1179 - Septic shock in Coccidioides immitis Infection

Background: Coccidiodes can cause severe or disseminated disease in a minority of patients, but coccidioidomycosis resulting in septic shock is rare.  We describe a case of fulminant C. immitis infection whose diagnosis was delayed by a markedly elevated serum procalcitonin. We review the published literature of coccidioidomycosis complicated by septic shock.

Case Report

A 74-year-old man presented with cough, fever, and three weeks of progressive decline. He was febrile at 39.1°C, tachycardic, and tachypneic with crackles in the left lung; an initial procalcitonin (PCT) was 1.73 ng/mL. Broad-spectrum antibacterials were administered. His condition worsened on the 2nd day, requiring vasopressors, endotracheal intubation, and hemodialysis. PCT rose to > 400 ng/mL.  Respiratory cultures grew fungi consistent with Coccidioides.  Liposomal amphotericin B (AmB) was initiated. His shock progressed, and he died on hospital day 6.

Methods: We performed a MEDLINE and Google Scholar search using the terms “coccidioidomycosis”, “Coccidioides”, “sepsis”, and “septic shock”. Indexed articles and conference abstracts were included if the patient had confirmed coccidioidomycosis and vasopressor-dependent shock with no alternate cause. Data on age, sex, ethnicity, comorbidities, antifungal therapy, and outcome were tabulated.

Results: We identified 18 reports describing 31 patients with vasopressor-dependent septic shock due to Coccidioides since 1993 (table 1). Of these cases, 23/31 (74.2%) died. Of those with reported race/ethnicity, 20/23 were Latino, 4/23 of African descent, 5/23 Asian-Pacific Islander, and 3/23 white. 27/31 (87.1%) were male. All but two were adults (median age 51.5 years). 21/31 (67.7%) had reported comorbid conditions. 20/31 patients (64.5%) and all of the survivors received AmB-based therapy.Table 1 - Published cases of coccidioidomycosis complicated by septic shock. All ages are in years. Abbreviations: HIV/AIDS = human immunodeficiency virus/acquired immunodeficiency syndrome; CAD = coronary artery disease; COPD = chronic obstructive pulmonary disease; ESRD = End stage renal disease; SLE = Systemic Lupus Erythematosus; APC = recombinant human activated protein C (drotrecogin alfa).


Conclusion: Coccidioidomycosis is an elusive diagnosis in critically-ill patients due to its rarity, the lack of rapid diagnostics, and its propensity to mimic other infections. Mortality is high, potentially due to delays in diagnosis. The marked elevation in PCT has not been previously noted in coccidioidomycosis and may further confound diagnosis. Improved diagnostics and the rapid institution of AmB may reduce mortality in patients with coccidioidal sepsis.