonary symptoms. All patients died. 5

Diagnosis of coccidioidomycosis includes fungal culture and serology. Undemanding growth requirements means the colonies can grow in 3-4 days in any artificial medium at most temperatures. Mature colonies are very infectious. Coccidioidin, which is a mycelial phase antigen, is a useful tool to the diagnosis of this infection. IgM appears early in 75% of patient. IgG appears later and disappear in several months time. Raised IgG is a marker of disseminated extrapulmonary disease. False positive results are rare.

Coccidioidomycosis can be treated with surgical and medical means. Lung abscess can be resected or drained. Amphotericin B (0.5- 0.7 mg/kg/day) and ketoconazole are commonly used to treat disseminated or symptomatic disease. Side effects of amphotericin B include gastrointestinal upset, febrile reaction, nephrotoxicity, hypokalemia, hypomagnesemia. Side effects of ketoconazole include gastrointestinal upset, hepatotoxicity, adrenal suppression, and gynaecomastia. A high relapse rate was noted after stopping ketoconazole therapy. 6 New therapies which are under investigation include voriconazole and interferon gamma with case reports showing their success.

Conclusion
Coccidioidomycosis is a relatively rare disease but is endemic in southwestern United States. Increased number of cases is found after earthquakes, landslides, duststorms etc. High index of suspicion is needed for an early diagnosis. Diagnosis is usually made by identification of spherules in tissues. Other tests such as serology, IgM detection by tube precipitation test, antigen detection by ELISA, complement fixation test for IgG are also available.

References
  1. Centers for Disease Control and Prevention. Addressing emerging infectious disease threats: a prevention strategy for the United States [executive summary]. MMWR Morb Mortal Wkly Rep I 994;43(RR-5): 1-18.
  2. Pappagianas D. Marked increase in cases of coccidioidomycosis in California: 1991, 1992 and 1993. Clin Infect Dis 1994;19:SI4-18.
  3. From the Center of Disease Control and Prevention. Increase in coccidioidomycosis-Arizona, 1998-2001. lAMA 2003 March 26;289(12)1500-1502.
  4. Rosenstein NE, Emery KW, Werner B et aI. Risk factors for severe pulmonary and disseminated coccidioidomycosis: Kern County, California, 1995-1996. Clin Infect Dis 2001;32:708-715.
  5. Arsura EL, Kilgore WB, Abraham n, et aI. Septic shock in coccidioidomycosis. Crit Care Med 1998;26:62-65.
  6. Vaz et aI. Coccidioidomycosis: An update. Hospital Practice 1998:09.
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