ZSFG AM Report Pearls 6/26/2017 – Cavitary Lung Lesions and Cocci, Cocci, Cocci

Thank you to Amy Ni, our rockstar pulmonology consultant, for presenting a very interesting case of a patient with an upper lobe cavitary lesion, whose work up revealed a diagnosis of pulmonary coccidioidomycosis.

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Top Pearls:

  • While there are many etiologies of cavitary lung lesions, TB should be strongly considered as a highly likely diagnosis, especially in the patient population at ZSFG. (See below for details).
  • Think about pulmonary coccidiodomycosis in patients with cavitary lesions with negative AFB smears and negative GeneXperts who had had exposure in endemic areas.
  • There are many ways to test for coccidiodomycosis, and the diagnostic approach is driven by localizing symptoms but Cocci can be found in serum, CSF, and in sputum samples or BAL

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DDx for Cavitary Lung Lesions:

  • What Causes a Cavity?
    1) Necrosis
         Suppurative necrosis – pyogenic abscess
         Caseous necrosis – tuberculosis
         Ischemic necrosis – pulmonary infarction
         Malignant necrosis – treatment related necrosis, internal liquefaction of tumor
    2) Cystic Dilation of Lung – ball valve lesion
    3) Replacement of Lung with Cysts – ex/ echinococcus infection
    Non-Infectious Causes of Lung Cavities:
    1) Malignancy
         a. Primary lung malignancy
         b. KS and lymphoma
         c. Metastatic Cancer to lung
    2) Rheumatologic Disease
         a. GPA (49% with cavitary nodules and 17% with cavitary consolidations in one study)
         b. Sarcoid (rare cavitation of nodules)
    3) Various Others – PE with pulmonary necrosis, cryptogenic organizing pneumonia, pulmonary Langerhans’ cell histocytosis
    Infectious Causes of Lung Cavities:
    1) Mycobacterial Infectious
         a. TB – cavities can be multiple and occurring in areas of consolidation
         b. NTM – more likely to be cavitary lung nodules
    2) Necrotizing Bacterial PNA and Lung Abscess
         a. S. aureus and Klebsiella PNA are more common causes
         b. S. pneumo and H. flu with CAP, but uncommon
    3) Uncommon Bacterial Infections
         a. Actinomycosis
         b. Meliodosis (ask LT about this one!)
         c. Rhodococcus equi
    4) Fungal Infections
         a. Aspergillosis
         b. Histoplasmosis, blastomycosis, coccidiomycosis, paracoccidiomycosis

Link to Great Article on Cavitary Lung Lesions: http://cmr.asm.org/content/21/2/305.long

Where Exactly Is Coccidioidomycosis Endemic?:

Cocci Endemic Areas

Extrapulmonary Cocci:

  • Occurs in 4.7% of recognized cocci infections, 0.2% of all respiratory infections
  • Individuals of African of Filipino ancestry or immunosuppressed patients are at greater risk of extrapulmonary infection
  • Common Sites
    • Skin or subcutaneous tissues
    • Skeleton
      • Joint involvement – often a single joint
      • Vertebral infection – may be single or multiple joints
  • Meninges – very serious if seen here

 

Cocci Diagnostic Options:

  • Serum: Cocci Ab Immunodiffusion test – screening serum test (IgM and IgG)
    • Not helpful if already confirmed from
  • Serum Cocci Ab Complement Fixation test – can provide a titer that can be followed
  • CSF: Cocci Ab Complement Fixation – can provide a titer that can be followed
    • Consider LP and testing if any Neurologic change or Altered mental status and confirmed Cocci in another location
  • -Sputum/Biopsy of Affected Organ: histopathology (visualizing spherules) or culture

 

Reference:

 

Evernotes:

  • Cavitary Lung Disease: https://www.evernote.com/shard/s509/sh/4527dd88-40e4-4aa0-9ec8-4bad276419be/7f247396c07258b0415e725ea4173222
  • Cocci Info: https://www.evernote.com/shard/s509/sh/ed7a2003-57db-4966-a7b9-40847d8f18cb/7607e766e7a851750b4fbef67a88600a
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