Pulmonary coccidioidomycosis is a common cause of benign respiratory tract infections in the Southwestern US. C.immitisare dimorphic fungi found in soil as saprophytes producing infectious arthroconidia when airborne. 60% of infections are asymptomatic, and 40% develop self-resolving flu-like symptoms. Cocci can lead to residual morbidity, however mortality is rare at 0.07%.
The literature suggests human rhinovirus (HRV) co-infection exponentially increases rates of severe fungal disease. HRV inhibits antigen specific T cell proliferation/cytotoxicity and processes reliant on ICAM-I/LFA-I binding. Primarily serving to enhance viral replication, T cell dysfunction increases susceptibility to other organisms.
We present a 62 y/o M with no PMHx who recently returned from a trip to TX complaining of fever, cough and discolored sputum. He was a non-smoker and avid gardener in Southern CA. Despite levofloxacin as an outpatient, he was admitted for respiratory failure requiring emergent intubation. Imaging/bronchoscopy revealed RLL pathology presumed to be CAP. With no improvement on broad-spectrum antibiotics, paralysis andproning he was transferred for placement of VV ECMO (day 8) for ARDS and hypercarbic respiratory failure. CocciIgM/IgG, rhino/enterovirus PCR were positive and BAL revealed C. immitus. Amphotericin B was initiated immediately. Oxygenation improved and the patient was maintained on ECMO over a month. Complications included pleural effusions, unstable brady/tachyarrythmias, thrombocytopenia, leukopenia, neutropenia, GI bleeds, AKI and hepatic insufficiency. After ruling out lung transplantation with no signs of meaningful recovery (BAL remained positive/no mountable antibody response), focus was shifted to supportive management and the patient died on ECMO day 32.
Cocci requiring ECMO for ARDS has been described in an immuncompromised patient, however there are no documented cases to our knowledge in immunocompetent patients. It is unclear whether patients with this severity of disease are able to recover with ECMO support.
