A 34-year-old, HIV positive male came to the emergency department with a one-week history of fever, headache, and confusion.
Physical examination revealed his body temperature of 39.3°C, and a large ulcer on his tongue (Panel A).
Investigations showed the following results:
- CD4 count – 39 cells per cubic millimeter (reference range, 500 to 1450)
- HIV viral load – 197,000 copies per milliliter.
- IgG antibodies to coccidioides in the blood, and cerebrospinal fluid (CSF)
- Coccidioides antigen in the blood, CSF, urine, and in the fluid sample obtained from bronchoalveolar lavage.
- Fungal culture of the bronchoalveolar lavage grew coccidioides.
- A chest radiograph revealed bilateral patchy infiltrates.
To further strengthen the diagnosis, histopathological evaluation was conducted on a sample taken from the ulcerative lesion on the tongue. The cultures grew multiple fungi with coccidioides spherules (Panel B).
Treatment was initiated with antifungals, amphotericin B and fluconazole, for 2 weeks, followed by fluconazole monotherapy. Some adjustments were made in his antiretroviral drugs when HIV genotype testing showed resistance to one of the drugs.
At a 3-month follow-up, the patient’s symptoms had subsided, the lesion on his tongue had substantially reduced in size, and the HIV viral load dropped to undetectable levels. It wasn’t possible to trace the treatment success further as the patient subsequently lost to follow-up.
Human Immunodeficiency Virus affects the capability of an individual to fight infection. This is because the virus attacks and impairs the function of the immune cells making the patient vulnerable to opportunistic infections. With a weakened immune system, the normally harmless pathogens can infect the patient, and the normally less severe and limited infection tends to spread widely through the body with increased severity.
with coccidiosis can be locally confined with competent T cell lymphocytes.
In an HIV positive patient, the replication of the virus and the defective T cell function fails to contain the fungal infection; thus, such immunocompromised patients are more prone to a severe, progressive, and disseminated infection.
Acute coccidioidomycosis in patients with the competent immune system is usually self-limiting and thus spontaneously resolves without any specific treatment. On the contrary, immunocompromised patients, such as HIV patients, have disseminated disease, that is, pulmonary and extrapulmonary manifestations are present; therefore, antifungal treatments are warranted. In a few cases, surgical debridement/removal of the affected tissues or localized lesions may also be necessary along with the antifungal drugs.
Some studies have shown evidence suggesting beneficial effects of lifelong treatment with antifungals for HIV-related coccidioidomycosis. It is also imperative to counsel immunocompromised patients to avoid endemic areas or minimize prolonged exposure to soil and dust (Coccidioides dwells here), as much as possible.
These fungal infections may not be harmful in immunocompetent individuals but can have fatal consequences in immunosuppressed patients.
Robert A. Myers, M. a. (2019, June 06). Disseminated Coccidioidomycosis. Retrieved from The New England Journal of Medicine: https://www.nejm.org/doi/full/10.1056/NEJMicm1811100
McNeil MM, Ampel NM. Opportunistic coccidioidomycosis in patients infected with human immunodeficiency virus: prevention issues and priorities. Clin Infect Dis. 1995 Aug;21 Suppl 1:S111-3