In the middle of a pandemic, patients with cough and fever are thought to have SARS-CoV-2 (severe acute respiratory syndrome coronavirus-2). It should be remembered that in the desert southwest of the United States, we have an ongoing epidemic of coccidioidomycosis (CM). There are additionally many other respiratory illnesses that could be confused with CoV-2 or overlooked. This is a case report of CoV-2 engrafted on chronic cavitary pulmonary CM. In a time where the coronavirus pandemic is becoming rampant, we demonstrate the case of a coinfection with cavitary pulmonary CM. In this case, the importance of detection of the coronavirus and treatment of the coinfection is explored.
Cryptococcus gattii is a species that has received more recognition in the recent past as distinct from Cryptococcus neoformans. C gattii is known to cause meningeal disease in both immunocompetent and immunosuppressed hosts. Patients may be clinically asymptomatic until immunosuppressive conditions occur such as corticosteroid treatment or an HIV infection. HIV-associated cryptococcal infections are most often due to C neoformans. C gattii is found in a minority. Speciation and subtyping of Cryptococcus are not always accomplished. In many parts of the world, there is no availability for speciation of Cryptococcus. Travel history may provide a clue to the most probable species. This case demonstrates a case of C gattii meningitis with a multiplicity of complications. These include advanced HIV disease secondary to nonadherence, immune reconstitution inflammatory syndrome, and superior sagittal sinus thrombosis. The patient represented diagnostic and therapeutic dilemmas over time. Headache was the primary symptom in cryptococcal meningitis, immune reconstitution inflammatory syndrome, and superior sagittal sinus thrombosis. All are discussed in detail as potential etiologies for the primary disease. Isavuconazonium is a relatively new broad-spectrum antifungal azole that was used as salvage therapy.
methylprednisolone in our patient), advanced age (more than 65 years), lung disease or fibrosis, leukopenia less than 500/mL, hypoalbuminemia and lymphopenia. 3 A retrospective case-control study of 17 patients investigating characteristics of patients with PJP showed that the median age was 68 years. The median length of time from the first adalimumab injection to the development of PJP was 12 weeks (14 weeks in our patient). 4 Clinical presentation of HIV-negative PJP is marked by fever, rapid-onset dyspnea, and cough with mean of 5 days until the diagnosis is made. Imaging is similar to HIV-related PJP with chest radiograph showing typically bilateral, symmetric, reticular, or granular opacities; at other times, it may even be normal. Computerized tomography scan of the lungs typically shows diffuse ground glass opacities. Pulmonary pneumatoceles or cysts occur in 3%-6% of non-HIV patients with PJP, which increases the risk of developing pneumothorax. 2,5,6 Given the low burden of parasites in non-HIV PJP infections, microscopy and staining of organisms obtained by bronchoscopy or induced sputum samples have a high false-negative rate. 7 A higher sensitivity test is PJP PCR with a negative predictive value of 98.7% in some studies. 8 It is also important to note that positive PCR results could indicate colonization rather than an active infection in asymptomatic patients.Based on the 2010 American Thoracic Society (ATS) statement for treating fungal infections, trimethoprim (15-20 mg/kg/d)-sulfamethoxazole (75-100 mg/kg/d) given in 4 divided doses for a total of 14 days is the most effective regimen used to treat severe pneumonia. Atovaquone, primaquine/clindamycin, and pentamidine are alternative choice in less severe cases. 9 The role of adjunctive corticosteroids in the treatment of PJP in HIVnegative patients remains uncertain with multiple trials failing to show survival benefit. 10
Coccidioidomycosis (CM) is an endemic fungal infection that is found in the Southwestern United States and adjacent areas of Mexico as well as Central and South America. In the United States, 150 000 to 300 000 infections occur annually. The majority are asymptomatic. Of the symptomatic cases, the majority are primary pneumonic disease that varies from mild to very severe. A minority of persons develop disseminated disease (extrapulmonary disease). These typically manifest as meningitis, osteomyelitis, synovitis, and integumentary. CM has been described in virtually every part of the body, including the genitourinary system. Disseminated CM to the genitourinary tract is well known to occur but is rarely documented. It is believed this is the first case to report disseminated CM to the renal parenchyma. Diagnosis and treatment are described in a 56-year-old Hispanic male.
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