Case Presentation:
A 19 year old African American female with no known past medical history presented to the ED with 3 months of dyspnea and dry cough. In the emergency department, the patient was afebrile, tachycardic, and in acute respiratory distress (RR of 24, O2 sat of 91% on room air). Her exam was notable for facial fullness, non‐pitting upper extremity edema and crackles bilaterally. She also had a blistering weeping lesion on her lower lip, nose and under the nail bed of the left 5th finger.
CT‐angiography of the chest demonstrated extensive diffuse bilateral pulmonary infiltrates, with marked mediastinal enlargement due to an infiltrating process. The superior vena cava was completely obliterated by the mediastinal infiltration with a continuous mass protruding into the right atrium.
Alpha‐fetoprotein, beta‐HCG, LDH and TSH were normal. The patient underwent TEE demonstrating a mobile mass protruding down from the superior vena cava into the right atrium. CT guided biopsy of the anterior mediastinal mass revealed spherules and endospores. This finding confirmed an infection with Coccidioides immitis. Upon further questioning it was revealed she had lived in California’s central valley for several months two years ago. The patient was promptly given treatment with intravenous amphotericin‐B and fluconazole. She had a prolonged hospital course with recovery, but has been readmitted for further respiratory failure.
Discussion:
Coccidioidomycosis is an infection caused by the fungus Coccidioides that is endemic to the southwestern US and California’s central valley. Although 60% of infected persons remain asymptomatic, approximately one in 200 people develop disseminated cocci, as our patient did. The patient most likely contracted the infection while living in central valley. She presented with clinical evidence of disseminated disease.
Cardiac involvement with coccidioides infections is rare. Infection usually presents as pericarditis or myocarditis. Fibrogranulomatous pericarditis, miliary granulomas and cardiac muscle abscesses can occur.
Autopsy studies suggest 5‐15% of patients with disseminated coccidioidomycosis have evidence of infection in the myocardium. A retrospective meta‐analysis of case reports ranging over thirty years of fungal endocarditis found that almost all patients had a single fungal pathogen. There were no reported fungal endocarditis infections with coccidioides species. We only found one other reported case of coccidioidomycosis presenting as a cardiac mass, however this was in a 10 year old boy.
Conclusions:
In this case, the patient presented with severe disseminated coccidioidomycosis involving the lungs, mediastinum, heart and skin. This case is unique due to the patients’ late presentation, as well as the involvement of not only the mediastinum, but also the heart, which is quite rare for coccidioidal infections. This case highlights the importance of getting a detailed travel history, and to always consider coccidioidomycosis infections in endemic areas
