Cytopathology Conference

10/20/2005

Case 5

FNA from a 1.5 cm left lung mass in a 61-year-old male.

Differential Diagnosis

• Histoplasmosis

• Coccidiodes

• Blastomycosis

• Cryptococcus

Diagnosis?

Coccidioides immitis

Coccidioides immitis

• Dimorphic fungus: filamentous, mycelia form and spherule form in tissues

• Coccidomycosis, a.k.a. Valley Fever or San Joaquin Valley fever

• Inhalation of arthrospores from the soil

• Endemic in Southwest

Coccidioides immitis

• 60% of primary infections are asymptomatic

• Remaining 40% usually recover form a flu-like illness (cough, fever, pleuritic chest pain)

• Dissemination more likely in Filipino, African American, Mexican and American Indian races.

Coccidioides immitis

• Diagnosis:

– Chest x-ray: hilar adenopathy, cavitations

– IgM precipitins present after 4 weeks of symptoms; complement fixing IgG antibodies appear later.

– Complement fixations titer > 1:16 or 1:32 is consistent with extrapulmonary dissemination

• Rx: – Amphotericin B, Ketaconazole