Author: V. Dimov, M.D., University of Chicago
Reviewer: S. Randhawa, M.D., NSU University
A 54-year-old lady had cough for 3-4 days and went to the emergency room (ER) for check-up. She had no fever or chills, no chest pain (CP) or shortness of breath (SOB).
Past medical history (PMH)
Family medical history (FMH)
Her husband recently had a newly converted positive PPD and was treated with anti-TB drugs, his chest X-ray (CXR) was negative.
Social history (SH)
Smoker, 20 pck-yrs.
What is the most likely diagnosis?
- TB? Her husband is a recent PPD converter after all.
It is important to ask about travel history. She was in Arizona 2 months ago.
What laboratory tests would you suggest?
CBCD, CMP, CXR.
The CXR showed a LUL lesion and the radiologist recommended a CT scan of the chest for further evaluation.
CXR: rhere is a small nodule in the left upper lobe peripherally (left); close-up of the nodule (right) (click to enlarge the images).
CXR report: An ill-defined 2.5 to 3 cm nodular density overlies the left upper chest laterally. This may represent an infiltrate, but lung lesion/neoplasm is not excluded and further evaluation by CT is recommended in this case. There is hyperinflation of the lungs with mild prominence of the perihilar markings, consistent with COPD.
CT chest: the small 1 cm nodule is barely visible on the CT scan of the chest (click to enlarge the images).
CT chest: the nodule is seen better on the CT scan with lung windows (click to enlarge the images).
CT chest with IV contrast: One cm thick walled cavitary mass in the posterior aspect of the left upper lobe with surrounding nodular infiltrative changes extending to the pleural surface.
"Is it cancer?", the patient asked.
What diagnostic test would you recommend next?
Bronchoscopy would be a consideration but the lesion was too peripheral to be accessed through a bronchoscope.
She had a VATS with lobectomy.
The mass turned out to contain granulomas and fungus elements characteristic of coccidiomycosis.
Lung biopsy shows coccidiomycosis (left); negative Histoplasma urinary antigen (right) (click to enlarge the images).
What happened next?
She had an uneventful recovery after surgery and was discharged home. The ID consultant did not recommend antifungal treatment because the patient was asymptomatic.
What did we learn from this case?
Always collect a detailed travel history in suspected ID cases. The clue to the diagnosis may lie in the travel history. Coccidiomycosis is endemic in California and Arizona.
In addition to inquiring about travel, also ask about any contact with pets, farm or wild animals.
Spherule and endospore forms of Coccidioides immitis. Image source: Wikipedia, CDC, public domain.
Geographic Distribution of Coccidioidomycosis. Image source: Wikipedia, obtained from the Public Library of Science. Illustration credit: Margaret Shear, 2005, Creative Commons Attribution 2.5 License.
Most immunocompetent patients with primary pulmonary coccidioidomycosis and no risk factors for dissemination do not need antifungal treatment. All patients with disseminated infection require triazole treatment.
Coccidioidomycosis. eMedicine Specialties > Pulmonology > Infectious Lung Diseases, 2006.
American Thoracic Society Issues Guidelines on Treating Pulmonary Fungal Infections. Medscape, 2011.
Incidence of coccidioidomycosis ("valley fever") increased 8-fold in the endemic area of U.S. between 1998-2011 http://buff.ly/YpvSyp