TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Clinical course and management of severe acute respiratory syndrome COVID-2 (Covid-19) infection has been full of uncertainties. As a viral respiratory illness, its presentation can be very similar to other respiratory diseases. Therefore, it is essential to have a high degree of suspicion for superimposed bacterial and fungal infections. CASE PRESENTATION: A 65-year-old male with insulin-dependent diabetes mellitus presented to the emergency department with fever, sudden shortness of breath, cough, and diffuse chest discomfort. Upon arrival his blood pressure was 155/76 mmhg, heart rate 91 bpm, respiratory rate of 22, with temperature of 101.9 F. The patient's Covid-19 PCR nasopharyngeal swab resulted positive. Imaging showed moderate to severe bilateral lung ground-glass infiltrates and consolidation pattern and a 1.9 cm, left upper lobe cavitary lesion. No prior imaging was available for review. Patient was treated with supplemental oxygen, antibiotic therapy for community acquired pneumonia, Remdicivir, and convalescent plasma therapy. Given low suspicion for active TB, steroid therapy was continued. Patient's QuantiFERON gold resulted positive, and he was found to have positive coccidioides IgG, but the complement fixation titer was negative on the day of admission. Three AFB samples, serum (1-3)-beta-D-Glucan assay and Aspergillus assay resulted negative. Bronchoalveolar lavage was performed. Serum coccidioides antibody complement fixation and immunodiffusion results were made available after the patient's passing, which showed positive for IgG and IgM with titers 1:256. Bronchoalveolar lavage cultures revealed Coccidioides Posadasii and Immitis. DISCUSSION: Coccidioidomycosis, commonly known as valley fever, is caused by dimorphic fungi of the Coccidioides family, which is endemic to California, south-central Washington, and northern Mexico. Pulmonary Coccidioides has a similar clinical presentation to Covid-19 infection and seldom, associated with cavitary lesions. Fever, cough, and shortness of breath are the most common presenting symptoms. Radiographic findings vary with COVID -19 showing bilateral peripheral ground glass opacifications with or without consolidations. Among the bacterial co-infections, streptococcus pneumoniae is the most common followed by Klebsiella pneumoniae and Haemophilus influenzae. Due to lengthy wait periods for many laboratory studies to be resulted, it is challenging to distinguish co-infection cases. Reactivation of coccidiodes has been seen in patients with HIV, and patients on chemo and immunotherapy despite antifungal prophylaxes. CONCLUSIONS: Given nonspecific radiological findings of Covid-19 infection that are seen with other causes of pneumonia and its uncertain and similar clinical course to other respiratory infections, it is crucial to have a high degree of suspicion for superimposed bacterial and fungal infections. REFERENCE #1: Freedman M, Jackson BR, McCotter O, Benedict K. Coccidioidomycosis Outbreaks, United States and Worldwide, 1940-2015. Emerg Infect Dis. 2018;24(3):417-423. doi:10.3201/eid2403.170623 REFERENCE #2: Galgiani JN, Ampel NM, Blair JE, et al. 2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Treatment of Coccidioidomycosis. Clin Infect Dis. 2016;63(6):e112-e146. doi:10.1093/cid/ciw360 REFERENCE #3: Zhu X, Ge Y, Wu T, et al. Co-infection with respiratory pathogens among COVID-2019 cases. Virus Res. 2020;285:198005. doi:10.1016/j.virusres.2020.198005 DISCLOSURES: No relevant relationships by Nami Moradi, source=Web Response No relevant relationships by Paloma Rivero-Moragrega, source=Web Response
REACTIVATION OF PULMONARY COCCIDIOIDES IN THE SETTING OF COVID-19 INFECTION