Fatal coccidioidomycosis involving the lungs, brain, tongue, and adrenals in a cirrhotic patient. An autopsy case

Abstract

In this paper, we describe a case of fatal disseminated coccidioidomycosis (CM). The patient was a 44-year old male with a history of cirrhosis who presented with altered mental status, cough, and an enlarged, ulcerated tongue. On evaluation, the patient was found to have coccidioidal infection of the tongue, lungs, and brain. Despite over two months of antifungal treatment, the patient died from aspiration pneumonia and at autopsy was found to have persistent infection of the tongue and lungs, extensive mycosis of the brain, and involvement of both adrenal glands. The fulminant course of coccidioidomycosis in this patient is ascribed to his baseline cirrhosis and lymphocytopenia. There are few autopsy cases of CM that have been described in the post-antifungal era and few published cases of CM with either tongue or adrenal involvement.

Keywords: Adrenals; Autopsy; Brain; Cirrhosis; Coccidioidomycosis; Lungs; Tongue.

Fig. 1

Photographs of the case patient showing: A (left) enlargement of the tongue and blood-encrusted nares; B (right), ulcer of the right buccal mucosa.

Fig. 2

Computerized tomograph of the chest showing tree-in-bud pattern indicative of bronchiolar obstruction.

Fig. 3

Section of the tongue showing squamous mucosa with thick-walled spherules (arrow) of Coccidioides in the lamina propria (Hematoxylin and Eosin stain (H&E), x200).

Fig. 4

Section of the lung showing necrosis (left-pointing arrow) with abundant thick-walled spherules of Coccidioides (star), some containing endospores (down arrow) surrounded by histiocytes (H&E, x200).

Fig. 5

Photomicrograph of a section of the brain showing spherules of Coccidioides (right-pointing arrow) surrounded by chronic inflammatory cells (left-pointing arrow), including lymphocytes and plasma cells (H&E, ×400).

Fig. 6

Photomicrographs of sections of the adrenal gland showing: A (left), spherules of Coccidioides (right-pointing arrow), multinucleated giant cells (down arrow) and marked chronic inflammation (star) (H&E x100); B (right), spherules of C. immitis (down arrow), histiocytes (right-pointing arrow) and chronic inflammatory cells (left-pointing arrow) (H&E, x400).