Fatal septic shock due to disseminated coccidioidomycosis: a case series and review of the literature

Abstract

Background: Coccidioidomycosis is a fungal infection endemic to the southwestern United States and regions of Latin America. Disseminated disease occurs in < 1% of cases. Septic shock is even rarer, with high mortality despite therapy. We describe two cases of coccidioidal septic shock. Both patients were older men of Filipino ancestry presenting with respiratory failure and vasopressor-dependent shock. Antifungal drugs were initiated after failure to improve with empiric antibiotics; in both, Coccidioides was isolated from respiratory cultures. Despite aggressive care, both patients ultimately died of their infections. We provide a review of the published literature on this topic.

Conclusions: Most of the 33 reported cases of coccidioidal septic shock occurred in men (88%) of non-white race and ethnicity (78%). The overall mortality rate was 76%. All survivors received amphotericin B as part of their treatment. Coccidioidomycosis-related septic shock is a rare disease with poor outcomes; delays in diagnosis and treatment are common. Improved diagnostic testing for coccidioidomycosis could enhance recognition of this disease in the future. Although data are limited, early treatment with amphotericin B in cases of coccidioidal septic shock may reduce mortality.

Keywords: Coccidioides; Coccidioidomycosis; Sepsis; Septic shock.

Fig. 1

Non-contrast enhanced computed tomography of the chest, patient #1, demonstrating multifocal airspace opacities and a left pleural effusion with a tube thoracostomy in place

Fig. 2

A Lung tissue from autopsy, patient #1, 40 × magnification, PAS-D stain, demonstrating the characteristic spherules of Coccidioides

Fig. 3

Anteroposterior radiograph of the chest, patient #2, demonstrating a cavitary lesion in the left upper lobe