The coccidioidomycosis conundrum: a rare parotid mass

Abstract

A man, age 62 years, presented to the clinic with a 2-week history of increased nontender, nonerythematous, indurated right-sided parotid swelling. A 4 × 6-cm firm, well-circumscribed mass was palpated in the right parotid gland. A fine-needle aspiration biopsy was performed on the parotid mass with aspiration of 0.5 cc of purulent fluid with some blood. Cultures from the aspirate revealed Coccidioides immitis confirmed by DNA probe. Pathology slides revealed fungal spores. The patient was treated with 800 mg of fluconazole every day for 3 months with resolution of the parotid swelling. However, persistent cervical adenopathy remains.Although this is a rare case of acute parotid swelling, Coccidioides immitis should be considered in the differential diagnosis of parotid masses in a patient with previous coccidioidomycosis. There may be a potential for an increase in frequency and variety of atypical extrapulmonary manifestations of coccidioidomycosis that parallels the increase in coccidioidomycotic pulmonary infections. Long-term antifungal therapy appears essential for control.

Figure 1a.

(left) Initial presentation. A man, age 62 years, presented to the clinic with a 2-week history of increased nontender, nonerythematous, indurated right-sided parotid swelling. A 4 × 6-cm firm, well-circumscribed mass was palpated in the right parotid gland.

Figure 1b.

(right) After treatment. The patient was initially given augmentin, but after histology, magnetic resonance imaging, and DNA probe confirmation, the treatment was switched to 800 mg fluconazole every day. At 3 months, parotid swelling was noted to be greatly improved.

Figure 2.

Coronal magnetic resonance imaging of the parotid mass. Multiplanar multisequence magnetic resonance images of the soft tissues of the neck were obtained using a 1.5-T scanner without and with Magnevist 20 mL intravenous gadolinium. A coronal T1-weighted sequence with fat saturation is seen here.

Figure 3.

Axial magnetic resonance imaging of the parotid mass. Multiplanar multisequence magnetic resonance images of the soft tissues of the neck were obtained using a 1.5-T scanner without and with Magnevist 20 mL intravenous gadolinium. An axial T1-weighted sequence with fat saturation after gadolinium is seen here.

Figure 4.

Histopathology of fine-needle aspirate with oil immersion lens microscopy. High-power microscopy revealed Coccidioides immitis spherules (< 70 μm in diameter), containing the classic endospores. Macrophages and polymorphonuclear neutrophils dominated the tissue reaction.