Arsura E L, Kilgore W B
Kern Medical Center, Department of Internal Medicine, Bakersfield, CA, USA.
Chest. 2000 Feb;117(2):404-9. doi: 10.1378/chest.117.2.404.
Miliary coccidioidomycosis indicates hematogenous or lymphatic spread of Coccidioides immitis and is characterized by the development of multiple small granulomas throughout the lungs and other organs. Previous reports have suggested that this disorder occurs almost exclusively in immunocompromised patients, with most patients succumbing to progressive respiratory failure. In this article, we describe the largest series of immunocompetent patients with miliary coccidioidomycosis, define clinical characteristics, and outline important aspects of diagnosis and treatment.
We identified eight patients (five men and three women; age range, 23 to 65 years) with miliary coccidioidomycosis diagnosed at Kern Medical Center (located in an endemic area) from 1990 to 1997. Four of the patients were white, two were African American, and two were Hispanic. A miliary pattern was defined as the presence of discrete 2- to 10-mm lesions diffusely distributed throughout both lung fields, as shown on chest radiograph. Microscopic examination and culture of C immitis from sputum, tissue, or body fluid confirmed diagnosis. Patients with HIV were excluded.
These patients constituted approximately 1% of those admitted to our institution for coccidioidomycosis from 1990 to 1997. Four patients had symptoms for < or = 1 week before admission (acute), and four had symptoms for between 5 and 12 weeks (chronic). Four patients demonstrated a miliary pattern on initial chest radiograph, and two of these patients received an initial diagnosis of miliary coccidioidomycosis. Five patients required mechanical ventilation. Arterial blood gas measurements revealed a mean PO(2) of 54.2 +/- 8. 6 mm Hg and a mean PCO(2) of 32.5 +/- 3.2 mm Hg. Five patients developed ARDS. Five patients had extrapulmonary involvement, with the meninges (n = 4) and skin (n = 4) being the most common sites. All patients were treated with fluconazole and/or amphotericin B. Three patients died; all had chronic involvement and received mechanical ventilation.
We present eight immunocompetent patients with a lower mortality rate and better outcome than previously reported. In our series, miliary coccidioidomycosis manifested as either an acute respiratory illness or an advanced stage of a chronic illness occurring in the context of widespread dissemination. All who died had chronic involvement. Prompt recognition of miliary coccidioidomycosis is crucial, but may be hindered by the large differential diagnosis. Important diagnostic factors include a history of travel through endemic areas, ethnicity, immunologic status, involvement of multiple organ sites, and pronounced hypoxemia not accounted for by the degree of pulmonary involvement seen on chest radiograph.
粟粒性球孢子菌病提示球孢子菌经血行或淋巴播散，其特征为在肺和其他器官形成多个小肉芽肿。既往报道表明，这种疾病几乎仅发生于免疫功能低下的患者，大多数患者死于进行性呼吸衰竭。在本文中，我们描述了最大系列的免疫功能正常的粟粒性球孢子菌病患者，明确了临床特征，并概述了诊断和治疗的重要方面。
我们确定了1990年至1997年在克恩医疗中心（位于流行区）诊断为粟粒性球孢子菌病的8例患者（5例男性和3例女性；年龄范围23至65岁）。其中4例患者为白人，2例为非裔美国人，2例为西班牙裔。粟粒样表现定义为胸部X线片显示两肺野弥漫性分布直径2至10毫米的离散病灶。通过痰液、组织或体液的显微镜检查及球孢子菌培养确诊。排除HIV患者。
这些患者约占1990年至1997年我院收治的球孢子菌病患者的1%。4例患者入院前症状持续≤1周（急性），4例患者症状持续5至12周（慢性）。4例患者初诊胸部X线片显示粟粒样表现，其中2例最初诊断为粟粒性球孢子菌病。5例患者需要机械通气。动脉血气测量显示平均动脉血氧分压为54.2±8.6毫米汞柱，平均动脉血二氧化碳分压为32.5±3.2毫米汞柱。5例患者发生急性呼吸窘迫综合征（ARDS）。5例患者有肺外受累，最常见的部位是脑膜（4例）和皮肤（4例）。所有患者均接受氟康唑和/或两性霉素B治疗。3例患者死亡；均为慢性病程且接受了机械通气。
我们报告了8例免疫功能正常的患者，其死亡率低于既往报道，预后更好。在我们的系列研究中，粟粒性球孢子菌病表现为急性呼吸疾病或在广泛播散背景下发生的慢性疾病的晚期阶段。所有死亡患者均为慢性病程。及时识别粟粒性球孢子菌病至关重要，但可能因鉴别诊断范围广而受到阻碍。重要的诊断因素包括有在流行区旅行史、种族、免疫状态、多器官受累以及胸部X线片所示肺部受累程度无法解释的明显低氧血症。
