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• W2895734624 abstract "SESSION TITLE: Chest Infections 3 SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/08/2018 11:00 AM - 12:00 PM INTRODUCTION: Coccidioides, also known as Valley fever, is the 2nd most common fungal infection in the United States. It has a wide range of symptoms, the most common manifestation being pulmonary disease. We report a case of pulmonary coccidioides after travel to Arizona, initially misdiagnosed as Langerhans histocytosis. CASE PRESENTATION: A 29-year-old male with no history and recent travel to Arizona, presented with a 3-week history of fever and worsening blood tinged productive cough that failed outpatient antibiotics. CT of the chest showed a large cavitary lesion and consolidation in left lower lobe and bilateral pulmonary nodules with surrounding ground glass opacities. He had significant mediastinal and bilateral hilar lymphadenopathy, and underwent bronchoscopy with transbronchial biopsies and endobronchial ultrasound. Subcarinal aspirates were negative for malignancy and showed benign lymphoid elements and increased eosinophils. A lavage of the LUL was composed of macrophages and mixed inflammatory cells including 18% eosinophils with negative bacterial, fungal, AFB and viral cultures. The transbronchial biopsies showed dense eosinophilic infiltrates and langerhans cell histocytosis. Peripheral flow cytometry, blood and sputum cultures and rheumatologic work up was negative. The diagnosis of pulmonary Langerhans histocytosis was made, and he was started on prednisone60mg daily. Despite therapy, he continued to be symptomatic and developed night sweats and a 15lbs weight loss over the following weeks. A repeat CT chest showed worsening mediastinal lymphadenopathy. Patient was referred for excisional lymph node biopsy via mediastinoscopy, with pathology showing necrotizing and non-necrotizing granulomatous inflammation with numerous coccidioides yeast. He was started on fluconazole, and within 2 weeks he had resolution of his fevers and cough. DISCUSSION: Approximately 95% of patients who develop symptoms due to coccidioides are self-limiting, however a subset of patients require antifungal treatment. Pulmonary coccidioides presents in a subacute time course with include high fevers, night sweats, pulmonary infiltrates and nodules. A through history including travel to key regions is crucial in accurately diagnosing cocciodies in areas outside endemic regions. Here, we present a case of misdiagnosed pulmonary coccidioides as eosinophilic pneumonia and Langerhans histiocytosis despite histopathological work up. This case highlights a diagnostic dilemma where Langerhans histocytosis may have similar presenting symptoms, and also a cause of eosinophilia. This lead down a separate treatment pathway with steroids causing progression of both symptoms and lymphadenopathy, emphasizing the importance of accurately diagnosing invasive fungal infection that can progress to fatal disease. CONCLUSIONS: An accurate diagnosis for fungal infections is crucial to prevent significant morbidity and mortality. Reference #1: Molina-Morant D, Sánchez-Montalvá A, Salvador F, Sao-Avilés A, Molina I (2018) Imported endemic mycoses in Spain: Evolution of hospitalized cases, clinical characteristics and correlation with migratory movements, 1997-2014. PLOS Neglected Tropical Diseases 12(2): e0006245. https://doi.org/10.1371/journal.pntd.0006245 Reference #2: Luke M Gabe MD, Joshua Malo MD, Keneth S Knox. Diagnosis and Management of Coccidioidomycosis. Clin cest Med 38 (2017) 417-433. DISCLOSURES: No relevant relationships by Hassan Al Khalisy, source=Web Response No relevant relationships by Ioana Amzuta, source=Web Response No relevant relationships by Ritu Modi, source=Web Response" @default.
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• W2895734624 date "2018-10-01" @default.
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• W2895734624 title "HISTOPATHOLOGICAL MISDIAGNOSIS OF PULMONARY COCCIDIODES" @default.
• W2895734624 doi "https://doi.org/10.1016/j.chest.2018.08.135" @default.
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