Exudative pleurisy of coccidioidomycosis: a case report and review of the literature.

Abstract

Community-acquired pneumonia is the most common manifestation in primary coccidioides infections (Coccidioides immitis, C. posadasii). It is essential that this endemic dimorphic fungus be considered in order to proceed with the most appropriate diagnostic tools and therapy.
We present a rare case of primary pleural coccidioides and a review of the current literature for optimal diagnostic methods and therapeutic strategies.
With increased domestic and international travel, coccidioidomycosis will likely be encountered in nonendemic regions. Recognition by physicians is critical for a timely diagnosis and therapy. Tissue culture can assist in the diagnosis and polymerase chain reaction analysis shows potential as a possible addition.

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BioMed Central
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Journal of Medical Case Reports
Open Access
Case report
Exudative pleurisy of coccidioidomycosis: A case report and review
of the literature
Kamyar Afshar*, Ayana BoydKing and Om P Sharma
Address: Division of Pulmonary and Critical Care Medicine, Keck School of Medicine, University of Southern California, 1200 North State Street
GH 11900, Los Angeles, CA 90033, USA
Email: Kamyar Afshar* - kafshar@usc.edu; Ayana BoydKing - aboyd@usc.edu; Om P Sharma - osharma@usc.edu
* Corresponding author
Abstract
Introduction: Community-acquired pneumonia is the most common manifestation in primary
coccidioides infections (Coccidioides immitis, C. posadasii). It is essential that this endemic dimorphic
fungus be considered in order to proceed with the most appropriate diagnostic tools and therapy.
Case presentation: We present a rare case of primary pleural coccidioides and a review of the
current literature for optimal diagnostic methods and therapeutic strategies.
Conclusion: With increased domestic and international travel, coccidioidomycosis will likely be
encountered in nonendemic regions. Recognition by physicians is critical for a timely diagnosis and
therapy. Tissue culture can assist in the diagnosis and polymerase chain reaction analysis shows
potential as a possible addition.
Introduction
Coccidioides species, which are dimorphic fungi, are
endemic to the Southwest United States and focal regions
in Central and South America. With increased domestic
and international travel, physicians must take a thorough
travel history to consider coccidioides infection, given its
non-specific presenting symptoms. Fortunately, infection
with coccidioides does not always lead to clinical disease
and may even result in lifelong cellular immunity. Typical
clinical manifestations of this fungus include malaise,
fever, cough and other non-specific symptoms that are
indistinguishable from an influenza infection. We present
a case of primary pleural coccidioidomycosis to add to the
literature [1-3] and discuss the diagnostic tools that can
assist in confirming the presence of a sole pleural effusion
as a rare manifestation of this disease.
Case presentation
A 39-year-old man was admitted in October 2006 with a
2-week history of sharp, non-radiating pain of the right
shoulder blade with associated dyspnea upon exertion
and 5 kg loss of weight. He denied fever, chills, night
sweats or cough. His symptoms did not interfere with his
occupation as a gardener. Vitals demonstrated a normo-
tensive, afebrile 155 cm, 100 kg man with an oxygen sat-
uration of 96% on room air.
Physical examination was normal with the exception of
decreased breath sounds half way up the right lung field
along with dullness to percussion and without tactile
fremitus. A chest radiograph showed a moderately sized,
right pleural effusion (Figure 1). The right thoracentesis
fluid analysis showed a slightly cloudy and yellow fluid.
Cell count results were 1,164 nucleated cells, 12% poly-
morphonuclear leukocytes, 80% lymphocytes, 7% mono-
Published: 3 September 2008
Journal of Medical Case Reports 2008, 2:291 doi:10.1186/1752-1947-2-291
Received: 29 August 2007
Accepted: 3 September 2008
This article is available from: http://www.jmedicalcasereports.com/content/2/1/291
© 2008 Afshar et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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cytes, 1% eosinophils, glucose 123 mg/dl, lactate
dehydrogenase (LDH) 103 units/l, and protein 5.3 g/dl
(pleural to serum protein ratio, 0.8; pleural to serum LDH
ratio, 0.7). Bacterial Gram stain and culture, acid-fast
bacilli smears, fungal culture and cytology were all nega-
tive. Histopathological evaluation of the pleural biopsy
noted granulomatous inflammation and fungal elements
consistent with coccidioides (Figure 2). Cultures for tuber-
culosis remained negative even after 7 weeks. Purified
protein-derivative skin test to the right forearm produced
a 0 mm induration. Tests for human immunodeficiency
virus were negative by both enzyme-linked immunosorb-
ent assay and Western blot. Serum coccidioidomycosis
complement fixation was normal (< 1:2). A post-thora-
centesis chest radiograph did not reveal any evidence of
parenchymal infiltrate. After several weeks of fluconazole
therapy, the patient improved clinically, and follow-up
chest radiograph showed near-complete resolution of the
pleural effusion.
Discussion
Even in endemic areas, primary pleural coccidioidomyco-
sis is rare. When it has been reported, it is mainly right
sided and can be present in all sizes. A pleural fluid lym-
phocyte-predominant exudative effusion is commonly
associated with tuberculosis pleurisy, other fungal infec-
tions and lymphoma. In general, exudative pleural effu-
sions present a diagnostic challenge because a wide
differential of organisms may potentially cause the effu-
sion, because numerous organs may serve as the foci of
infection (Table 1), and because of limitations in com-
mercially available confirmatory studies. This is particu-
larly true when a rare presentation of an infectious
organism is observed, as in our case.
The incidence of coccidioidomycosis is increasing, with
the majority of reports from the states of Arizona and Cal-
ifornia. There is particular risk associated with outdoor
activity owing to seasonal precipitants and aerosolization
of fine sand and silt, particularly in Filipinos and African-
Americans.
A number of methods assist in the diagnosis of sympto-
matic coccidioidomycosis infections, but recognition of
its existence is of primary importance. A positive skin reac-
tion can occur as early as 6 to 48 hours after injection, but
a positive test is not entirely diagnostic of an active infec-
tion; it merely raises suspicion of cellular immunity [4].
The limitations of this test include false-positive test
results in individuals vaccinated against or previously
exposed to coccidioides. In addition, cross-reactivity with
histoplasma capsulatum can occur. The expression of this
Chest radiograph showing moderate right pleural effusion
Figure 1
Chest radiograph showing moderate right pleural
effusion.
Closed pleural biopsy showing coccidioidomycosis with evi- dence of endospores
Figure 2
Closed pleural biopsy showing coccidioidomycosis
with evidence of endospores.
Table 1: Differential diagnosis for lymphocytic pleural effusion
Tuberculosis
Non-tuberculosis Mycobacterium
Fungal pleurisy
Viral pleurisy
Malignancy
Lymphoma
Solid tumors
Sarcoidosis
Chylothorax
Post-Coronary Bypass Graft
Yellow-Nail Syndrome

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delayed-type hypersensitivity is lower with disseminated
disease.
It is the active and passive immunity that are used in
detection and monitoring strategies. Serum immunoglob-
ulin levels are used to detect the presence of an acute infec-
tion or immunity, depending on the immunoglobulin
type: IgM or IgG. Coccidioides IgM levels may be persist-
ently elevated for up to 6 months in acute infections.
Complement fixation is another useful tool for monitor-
ing both the extent of coccidioidomycosis and the
response to treatment. Low serum quantified titers of
between two and four have been encountered in early-
phase coccidioidal infection, limited dissemination and
late-stage disease as the titer is declining [5]. A serum com-
plement fixation titer level greater than 32 is generally a
sign of disseminated disease. If dissemination is consid-
ered, then a lumbar puncture needs to be performed
because of the risk of coccidioidomycosis meningitis. Cer-
ebrospinal infection occurs in approximately 35% of
patients with disseminated disease, even in the absence of
meningeal signs. A cerebrospinal fluid complement fixa-
tion titer of 1:2 or greater usually indicates the presence of
meningitis [6].
Coccidioides immitis can be cultured from tissue and body
fluids. Saubolle et al. showed that the respiratory tract has
the highest yield of recovery [7]. Cultures may take 3 to 4
weeks to grow, delaying diagnosis. The distinguishing fea-
ture is the presence of a thick-walled spherule with
endospores. A more rapid approach to identification
involves real-time polymerase chain reaction (PCR) [8].
Cross-reactivity comparisons with bacteria, other fungi,
mycobacteria and viruses demonstrate 100% specificity to
coccidioides. Biopsies and surgical specimen cultures are
more likely to result in a positive culture than microscopic
examination. Between 25% and 50% of sputum samples,
bronchial washings, spinal fluid and urine specimens
yield positive cultures [7]. Blood cultures are unlikely to
yield the presence of coccidioides, but when positive, they
are associated with acute infection, dissemination and a
high mortality.
The Infectious Disease Society of America's recommenda-
tion for initial therapy of non-meningeal extrapulmonary
infection is with an oral azole agent [9]. Clinical trials
have shown that fluconazole daily dosage eradicates the
disease in a majority of patients. In cases of clinical dete-
rioration, amphotericin B 0.5 to 1.5 mg/kg per day should
be administered. The newer extended spectrum azoles
voriconazole and posaconazole appear to be effective in
small clinical trials but are not yet suitable to be consid-
ered as first-line therapy. In small clinical trials, the use of
posaconazole in the treatment of refractory coccidioid-
omycosis shows promising results with minimal side
effects [10]. Measuring the response to treatment can be a
slow and challenging process. To establish adequate ther-
apy, patients should be routinely followed up every 3 to 6
months for up to 2 years.
Conclusion
With increased domestic and international travel, coccid-
ioidomycosis will likely be encountered in nonendemic
regions. A parapneumonic effusion from pulmonary coc-
cidioidomycosis is seen in up to 50% of cases; primary
pleural coccidioidomycosis, however, is a rare clinical fea-
ture of an endemic infectious disease. This lymphocytic-
predominant effusion mimics other diseases, therefore
recognition by physicians is critical for a timely diagnosis
and therapy. Tissue culture can assist in the diagnostic
approach and PCR analysis shows potential as a possible
addition.
Abbreviations
LDH: lactate dehydrogenase; PCR: polymerase chain reac-
tion.
Competing interests
The authors declare that they have no competing interests.
Consent
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
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