Pediatric coccidioidal orbital granuloma

Abstract

Purpose: To report a case of orbital coccidiomycosis in an otherwise healthy 11-month-old male.

Observations: An 11-month-old male presented to his pediatrician with parental complaints of swelling, erythema, and pain of the right orbit that increased over ten days in the absence of constitutional symptoms. The child's parents reported an earlier fall onto a carpeted floor. After four weeks of conservative treatment and a course of oral cephalexin, he developed a fever, increased erythema, and palpable enlargement of a mass posterior to the lower eyelid. Ultrasound revealed an encysted mass in the inferior orbit, suggestive of an abscess. Urgent ophthalmic referral led to incision and drainage via orbitotomy. Culture, histopathology, and serological testing were positive for Coccidioides spp.. Blood studies revealed mild anemia and thrombocytosis. There was complete resolution of symptoms after surgical drainage and several weeks of oral fluconazole.

Conclusion and importance: We describe a patient with orbital coccidiomycosis without apparent systemic involvement, following what was most likely an unrelated minor trauma. Despite being rare, orbital coccidiomycosis should be considered as a primary manifestation of infection when ocular inflammation is encountered, especially in endemic regions.

Keywords: Coccidioides spp.; Coccidioidomycosis; Granulomatous disease; Orbit granuloma; Valley fever.

Fig. 1

Real time ultrasound of mass below right eye. The scans and measurements indicate a complex thick-walled cystic lesion in subcutaneous tissues of the orbit, measuring approximately 1.5 cm horizontally X 1.07 cm anterior-posteriorly. The companion Doppler studies indicated prominent surrounding vascularity.

Fig. 2

Photomicrographs of C. immitis/podasaii from an orbital specimen. (A) A section stained with H&E showing an encapsulated spherule with a distinctive thick-walled capsule containing deteriorating endospores in an acute and chronic inflammatory infiltrate (X400). (B) Higher magnification of the same section (X1,000). (C) Section stained with GMS demonstrating the thick walled spherule (X400).