coccidioidomycosis presenting as an omental mass

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Coccidioidomycosis Presenting as an Omental Mass Author(s): David P. Dooley, Ramakota K. Reddy and Craig E. Smith Source: Clinical Infectious Diseases, Vol. 19, No. 4 (Oct., 1994), pp. 802-803 Published by: Oxford University Press Stable URL: http://www.jstor.org/stable/4458121 . Accessed: 20/12/2014 11:34 Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at . http://www.jstor.org/page/info/about/policies/terms.jsp . JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact [email protected]. . Oxford University Press is collaborating with JSTOR to digitize, preserve and extend access to Clinical Infectious Diseases. http://www.jstor.org This content downloaded from 128.235.251.160 on Sat, 20 Dec 2014 11:34:26 AM All use subject to JSTOR Terms and Conditions

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Page 1: Coccidioidomycosis Presenting as an Omental Mass

Coccidioidomycosis Presenting as an Omental MassAuthor(s): David P. Dooley, Ramakota K. Reddy and Craig E. SmithSource: Clinical Infectious Diseases, Vol. 19, No. 4 (Oct., 1994), pp. 802-803Published by: Oxford University PressStable URL: http://www.jstor.org/stable/4458121 .

Accessed: 20/12/2014 11:34

Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at .http://www.jstor.org/page/info/about/policies/terms.jsp

.JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range ofcontent in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new formsof scholarship. For more information about JSTOR, please contact [email protected].

.

Oxford University Press is collaborating with JSTOR to digitize, preserve and extend access to ClinicalInfectious Diseases.

http://www.jstor.org

This content downloaded from 128.235.251.160 on Sat, 20 Dec 2014 11:34:26 AMAll use subject to JSTOR Terms and Conditions

Page 2: Coccidioidomycosis Presenting as an Omental Mass

802 Correspondence CID 1994; 19 (October)

for Y. enterocolitica, with serotypes 03 and 08 being the most common isolates.

Mortality among patients with cardiovascular Y. enterocolitica has been high (5 of 11 [46%]) despite treatment regimens with multiple antimicrobial agents. The duration of successful ther-

apy has varied from as few as 8 days to as many as 54 days. Our case is notable for the lack of significant fever. This patient most

likely had an existing abdominal aortic aneurysm that was in- fected by Y. enterocolitica. It is not known what role the infec- tion played in the progressive development of the aneurysm. In addition, this is the first case in which a quinolone or monobac- tam was used to treat cardiovascular yersinia infection. Al-

though the patient had a complicated postoperative course, there was no evidence of recurrent infection. The utility of these antimicrobial agents is difficult to assess, but they may be useful in the treatment of extraintestinal yersinia infections.

Michael E. Hagensee Division of Allergy and Infectious Disease, Department of Medicine,

University of Washington, Seattle, Washington

References

1. Cover TL, Aber RC. Yersinia enterocolitica. N Engl J Med 1989; 321:16-24.

2. Plotkin GR, O'Rourke JN Jr. Mycotic aneurysm due to Yersinia entero- colitica. Am J Med Sci 1981;281:35-42.

3. Appelbaum JS, Wilding G, Morse LJ. Yersinia enterocolitica endocardi- tis. Arch Intern Med 1983; 143:2150-1.

4. Green HT, Morris Al, Haqqani MT, Nair P. Infective endocarditis due to Yersinia enterocolitica. J Infect 1983; 7:267-9.

5. Urbano-Marquez A, Estruch R, Agusti A, et al. Infectious endocarditis due to Yersinia enterocolitica. J Infect Dis 1983; 148:940.

6. Verhaegen J, Dedeyne G, Vansteenbergen W, Vandepitte J. Rupture of vascular prosthesis in a patient with Yersinia enterocolitica bacteremia.

Diagn Microbiol Infect Dis 1985;3:451-4. 7. Foberg U, Fryden A, Kihlstrom E, Persson K, and Weiland O. Yersinia

enterocolitica septicemia: Clinical and microbiological aspects. Scand J Infect Dis 1986; 18:269-79.

8. Van Noyen R, Peeters P, Van Dessel F, Vandepitte J. Mycotic aneurysm of the aorta due to Yersinia enterocolitica. Contrib Microbiol Immunol 1987;9:122-6.

9. Watanakunakorn C. Acute infective endocarditis due to Yersinia entero- colitica. Am J Med 1989;86:723-4.

Coccidioidomycosis Presenting as an Omental Mass

SIR-Despite the increasing incidence of disease caused by the fungus Coccidioides immitis [1], reports of gastrointestinal mani- festations of illness due to this fungus have been rare. Few case reports documenting primary peritoneal involvement have been published [2-7]. To our knowledge, only two patients with frank abdominal masses caused by coccidioidomycosis have been described [3]. We describe a patient who presented with an omental mass in addition to lung involvement due to coccidioi- dal infection.

A 23-year-old Black man noted the onset of fever, dyspnea, and a dry cough following a 1-month military deployment to Southern California. The cough persisted for 3 months and grad- ually became productive; he experienced night sweats. Because of right chest pain, radiography was performed, which revealed a pleural effusion. Results of studies of pleural fluid were non- diagnostic. The patient began to complain of abdominal pain and weight loss and he was admitted to the hospital.

The patient's temperature was 102.8?F. His weight was 119 lb, down from a weight of 160 lb 6 months earlier. Physical examination revealed a moderately ill man with dullness and diminished breath sounds at the base of the right lung, diffuse abdominal tenderness, and a large area of induration between the symphysis pubis and umbilicus. Bowel sounds were present, and there was no apparent ascites. A chest roentgenogram

The opinions expressed in this article are those of the authors and do not reflect the official policy of the Department of Defense or other Depart- ments of the U.S. Government.

Correspondence or reprints: Dr. David P. Dooley, HSHE-MDI/Infectious Diseases, Brooke Army Medical Center, Fort Sam Houston, Texas 78234.

Clinical Infectious Diseases 1994;19:802-3 ? 1994 by The University of Chicago. All rights reserved. 1058-4838/94/1904-0034$02.00

showed consolidation of the right middle lobe and right lower lobe with surrounding effusion. An abdominal computed tomo-

graphic (CT) scan demonstrated ascites and a markedly thick- ened omentum with a mass extending into the pelvis (figure 1). Samples obtained by thin-needle biopsy of the omental mass revealed spherules diagnostic of C. immitis infection; all cultures of the aspirate were negative. Quantitative immunodiffusion

complement fixation (IDCF; performed by Dr. D. Pappagianis, University of California, Davis) revealed titers of C. immitis an-

tibody of 1:256. Findings of a bone scan and results of a lumbar

puncture were normal. Amphotericin B was administered (0.8 mg/[kg * day]); the patient defervesced and showed gradual clin- ical improvement with diminished abdominal pain. Results of a CT scan performed 3 weeks later showed less ascites and a thin- ner omentum, although the mass persisted. Levels ofamphoteri- cin B in serum and peritoneal fluid obtained simultaneously (12 hours after the most recent dose) were 0.53 ,tg/mL and 0.42

tg/mL, respectively (bioassay performed by M. Rinaldi, Depart- ment of Veterans Affairs Mycology Reference Laboratory, San Antonio, Texas). The patient completed a 4.3-g course of am-

photericin B and then received maintenance therapy with itra- conazole (200 mg/day). All symptoms resolved, the patient re-

gained his weight, titers of antibody fell to 1:64 (IDCF tests) and 8 months after presentation an abdominal CT scan revealed

only a scant, stable, residual thickening of the omentum. Gastrointestinal involvement in cases of coccidioidomycosis,

is extremely rare; fewer than 40 cases of peritoneal disease have been reported since the first description of this infection in 1946

[2-9]. Although patients with coccidioidal peritonitis can pre- sent with severe symptoms [3], more commonly, signs and

symptoms are minimal, and the condition is often found inci-

dentally [2, 4]. In most of the reported cases there has been no dissemination beyond pulmonary and gastrointestinal sites. Pa- tients with peritoneal disease have generally responded rapidly to therapy, or their conditions have improved without therapy.

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Page 3: Coccidioidomycosis Presenting as an Omental Mass

CID 1994; 19 (October) Correspondence 803

Figure 1. Abdominal computed tomographic scan demonstratingan ante- rior abdominal mass (arrows) in a man with coccidioidomycosis.

These observations suggest that unrecognized, minimally symp- tomatic peritoneal disease may occur frequently in primary coc-

cidioidomycosis, and that this condition lacks the unfavorable

prognostic implications of bone or meningeal involvement. This report documents the third known patient presenting

with frank intraabdominal masses due to C. immitis infection. The first two patients were both women with pelvic masses [3]. A left adnexal mass was detected in one of these patients; upon removal the mass was found to be due to infection with C. immi- tis. This patient remained well for another 10 years with no

therapy. The second patient presented with a pelvic mass that was shown at laparotomy to consist of matted omentum and bowel. Biopsy samples of peritoneum and omentum revealed the presence of C. immitis. No treatment or follow-up was re- corded. Our patient had massive omental infiltration, an adja- cent pelvic mass, and ascites. Extensive disease and debilitation

initially prevented surgical debulking of the mass, so antifungal therapy alone was initiated, which resulted in a slow response. The data from these three cases are not sufficient to determine

whether surgery, in addition to medical therapy, is necessary when bulky abdominal disease is present.

Penetration of amphotericin B into peritoneal fluid has been reported to be poor [10]. However, in our patient penetration into peritoneal fluid was excellent, possibly due to an inflamed peritoneum, a feature absent in the patient in the previous re- port [10]. This suggests that the sluggish response to therapy with amphotericin B was not due to poor fluid penetration, but instead may have been due to poor deliverance ofamphotericin B to the mass itself.

David P. Dooley, Ramakota K. Reddy, and Craig E. Smith From the Departments of Medicine, Brooke Army Medical Center, Fort

Samn Houston, and Wilford Hall Medical Center, Lackland Air Force Base, Texas; and Dwight D. Eisenhower Army Medical Center, Fort

Gordon, Georgia

References

1. Centers for Disease Control and Prevention. Coccidioidomycosis- United States, 1991-1992. MMWR Morb Mortal Wkly Rep 1993;42:21-4.

2. Crum RB. Peritoneal coccidioidomycosis. Arch Surg 1959;78:91-5. 3. Saw EC, Shields SJ, Comer TP, Huntington RW Jr. Granulomatous

peritonitis due to Coccidioides immitis. Arch Surg 1974; 108:369-71. 4. Chen KTK. Coccidioidal peritonitis. Am J Clin Pathol 1983; 80:514-6. 5. Ampel NM, White JD, Varanasi UR, Larwood TR, Van Wyck DB,

Galgiani JN. Coccidioidal peritonitis associated with continuous am-

bulatory peritoneal dialysis. Am J Kidney Dis 1988; 11:512-4. 6. Byrne WR, Dietrich RA. Disseminated coccidioidomycosis with perito-

nitis in a patient with acquired immunodeficiency syndrome. Pro-

longed survival associated with positive skin test reactivity to coc- cidioidin. Arch Intern Med 1989; 149:947-8.

7. Jamidar PA, Campbell DR, Fishback JL, Klotz SA. Peritoneal coc-

cidioidomycosis associated with human immunodeficiency virus in- fection. Gastroenterology 1992; 102:1054-8.

8. Forbus WD, Bestebreurtje AM. Coccidioidomycosis: a study of 95 cases of the disseminated type with special reference to the pathogen- esis of the disease. Mil Surg 1946;99:653-719.

9. Meis PR, Larwood TR, Winn WA. Coccidioidal peritonitis. In: Ajello L, ed. Coccidioidomycosis. Tucson, AZ: University of Arizona Press, 1967:85-7.

10. Muther RS, Bennett WM. Peritoneal clearance ofamphotericin B and

5-fluorocytosine. West J Med 1980; 133:157-60.

Surgical-Site Infection Due to Streptococcus pneumoniae Following Laparoscopic Cholecystectomy

SIR-Streptococcus pneumoniae is increasingly being recognized as a cause of a wide variety of extrapulmonary infections [1], particularly in patients with underlying conditions such as dia- betes mellitus, systemic lupus erythematosus, intravenous drug use, or alcoholism [2]. Cellulitis and pyogenic myositis due to S.

Reprints or correspondence: Dr. Juan Carlos Cha Torea, Av. Mariano Pelliza 2345, Olivos (1636), Buenos Aires, Argentina. Clinical Infectious Diseases 1994;19:803-4 ? 1994 by The University of Chicago. All rights reserved. 1058-4838/94/1904-0035$02.00

pneumoniae have been described [2-5], but as far as we know, surgical wound infection due to this microorganism has not been reported. Herein we report a case of surgical wound infec- tion due to S. pneumoniae following laparoscopic cholecystec- tomy.

A 34-year-old woman without underlying illnesses under- went a laparoscopic procedure because of gallbladder stones. She was discharged the next day without apparent complica- tions. Twenty-four hours later she was febrile, had shaking chills, and complained of abdominal pain. She was hospitalized and on physical examination appeared to be acutely ill. She had a temperature of 39?C, pulse of 120/min, and blood pressure of 130/80 mm Hg; the lungs were clear and the heart was normal on auscultation. The abdomen was painful, and there was an

erythematous area over the periumbilical surgical wound.

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