Coccidioidomycosis, an infection caused by dimorphic fungi Coccidioides immitis and C. posadasii, is endemic to the southwestern US. It is estimated that there are 150,000 new infections in the US every year. Patients with primary infection are asymptomatic 60% of the time, and 40% have a wide spectrum of clinical manifestations, most commonly a community-acquired pneumonia. Overall, <1% develop extrapulmonary manifestations. Pericardial involvement is rare, with only 23 detailed cases reported in the medical literature. We report the case of our patient and review the relevant published cases of coccidioidal pericarditis.
Case Report
A 21-year-old man from Thailand presented to the Student Health Clinic with worsening cough, chest pain, and dyspnea. He had moved to Arizona 2.5 years before his presentation. His illness began with fever and productive cough 2 months before admission. The patient was given a course of levofloxacin for presumed bacterial community-acquired pneumonia. However, his symptoms progressed and included night sweats, decreased appetite, dysphagia, chest pain, and dyspnea. He was seen again at the clinic and subsequently diagnosed with coccidioidomycosis. Labs showed a positive immunoglobulin (Ig)M and IgG enzyme immunoassay with complement fixation titer 1:256 (reference range <1:2). Coccidioidomycosis serum antigen was positive. Human immunodeficiency virus, QuantiFERON gold (Qiagen, Valencia, CA) tuberculosis, and (1-3)-Beta-D-Glucan tests were negative. The patient was started on oral fluconazole 400 mg daily without improvement.
On admission, the patient was afebrile and tachycardic with a heart rate of 121 beats per minute. His blood pressure was 108/60 mm Hg. A firm, nontender left supraclavicular mass of 3 cm × 4 cm was present. Complete blood count showed an elevated white blood count of 12,900/μL with 84.3% neutrophils, 8.2% lymphocytes, and 1% eosinophils, normocytic anemia with hemoglobin 9.5 g/dL, and elevated platelet count of 525,000/μL. Transthoracic echocardiogram revealed a large circumferential pericardial effusion with evidence of tamponade. Computed tomography of the chest showed extensive necrotizing lymphadenitis with involvement of the mediastinum and bilateral hilar adenopathy causing esophageal impingement.
Pericardiocentesis was performed with 680 mL of bloody fluid aspirated from the pericardial space. Pericardial fluid showed red blood cell of 2,848,000, white blood count of 5778 with neutrophils 51%, lymphocytes 44%, eosinophils 2%, glucose 70 mg/dL, and lactic dehydrogenase 447 IU/L (serum lactate dehydrogenase 279 IU/L). Gram stain did not show any organisms, and both stains and culture for fungal and acid-fast bacilli were negative. Tuberculosis polymerase chain reaction and adenosine deaminase from the fluid were negative. Cytology was negative for metastatic malignancy. The patient was started on liposomal formulation of amphotericin B at 5 mg/kg, intravenous fluconazole 400 mg twice a day, and prednisone 20 mg daily. The supraclavicular mass was excised, and pathology showed necrotizing granulomatous lymphadenitis with Coccidioides spherules, a positiveC. immitis by deoxyribonucleic acid probe, and without evidence of lymphoma. After 10 days of therapy, the patient was discharged on oral fluconazole 400 mg twice a day and a prednisone taper. The patient responded very well to treatment and continued to do well 8 weeks after discharge.
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-Onyee Chan, MD, See Wei Low, MD, Rafael Urcis, MD, Naser Mahmoud, MD, Ily Kristine T. Yumul, MD, John Leander Z. Po, MD, Tirdad T. Zangeneh, DO
This article originally appeared in the March 2016 issue of The American Journal of Medicine.
Editor’s Note: Why did we use a featured image of the desert with this story? Because Coccidioidomycosis– also know as Valley Fever in Arizona– is very common in the desert Southwest.
