University of Texas Health Sciences Center, San Antonio, TX, USA.
J Investig Med High Impact Case Rep. 2020 Jan-Dec;8:2324709620949315. doi: 10.1177/2324709620949315.
A 35-year-old male presented to our university hospital with night sweats, fevers, ulcerated skin lesions to the lower mouth and posterior neck, shortness of breath, and an enlarging cervical lymph node. The patient was evaluated 2 months prior for respiratory symptoms, cervical lymphadenopathy, and skin lesions resulting in a diagnosis of primary pulmonary coccidioidomycosis and was treated with a 4-week course of fluconazole. On presentation to our hospital, initial laboratory test results revealed leukocytosis, increased liver enzymes, elevated inflammatory markers, and hypercalcemia. Computed tomography scan of the chest revealed lung nodules in a miliary pattern and prominent mediastinal lymphadenopathy. Magnetic resonance imaging revealed multiple vertebral and iliac bone lesions, as well as bilateral psoas muscle lesions. Serum ELISA (enzyme linked immunosorbent assay) detected elevated serological markers against coccidioides, and sputum culture revealed coccidioides arthroconidia, confirming the presence of an acute coccidioides infection. Biopsy of the right iliac crest and cervical lymph node revealed spherules resembling coccidioides, escalating the diagnosis to disseminated coccidioidomycosis. The patient's hospital course was complicated by septic shock, acute respiratory distress syndrome requiring several days of mechanical ventilation, and acute kidney injury. He was ultimately treated with several weeks of voriconazole and liposomal amphotericin-B. He made a full recovery and was discharged on an extended course of oral voriconazole. Our case highlights the importance of recognition and appropriate treatment duration of disseminated coccidioidomycosis at initial presentation. Failure to do so may lead to increased morbidity and mortality.
一位 35 岁男性因夜间出汗、发热、口腔下部和后颈部溃疡性皮肤损伤、呼吸急促和颈部淋巴结肿大而到我们的大学医院就诊。两个月前，该患者因呼吸道症状、颈部淋巴结病和皮肤损伤就诊，被诊断为原发性肺球孢子菌病，并接受了氟康唑 4 周疗程的治疗。该患者此次到我院就诊时，最初的实验室检查结果显示白细胞增多、肝酶升高、炎症标志物升高和高钙血症。胸部计算机断层扫描显示肺部结节呈粟粒状，纵隔淋巴结肿大明显。磁共振成像显示多个椎体和髂骨病变，以及双侧腰大肌病变。血清 ELISA（酶联免疫吸附试验）检测到针对球孢子菌的血清学标志物升高，痰培养显示球孢子菌分生孢子，证实存在急性球孢子菌感染。右髂嵴和颈部淋巴结活检显示类似于球孢子菌的球体，将诊断升级为播散性球孢子菌病。该患者的住院过程复杂，出现败血症性休克、需要数天机械通气的急性呼吸窘迫综合征和急性肾损伤。最终，他接受了数周的伏立康唑和脂质体两性霉素 B 治疗。他完全康复，并出院接受延长疗程的口服伏立康唑治疗。我们的病例强调了在初次就诊时识别和适当治疗播散性球孢子菌病的重要性。如果不这样做，可能会导致发病率和死亡率增加。
