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Special Feature
January 2012

Image of the Month—Diagnosis

Arch Surg. 2012;147(1):96. doi:10.1001/archsurg.2011.656b

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.