A Case of Refractory Pulmonary Coccidioidomycosis Successfully Treated with Posaconazole Therapy

Case Report

J Fam Med. 2017; 4(6): 1130.

A Case of Refractory Pulmonary Coccidioidomycosis Successfully Treated with Posaconazole Therapy

Patel RH¹, Pandya S², Nanjappa S³ and Greene JN4*

¹Undergraduate Student, University of South Florida, USA

²Chief Infectious Diseases Fellow, University of South Florida, Morsani College of Medicine, USA

³Assistant Member, Department of Internal Hospital Medicine, H. Lee Moffitt Cancer Center and Research Institute, Department of Oncologic Sciences, University of South Florida, Morsani College of Medicine, USA

4Chief, Infectious Diseases and Hospital Epidemiologist, H. Lee Moffitt Cancer Center and Research Institute, USA

*Corresponding author: John N. Greene, Chief, Infectious Diseases and Hospital Epidemiologist, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, FOB-3, Tampa, FL 33612-9497, USA

Received: October 14, 2017; Accepted: November 14, 2017; Published: November 21, 2017


Coccidioidomycosis is an endemic fungal infection caused by the inhalation of the spores of Coccidioides species. Patients with underlying immunosuppressive illness can contract chronic or disseminated disease which requires prolonged systemic therapy. Pulmonary coccidioidomycosis remains as an illusory and abstruse disease, with increased prevalence that poses as a challenge for clinicians in developing an effective strategy for treatment. Here, we report successful treatment of a refractory case of chronic relapsing pulmonary coccidioidomycosis in a 50-year old woman with a thin-walled cavitary lung lesion who was ultimately treated with posaconazole.

Keywords: Pulmonary coccidioidomycosis; Posaconazole; Fluconazole; Cavitary lesion


Coccidioidomycosis is an endemic fungal infection caused by the inhalation of arthroconidia. The two fungal species present in areas of endemicity are Coccidioides immitis and Coccidioides posadasii. These two species are present in the soil of the southwest United States, northwest Mexico, and parts of Central and South America [1,2]. The disturbance of endemic soil may cause airborne intrusion of highly-infectious arthroconidia from hyphae, which may cause disease through inhalation in humans and animals. Generally, coccidioidomycosis can be classified as an acute, chronic and disseminated form. Patients with acute coccidioidomycosis are mostly asymptomatic and may develop complications and do not require long-term clinical monitoring. However, patients with immunosuppressive illness may present with a chronic or disseminated form which requires long-term clinical follow-up and treatment.

Pulmonary coccidioidomycosis is the most common form of the disease found in 95% of cases. Sixty percent of these cases are asymptomatic, while 40% present with an influenza-like syndrome or pneumonia [1]. Other symptoms may include fever, cough, headache, fatigue, night-sweats, and weight-loss. Rarely, patients may develop persistent pneumonia, hemoptysis, fibrocavitary infection, or cavitary complication. Infrequently, a persistent parenchymal cavity may develop and can persist along with chronic symptoms [1,3]. These pulmonary cavitary lesions develop in 13-15% of acute and chronic forms, however, they are uncommon in cases of disseminated disease or in immunocompromised patients [4,5]. They are usually present as thin- or thick-walled cavitary lesions and are generally only a single cavity [3,6]. They may persist for years in asymptomatic patients, but may also resolve spontaneously without the need for antifungal therapy in many cases [6].

Besides coccidioidomycosis, pneumocystis pneumonia, and Echinococcus infection have been classically associated with thinwalled cavitary lesions or nodules [3,7]. Although most cavities are asymptomatic, patients may occasionally present with symptoms of ruptured cavities which includes discomfort, bacterial super infection, or hemoptysis. Early identification and proper treatment is crucial in developing a successful treatment strategy and for avoiding complications. Diagnosis involves fungal culture, microscopy and serology testing [8]. Genomic analysis and histopathology can also be used for diagnosis of coccidioidomycosis [9]. Bronchoscopy, needle biopsy and wedge resection provides tissue specimens to aid in the confirmation of coccidioidomycosis cases.

There is an increasing prevalence of the disease in areas of endemicity, primarily in Arizona and California. Antifungal therapy is needed for chronic and disseminated coccidioidomycosis. Patients with severe pneumonia with symptoms lasting greater than four weeks may benefit from triazole antifungal therapy and require longterm clinical monitoring to ensure a successful outcome. Intravenous amphotericin B may be used in severe cases in combination with azole antifungals for 1 to 2 weeks while stabilizing the dosage of the azole antifungals [10]. Although azole antifungals are the most common option for treatment, relapse after cessation of antifungal therapy is possible [11]. Oral therapy with azole antifungals for treatment of cavitary disease may result in partial improvement [10]. Alternatively, resection via thoracotomy may be considered in patients with progressive cavity enlargement, and severe hemoptysis.

Fluconazole is the most common therapy for coccidioidomycosis. Newer triazole antifungal agents, namely posaconazole and voriconazole, have demonstrated efficacy when fluconazole is ineffective [12].

Case Presentation

A 50-year-old white female resident of Arizona presented on July of 2014 with a severe cough, hemoptysis, and influenza-like symptoms. Her symptoms started one year prior to presentation with fevers, arthralgia and a diffuse rash. She was treated for possible Lyme disease. An anticoccidioidal complement fixation titer for IgG was obtained during the initial visit which was found to be 1:32 which along with consideration of accompanying symptoms, was considered to be a sign of disseminating infection. A computed tomography of the thorax revealed a thin-walled pulmonary cavitary lesion which increased up to 5cm in size until it was surgically resected (Figure 1). She underwent several diagnostic procedures including fine needle aspiration, bronchoscopy and ultimately a wedge resection of the mass which demonstrated necrotizing granuloma with positive fungal stain for Coccidioides immitis which ultimately grew on fungal cultures. She was treated with oral fluconazole (400mg/day) for three months which led to slight improvement.