Our patient was a 56 year-old immunocompromised male with a history of active CML (Chronic Myelocytic Leukemia) on active chemotherapy who was undergoing treatment with doxycycline and fluconazole for actinomycosis and coccidioidomycosis diagnosed via BAL (bronchoalveolar lavage) and sputum culture respectively during a recent hospitalization two weeks prior. He presented with persistent non-productive cough, generalized weakness and malaise. Initial CBC (Complete Blood Count) and vital signs were unremarkable though a CXR (Chest X-Ray) suggested worsening reticulonodular opacities and subsequent thoracic CT scan exhibited increasing innumerable pulmonary nodules bilaterally with worsening hilar lymphadenopathy in comparison to earlier imaging. An open lung biopsy by VATS (Video Assisted Thoracoscopic Surgery) performed revealed suppurative necrotizing granulomas associated with acute organizing bronchopneumonia with fungal organisms consistent with blastomyces. Given the history of coccidioidomycosis however, deeper biopsy sections were examined which revealed the presence of spherules both with and without endospores characteristic of coccidioides immitis(coccidioidomycosis) concurrently. Because of the disease severity, treatment with Amphotericin B was started and fluconazole was discontinued. The patient symptomatically improved and since being discharged has remained stable with frequent outpatient follow-up appointments.
Discussion:
Blastomyces dermatitidis and coccidioides immitisare both dimorphic fungi with the potential to cause significant damage in immunocompromised individuals. Because of this, it is essential to keep both high in the differential when caring for those at risk. However the prevalence of each has been well documented with coccidiodes being endemic to the southwestern US and blastomyces to the central/southeastern US and central New York state though this particular case does not follow the geographic pattern. Unfortunately, the clinical manifestations of both are variable ranging from asymptomatic to fatigue, respiratory distress, malaise, weight loss or other non-specific complaints and are difficult to diagnose. What’s more, co-infection with dual concurrent fungal infections is a seldom reported occurrence. This particular case highlights the need to keep simultaneous endemic infections high in the differential in susceptible individuals who present with unclear findings and an apparently non-improving infectious etiology.
Conclusions:
Immunocompromised individuals such as those undergoing active chemotherapy are at the highest risk of contracting opportunistic infections. Because endemic infections produce a spectrum of illness ranging from being subclinical to severe progressive disseminated diseases, diagnosis requires a high index of suspicion. However, we must keep the possibility of duo infectious etiologies such as concurrent fungal infections in the case of our patient high in the differential to better care for at risk populations.