Winning Abstracts from the 2013 Medical Student Abstract Competition: Disseminated Coccidioidomycosis with Spinal Involvement in an Immunocompetent Patient
Ross T. McCormack, NYU School of Medicine, Class of 2014
Coccidioidomycosis is an airborne fungal infection endemic in parts of the Southwestern United States that typically presents as a mild, flu-like illness. Extrapulmonary manifestations have an estimated prevalence of 4.7%. While disseminated infection is classically associated with immunocompromised patients, in rare cases, it has affected immunocompetent hosts.
A 28 year-old African-American male with hypertension presented with two years of cough productive of green sputum, back pain, and cutaneous facial lesions. Five years prior to admission the patient reports visiting a desert in Northern California where he was exposed to high levels of airborne dust. Two years prior to admission, he developed facial lesions, followed shortly thereafter by shortness of breath, productive cough and back pain. He was diagnosed with disseminated coccidioidomycosis with lung, skin, and spine lesions, and was treated with two weeks of amphotericin B followed by fluconazole, to which he was intermittently adherent for the five months prior to admission. Two weeks prior to admission, he traveled to New York City and noticed recurrence of the facial lesions, productive cough, and back pain.
Physical exam was notable for exaggerated lumbar kyphosis with marked paraspinal tenderness bilaterally. Additionally, scattered rales were appreciated in bilateral lung fields.
HIV rapid screen and PPD were negative. Chest CT showed innumerable small centrilobular nodules; MRI of the lumbar spine suggested osteomyelitis involving L2-L4, retropulsion of L4, as well as canal stenosis and infarction of L3; cutaneous lesion biopsy showed coccidioides fungi. He was treated with amphotericin B for 14 days and followed by fluconazole. His cutaneous lesions and back pain decreased prior to discharge.
This case demonstrates the potential need for long-term anti-fungal therapy in patients with disseminated coccidioidomycosis, regardless of immune status. Proposed deficiencies in IL-12/IL-23/INF-y have been suggested as the mechanism of susceptibility to disseminated coccidioides infections. In fact, several studies demonstrated patients, who appeared to be immunocompetent with disseminated coccidioidomycosis, were later found to have IL-12B2 receptor deficiency as well as an IFN-y receptor 1 deficiency. This suggests an underlying, as yet unexplored immunocompromised phenotype, potentiating the risk for more aggressive infection. Although not thoroughly studied, if these deficiencies are in fact prevalent, this would support the utility of long-term azole therapy.