Brooke Army Medical Center San Antonio, TX, United States
Cyrus V. Edelson, MD, Matthew Schwartz, MD, Jerome Edelson, MD Brooke Army Medical Center, San Antonio, TX
Introduction: Recent liver transplantation and subsequent immunosuppression are known to be high risk for opportunistic infections and disseminated infectious processes. Diagnosis of Coccidiomycosis utilizing liver biopsy is atypical, despite post-mortem findings suggestive of frequent hepatic involvement in the setting of disseminated disease. We present a case of disseminated coccidiomycosis diagnosed in a post-orthotopic transplant following routine post-transplant liver biopsy and confirmed using serology and bronchioalveolar lavage.
Case Description/Methods: Our patient is a 57-year-old male with a history significant for NASH cirrhosis status-post orthotopic liver transplant with minimal complications during the peri-operative period on standard immunosuppression and infectious prophylaxis. Three weeks post transplantation, he was admitted for septic shock with unclear source. On chart review, no significant toxic or infectious exposures beyond his residence in central Mexico were identified. Initial infectious workup was remarkable for elevated fungitel (263 pg/mL). His hospitalization was complicated by respiratory failure requiring intubation. Chest CT demonstrated scattered nodular and ground glass opacities concerning for atypical infection. Worsening liver dysfunction prompted a liver biopsy which showed fungal elements surrounded by granulomatous inflammation consistent with coccidiomycosis. Bronchoalveolar lavage and Coccidio-CF antibody both confirmed coccidiomycosis and Amphotericin-B was initiated.
Discussion: Coccidiomycosis is a rare infectious process that can be potentially fatal in immunosuppressed or immunocompromised patients without prompt identification and diagnosis. Coccidiomycosis can be diagnosed by multiple modalities to include serologic testing, blood cultures, PCR, and histology via bronchoalveolar lavage. Tissue histology, although atypical, can also be diagnostic in disseminated disease. Therefore, our patient’s liver biopsy confirmed the diagnosis. Although our patient’s presentation is atypical when contrasted with pulmonary forms of the disease, disseminated Coccidioides infection remains a high concern in endemic regions, especially among immunosuppressed patients who may see infection re-activation. Thus, coccidiomycosis should be in the differential diagnosis of any post-transplant patient from an endemic region presenting with sepsis. In our case, findings of Coccidioides on liver biopsy were consistent with disseminated disease, and represent a rare finding.
Figure: Coccidioides species, liver biopsy
Disclosures: Cyrus Edelson indicated no relevant financial relationships. Matthew Schwartz indicated no relevant financial relationships. Jerome Edelson indicated no relevant financial relationships.
Cyrus V. Edelson, MD, Matthew Schwartz, MD, Jerome Edelson, MD. P1936 - Better Biopsy That: Disseminated Coccidiomycosis in Post-Orthotopic Transplant Patient, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.