Case of the Week
Section Editors: Matylda Machnowska1 and Anvita Pauranik2
1University of Toronto, Toronto, Ontario, Canada
2BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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Disseminated Coccidiodomycosis
- Coccidioides immitis is a dimorphic fungus in the topsoil of the Southwest United States and Northern Mexico. Incidence of new infection is 60,000 to 80,000 per year; disseminated disease reported in less than 1%.
- Up to 60% of infections are asymptomatic. Primary infection is pulmonic. Presenting symptoms may include cold or flu-like symptoms. Hematogenous spread to virtually any organ, with predilection for the CNS, skin, soft tissue, bone, and joints. Immunosuppressed or pregnant patients are more susceptible. Disseminated disease carries very poor prognosis.
- Key Diagnostic Features: Constellation of findings and temporal evolution are key to radiological diagnosis. Brain: Look for basilar meningitis, hydrocephalus, possible infarcts. Intraparenchymal lesions and spinal cord lesions rare. Paraspinal infection may be pronounced in advanced disease. Osseous lesions may be hard to discern from metastases. Miliary pulmonary lesions, mediastinal adenopathy, hepatic, and splenic lesions that calcify over time are seen.
- DDx: Other granulomatous disease, metastasis
- Rx: Antifungals—leptomeningeal involvement needs long-term (lifelong) treatment.
Suggested Reading
Erly WK, Labadie E, Williams PL, et al. Disseminated coccidioidomycosis complicated by vasculitis: a cause of fatal subarachnoid hemorrhage in two cases. AJNR Am J Neuroradiol1999;20:1605–08
Erly WK, Bellon RJ, Seeger JF, et al. MR imaging of acute coccidioidal meningitis. AJNR Am J Neuroradiol 1999;20:509–14
Dublin AB, Phillips HE. Computed tomography of disseminated coccidiodomycosis. Radiology1980;135:361–68. doi: 10.1148/radiology.135.2.7367627
Herron LD, Kissel P, Smilovitz D. Treatment of coccidioidal spinal infection: experience in 16 cases. J Spinal Disord1997;10:215–22