0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Special Feature |

Image of the Month—Quiz CaseImage of the Month—Quiz Case FREE

Eric C. Nelson, MD; George R. Thompson, MD; Tamas J. Vidovszky, MD
[+] Author Affiliations

Author Affiliations: Department of Surgery (Drs Nelson and Vidovszky) and Division of Infectious Diseases, Department of Internal Medicine, University of California, Davis, Medical Center (Dr Thompson), University of California, Davis, Sacramento, and Department of Medical Microbiology and Immunology, Coccidioidomycosis Serology Laboratory, University of California, Davis, Davis (Dr Thompson).


Arch Surg. 2012;147(1):95. doi:.
Text Size: A A A
Published online

A 53-year-old African American man presented with abdominal bloating and pain over 3 weeks. Intermittent nausea and vomiting was associated with the pain and he lost about 11 kg over the past 3 months despite good appetite. Three months prior, he had several weeks of dry cough and was diagnosed with walking pneumonia. This was treated with antibiotics and resolved. The patient had no medical problems and was human immunodeficiency virus (HIV) negative. He had an umbilical hernia repaired many years ago and did not take any medications. He did not smoke. He worked doing home construction in central California.

On examination, the patient had normal vital signs and appeared well. His abdomen was distended with a fluid wave and he had mild right upper quadrant tenderness but no rebound, guarding, or masses. Chemistry, complete blood cell count, and liver function test findings were significant only for mild anemia. Results of an upper endoscopy were normal. Computed tomography of his abdomen and pelvis demonstrated studding of his peritoneal lining (Figure 1) and large ascites as well as a 2-cm nodule in his right lower lobe. Chest computed tomography demonstrated no further abnormalities and the lesion was biopsied under computed tomographic guidance with findings of “granulomatous disease.” A paracentesis aspirated 1.4 L of serous ascitic fluid that showed numerous lymphocytes but pathology and culture results were negative. The patient then underwent diagnostic laparoscopy with peritoneal biopsy with findings as shown in Figure 2.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. Peritoneal studding on the anterior wall of the abdomen seen during laparoscopy.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. Pathology specimen of peritoneal biopsy.

A.  Adenocarcinomatosis of unknown primary origin

B.  Disseminated coccidioidomycosis

C.  Peritoneal tuberculosis

D.  Primary peritoneal mesothelioma

Coccidioidomycosis refers to the spectrum of disease caused by Coccidioides species and clinical manifestations vary. Coccidioides are soil-dwelling fungi that exist solely in semiarid to arid areas and the incidence of infection has increased in recent years owing to population growth and accompanying construction within the southwestern United States.1,2 Individuals whose occupations involve the frequent aerosolization of soil are at particularly high risk of contracting coccidioidomycosis. Additionally, the increased number of immunosuppressed patients due to the use of immune-modulating drugs,3 transplants,4,5 and HIV6 have also contributed to the increased incidence.

An ethnic predisposition to coccidioidal infection causes Filipino and African American patients to have a disproportionate burden of disseminated disease with a 10- to 175-fold higher relative risk. Extrapulmonary disease most commonly manifests in the skin, joints, or central nervous system. Peritoneal coccidioidomycosis is an unusual extrapulmonary manifestation of infection affecting less than 1% of all patients with coccidioidomycosis. Most present with abdominal pain, swelling, or the new onset of an inguinal hernia.7 Rare cases have presented with abdominal or pelvic mass lesions, including 1 case presenting with vaginal prolapse.7,8 Despite peritoneal disease representing disseminated infection, fever is uncommon, found at presentation in only 5 of 26 prior cases.7 Diagnosis was established in 4 of 26 cases by nonsurgical means using culture of the ascitic fluid. Interestingly, 8 of 26 cases had the diagnosis incidentally discovered during herniorrhaphy after thick edematous tissue or granulomas were noted within the hernia sac. All patients demonstrated Coccidioides -specific antibody titers 1:16 or more, a value consistent with disseminated disease.9 Three patients ultimately died of disseminated coccidioidomycosis despite only 14 of 26 receiving antifungal therapy. Of these 3 mortalities, only 1 had been treated with amphotericin B (an HIV-positive patient with a CD4 cell count of 10); the other 2 did not receive treatment for unclear reasons. One other patient was HIV positive (CD4 cell count <200) and was treated with amphotericin B, eventually clearing the infection. Ultimately, 19 of 26 exhibited a complete response with no evidence of ongoing infection at follow-up. Of these 19, 5 cleared their infection without any antifungal treatment. These observations suggest the role of host immunogenetics in the ultimate control of invasive fungal infection.

Based on these findings, peritoneal coccidioidomycosis has a better prognosis than other extrapulmonary manifestations and is one of the few coccidioidal infections that may be cured. In our experience, during acute presentation, high-dose triazoles such as fluconazole or a lipid amphotericin B formulation should be administered. Following stabilization of disease, treatment with fluconazole or another triazole should be initiated until the patient returns to baseline and serologic titers have declined to normal values. At this time, discontinuation of antifungal therapy may be appropriate.

This case illustrates the potential for coccidioidal infection to mimic other pathology. Similar to the approach to pulmonary nodules within Coccidioides endemic regions where Coccidioides- specific serologies are obtained in an attempt to avoid unnecessary procedures, we advocate considering coccidioidal infection in all patients residing in or traveling to an endemic area if clinical parameters suggest the possibility of this diagnosis.

Submissions

The Editor welcomes contributions to the Image of the Month. Manuscripts should be submitted via our online manuscript submission and review system (http://manuscripts.archsurg.com). Articles and photographs accepted will bear the contributor's name. Manuscript criteria and information are per the Instructions for Authors for Archives of Surgery (http://archsurg.ama-assn.org/misc/ifora.dtl). No abstract is needed, and the manuscript should be no more than 3 typewritten pages. There should be a brief introduction, 1 multiple-choice question with 4 possible answers, and the main text. No more than 2 photographs should be submitted. There is no charge for reproduction and printing of color illustrations.

Correspondence: Tamas J. Vidovszky, MD, Department of Surgery, Division of Gastrointestinal Surgery, University of California, Davis, Health System, 2221 Stockton Blvd, 3rd Floor, Sacramento, CA 95817 (tamas.vidovszky@ucdmc.ucdavis.edu).

Accepted for Publication: April 26, 2011.

Author Contributions:Study concept and design: Nelson, Thompson, and Vidovszky. Acquisition of data: Thompson. Drafting of the manuscript: Nelson, Thompson, and Vidovszky. Critical revision of the manuscript for important intellectual content: Thompson and Vidovszky. Administrative, technical, and material support: Nelson. Study supervision: Thompson and Vidovszky.

Financial Disclosure: None reported.

Sunenshine RH, Anderson S, Erhart L,  et al.  Public health surveillance for coccidioidomycosis in Arizona.  Ann N Y Acad Sci. 2007;1111:96-102
PubMed   |  Link to Article
Centers for Disease Control and Prevention (CDC).  Increase in coccidioidomycosis: California, 2000-2007.  MMWR Morb Mortal Wkly Rep. 2009;58(5):105-109
PubMed
Bergstrom L, Yocum DE, Ampel NM,  et al.  Increased risk of coccidioidomycosis in patients treated with tumor necrosis factor alpha antagonists.  Arthritis Rheum. 2004;50(6):1959-1966
PubMed   |  Link to Article
Blair JE, Logan JL. Coccidioidomycosis in solid organ transplantation.  Clin Infect Dis. 2001;33(9):1536-1544
PubMed   |  Link to Article
Glenn TJ, Blair JE, Adams RH. Coccidioidomycosis in hematopoietic stem cell transplant recipients.  Med Mycol. 2005;43(8):705-710
PubMed   |  Link to Article
Masannat FY, Ampel NM. Coccidioidomycosis in patients with HIV-1 infection in the era of potent antiretroviral therapy.  Clin Infect Dis. 2010;50(1):1-7
PubMed   |  Link to Article
Phillips P, Ford B. Peritoneal coccidioidomycosis: case report and review.  Clin Infect Dis. 2000;30(6):971-976
PubMed   |  Link to Article
Saw EC, Shields SJ, Comer TP, Huntington RW Jr. Granulomatous peritonitis due to Coccidioides immitis Arch Surg. 1974;108(3):369-371
PubMed   |  Link to Article
Galgiani JN, Ampel NM, Catanzaro A, Johnson RH, Stevens DA, Williams PL.Infectious Diseases Society of America.  Practice guideline for the treatment of coccidioidomycosis.  Clin Infect Dis. 2000;30(4):658-661
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. Peritoneal studding on the anterior wall of the abdomen seen during laparoscopy.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. Pathology specimen of peritoneal biopsy.

Tables

References

Sunenshine RH, Anderson S, Erhart L,  et al.  Public health surveillance for coccidioidomycosis in Arizona.  Ann N Y Acad Sci. 2007;1111:96-102
PubMed   |  Link to Article
Centers for Disease Control and Prevention (CDC).  Increase in coccidioidomycosis: California, 2000-2007.  MMWR Morb Mortal Wkly Rep. 2009;58(5):105-109
PubMed
Bergstrom L, Yocum DE, Ampel NM,  et al.  Increased risk of coccidioidomycosis in patients treated with tumor necrosis factor alpha antagonists.  Arthritis Rheum. 2004;50(6):1959-1966
PubMed   |  Link to Article
Blair JE, Logan JL. Coccidioidomycosis in solid organ transplantation.  Clin Infect Dis. 2001;33(9):1536-1544
PubMed   |  Link to Article
Glenn TJ, Blair JE, Adams RH. Coccidioidomycosis in hematopoietic stem cell transplant recipients.  Med Mycol. 2005;43(8):705-710
PubMed   |  Link to Article
Masannat FY, Ampel NM. Coccidioidomycosis in patients with HIV-1 infection in the era of potent antiretroviral therapy.  Clin Infect Dis. 2010;50(1):1-7
PubMed   |  Link to Article
Phillips P, Ford B. Peritoneal coccidioidomycosis: case report and review.  Clin Infect Dis. 2000;30(6):971-976
PubMed   |  Link to Article
Saw EC, Shields SJ, Comer TP, Huntington RW Jr. Granulomatous peritonitis due to Coccidioides immitis Arch Surg. 1974;108(3):369-371
PubMed   |  Link to Article
Galgiani JN, Ampel NM, Catanzaro A, Johnson RH, Stevens DA, Williams PL.Infectious Diseases Society of America.  Practice guideline for the treatment of coccidioidomycosis.  Clin Infect Dis. 2000;30(4):658-661
PubMed   |  Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections