Clinical Investigation
Abdominal and Pelvic Coccidioidomycosis

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Abstract

Coccidioidomycosis is a fungal infection endemic to the Southwestern United States that has a clinical presentation resembling community-acquired pneumonia. Disease occurs after inhalation of airborne arthroconidia. Dissemination to a variety of organ systems via hematogenous spread from a primary pulmonary focus may then occur. Coccidioidomycosis rarely involves the abdominal cavity. The authors review the spectrum of abdominal and pelvic presentations of coccidioidomycosis and report 6 unusual cases, including acute appendicitis, hepatitis and adnexal masses. Pathologists played a critical role in the diagnosis of these presentations by recognizing spherules in tissue. In only 2 of the cases were Coccidioides species cultured.

Section snippets

CASE 1: ACUTE APPENDICITIS

A 56-year-old man was hospitalized with abdominal pain in 2007. He complained of diarrhea but denied fever, cough, shortness of breath or chest pain. He was a long-term resident of Sonora, Mexico, and moved recently to southern Arizona. His physical examination was unremarkable with exception of right lower quadrant pain. A chest x-ray was normal. Stool gram stain showed eosinophils. The white blood cell count was 12,800 cells/μL with a normal differential count. He was diagnosed with

CASE 2: INTESTINAL AND OMENTAL INFECTION

An 86-year-old man lived in Tucson, Arizona, since 2003. In early 2006, the patient reported fatigue, nausea and loss of appetite with a 20-pound weight loss over 3 to 4 months. He denied respiratory symptoms or night sweats. A computed axial tomography scan of his abdomen and pelvis showed ascites, mesenteric fat stranding and lymphadenopathy. Biopsies of omental nodules disclosed granulomatous lymphadenitis. Mesenteric and small bowel tissue biopsies demonstrated spherules of Coccidioides (

CASE 3: HEPATITIS

A 57-year-old man from Phoenix, Arizona, had a history of heart transplantation 6 years previously and a 2-year history of hemodialysis. He had a history of primary pulmonary coccidioidomycosis and was taking fluconazole 200 mg daily since the diagnosis, but he stopped fluconazole 2 months before admission. He complained of diarrhea, weakness and abdominal pain for several months. He was diagnosed with cholecystitis and underwent an emergent cholecystectomy. During the operation, a liver biopsy

CASE 4: INFECTION OF THE LIVER AND SPLEEN

A 6-year-old boy with no medical history complained of 2 months of intermittent fever and fatigue. On physical examination, he was found to have fever to 105°F, a fine sandpaper rash, coarse breath sounds and hepatosplenomegaly. A chest x-ray showed fine nodular opacities. A liver biopsy performed because of increased liver enzymes demonstrated granulomas, immature Coccidioides spherules and eosinophilic infiltration of the liver parenchyma (Table 1; Figure 2). Cerebrospina fluid, blood, urine

CASE 5: ADNEXAL MASS AND SALPINGITIS

A 64-year-old woman with a history of poorly controlled type 2 diabetes mellitus, fatigue and weight loss was found to have a pelvic mass. Initial white blood cell count was 7000 cells/μL. Surgical exploration revealed an adenexal mass and a bilateral-salpingo-oophorectomy was performed. Ovarian tissue demonstrated serous cystadenoma, and fallopian tubes contained Coccidioides spherules (Table 1; Figure 3). After surgery, the patient noted improvement in her fatigue and weight loss; Coccidioides

CASE 6: SALPINGITIS

A 54-year-old woman presented with 6 months of bloating and progressively increasing abdominal girth. Examination revealed a pelvic mass. The white cell count was 13,300 cells/μL with a normal differential. The chest x-ray was negative. Computed tomography of the abdomen and pelvis revealed a 33-cm cystic mass in the pelvis. A salpingo-oopho- rectomy was performed. The mass was a mucinous ovarian tumor, and the right fallopian tube had granulomatous salpingitis with Coccidioides spherules (

DISCUSSION

Infection of the peritoneum is the most common presentation of abdominal infection with Coccidioides.3 Coccidioidal peritonitis may present without symptoms, or it may mimic bacterial peritonitis.3 Weight loss (or weight gain from ascites), malaise, low-grade fever, nausea, night sweats, diarrhea, ileus and abdominal pain may occur. The peritoneal fluid is typically exudative with an increase of peritoneal white blood cell count, protein and lactate dehydrogenase along with low glucose.9 The

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