Coccidioidal Pulmonary Cavitation: A New Age.

Coccidioides species are thermally dimorphic fungi found in geographically defined areas of the Western Hemisphere. The primary portal of entry is respiratory, with symptomatic pneumonic diseases as the most common presentation. Subsequent pulmonary complications as well as extrapulmonary metastatic infection may occur, either of which may be the presenting disease manifestation. Cavitary lung disease may be found incidentally or when investigating symptoms such as cough or hemoptysis. This study aims to explore the spectrum of coccidioidal cavities and the evaluation and management in a cohort of patients seen at Kern Medical over the last 12 years.

A Case of Concurrent Disseminated Coccidioidomycosis and Embryonal Carcinoma When Lice and Fleas Coexist.

Coccidioidomycosis (CM) is a fungal infection endemic to the southwestern United States with a wide range of clinical presentations depending on the infected organ systems. Most infections are asymptomatic. Coccidioidomycosis causes a primary pulmonary infection and when symptoms occur, they most often resemble community-acquired pneumonia. One percent of cases disseminate, typically via hematogenous or lymphatic spread. It is in these cases that more severe symptoms may present and potentially overlap with those characteristics of other systemic illnesses. This is a case of CM disseminated to lymph nodes in a 24-year-old man with concomitant metastatic embryonal carcinoma. It is difficult to identify the primary etiology for many components of this patient's presentation, including diffuse lymphadenopathy and multiple pulmonary nodules. Furthermore, the relationship between these 2 concurrent disease processes is not entirely clear. Factors that may contribute include the well-known phenomenon of locus minoris resistentiae (LMR) or potentially a shared immune failure between infectious organisms and malignant cells.

Coccidioidal Peritonitis: A Review of 17 Cases.

Coccidioidomycosis is the second most common endemic fungal infection in the United States. Prior descriptions of coccidioidal peritonitis include only single cases. We describe 17 new cases previously unreported from healthcare institutions in California. The majority of cases presented with nonspecific abdominal complaints. PubMed and Google Scholar were searched for additional case series and only single case reports and reviews of single cases were found. The diagnosis was confirmed by culture or histopathology and/or serology in each patient. All patients were treated with anti-fungal therapy. This case series demonstrates that coccidioidal peritonitis may be asymptomatic or present with only subtle abdominal symptoms. In a minority of our patients, the diagnosis was established incidentally during surgery. Based on this series, the overall outcome of coccidioidal peritonitis is favorable with long-term triazole treatment. The term cure is not usually used in disseminated coccidioidal disease because of the risk of late relapse.

Neutrophilic Dermatosis in Myelodysplastic Syndrome and Chronic Active Hepatitis C.

In this article, we describe a case of neutrophilic dermatosis of the dorsal hands (NDDH) complicated with myelodysplastic syndrome and chronic active hepatitis C infection. NDDH was first suggested by Galaria et al in 2000. After comparing features of NDDH with Sweet syndrome in terms of encompassing clinical, laboratory, and histological characteristics, it can be concluded that "distributional or localized variant" of Sweet syndrome is classified as NDDH. Early diagnosis and treatment can improve prognosis. Systemic glucocorticoids are the mainstay of treatment.

A Rare Case of Cryptococcus gattii Meningitis in Advanced HIV Disease, Sagittal Thrombosis, and Immune Reconstitution Syndrome, Resolved With Isavuconazonium.

Cryptococcus gattii is a species that has received more recognition in the recent past as distinct from Cryptococcus neoformans. C gattii is known to cause meningeal disease in both immunocompetent and immunosuppressed hosts. Patients may be clinically asymptomatic until immunosuppressive conditions occur such as corticosteroid treatment or an HIV infection. HIV-associated cryptococcal infections are most often due to C neoformans. C gattii is found in a minority. Speciation and subtyping of Cryptococcus are not always accomplished. In many parts of the world, there is no availability for speciation of Cryptococcus. Travel history may provide a clue to the most probable species. This case demonstrates a case of C gattii meningitis with a multiplicity of complications. These include advanced HIV disease secondary to nonadherence, immune reconstitution inflammatory syndrome, and superior sagittal sinus thrombosis. The patient represented diagnostic and therapeutic dilemmas over time. Headache was the primary symptom in cryptococcal meningitis, immune reconstitution inflammatory syndrome, and superior sagittal sinus thrombosis. All are discussed in detail as potential etiologies for the primary disease. Isavuconazonium is a relatively new broad-spectrum antifungal azole that was used as salvage therapy.

A Case of Testicular Granulomatous Inflammation Mistaken for Malignancy: Tuberculosis Identified Post Orchiectomy.

We describe the case of a 41-year-old Hispanic male, inconsistently adherent to visits and workup due to socioeconomic challenges, who presented with a right testicular mass. Because of the overriding concern that this was malignant, he underwent a right orchiectomy. Pathology revealed granulomatous disease with no evidence of malignancy. No specific diagnosis was made histologically or microbiologically on primary laboratory investigation. Six months later, he developed swelling of the left testicle and was subsequently seen in consultation at the Infectious Disease Clinic Kern Medical. An extensive evaluation for granulomatous inflammation was undertaken without a positive result. A clinical diagnosis of tuberculous epididymal orchitis was made and the patient was initiated on standard 4-drug antituberculous therapy. There was a gradual resolution of pain and swelling. After 6 months of therapy, there was no evidence of residual disease. The patient remains asymptomatic after 8 months of post-therapy follow-up.

Erythema Sweetobullosum: A Reactive Cutaneous Manifestation of Coccidioidomycosis.

Reactive cutaneous coccidioidal skin manifestations are commonly noticed during the early stage of coccidioidomycosis. These skin lesions are devoid of any active coccidioidal organism, and the immune trigger mechanisms are not elucidated. We describe 6 cases of unusual reactive cutaneous coccidioidal manifestation, characterized by painful vesiculobullous lesions known as erythema sweetobullosum. The biopsy of the lesions revealed neutrophilic dermatosis with inflammatory cells resulting in a cleft and elevation of the most superficial layer of the skin forming a bulla. The reactive cutaneous lesion is self-limited and requires no specific therapy.

Genitourinary malignancy presenting as an ocular metastasis: A case report and review of the literature.

Metastases to the eye or orbit as the initial presentation of genitourinary malignancy are unusual and can be a diagnostic challenge. We report an 81-year-old man who presented with pain and proptosis in an eye that had been blind for 50 years. Radiologic investigations identified a mass involving the left globe and orbit. Histology of the enucleation specimen was consistent with a metastatic poorly differentiated carcinoma suggestive of a prostate primary. With the constellation of obstructive urinary symptoms, an abnormal digital rectal examination, elevated prostate-specific antigen and a positive bone scan, androgen deprivation therapy was initiated for metastatic prostate cancer. After an initial response to treatment, the patient's disease progressed in a manner atypical for prostate cancer. After describing our case, we review the literature on ocular and orbital metastases and their relation to genitourinary malignancies.

Pegging the porous orbital implant.

PURPOSE: Hydroxyapatite (HA) orbital implants are commonly used for the anophthalmic socket. With a HA implant, if motility is not satisfactory then a peg system can be surgically placed in attempts to improve motility. The authors report the technique and results of 83 patients who received motility peg placement over an 8-year period by a single surgeon. METHODS: Retrospective chart review of all patients with previous enucleation with either primary or secondary insertion of a HA implant who received a motility peg by a single oculoplastic surgeon between January 1999 and February 2007. RESULTS: Eighty-three patients underwent placement of a titanium peg and sleeve during the study period. Complications seen in the follow-up period included discharge, pyogenic granuloma, and others. Infection was experienced in 1 case. Fourteen patients (17%) required further surgical management due to complications. CONCLUSIONS: The largely positive results of this moderately sized case series validates the efficacy of pegging a hydroxyapatite orbital implant with minor risk of serious complications; this may have been due to a combination of factors including an experienced surgeon and adequate follow-up. As a procedure that can be completed in a hospital or minor surgical suite with sedation, it remains a viable option for many patients.

Third place: Flank position is associated with higher skin-to-surface interface pressures in men versus women: implications for laparoscopic renal surgery and the risk of rhabdomyolysis.

BACKGROUND AND PURPOSE: There have been several reports of rhabdomyolysis occurring after prolonged laparoscopic procedures in the flank position. Accordingly, we evaluated interface pressures between the skin and three commonly used operating room table surfaces. The aim of our study was to determine if pressure changes could be related to body mass index (BMI), sex, position, and/or the table surface material. PATIENTS AND METHODS: Ten men and 10 women were grouped according to BMI <25 or >or=25, with five participants in each group. Subjects were placed in the left lateral decubitus position with the operating table flat, half flexed, fully flexed, half flexed with the kidney rest elevated, and fully flexed with the kidney rest elevated. Interface pressures were recorded, using an X-Sensor pressure sensing mat, for 5-minute periods in each of the described positions on each surface. RESULTS: Sex and BMI were statistically significant predictors of increased pressures (P= 0.0042 and 0.0402, respectively). The parameter estimate for the difference between men and women was 4.63 mm Hg (P= 0.0002), and the difference for BMI >or= 25 compared with <25 was also significant (P < 0.0209). Full table flexion (50-degree) produced significantly higher pressures than both flat (P= 0.0001) and the half-flexed (25-degree) position (P < 0.0001). Positions with the kidney rest elevated were associated with significantly higher pressures than without elevation (P < 0.0001). With regard to the surface used, egg crate provided lower pressures than gel pads (P= 0.0117). CONCLUSION: Women have significantly lower interface pressures when compared with men. BMI >or= 25 also increases interface pressures. The use of the kidney rest is associated with markedly increased pressure; use of a half-flexed position is preferable to a full-flexed position. These data have implications for patient positioning and identification of persons at risk for rhabdomyolysis during laparoscopic renal surgery.

A new case of oculoectodermal syndrome.

An 11-month-old infant girl presented with right-sided features of aplasia cutis congenita of the scalp, unilateral epibulbar dermoids, eccentric pupil, coloboma of the right upper eyelid, and depigmentation of the fundus surrounding the right optic nerve. These findings were similar to the oculoectodermal syndrome reported by other clinicians and researchers.

Cerebral cholesterol granuloma in homozygous familial hypercholesterolemia.

Familial hypercholesterolemia (FH) is characterized by the accumulation of excess cholesterol in tissues including the artery wall and tendons. We describe a patient with homozygous FH who presented with asymptomatic cholesterol granuloma of the brain. The patient's plasma low-density lipoprotein cholesterol level was remarkably responsive to combination hypolipidemic therapy with statin plus ezetimibe. This case illustrates another potential complication of whole-body cholesterol excess and underscores the differences in phenotype and in response to therapy among patients with FH.

Hypercalcemia in patients with disseminated coccidioidomycosis.

OBJECTIVE: Granulomatous disorders may be associated with hypercalcemia. In sarcoidosis, the pathogenesis of hypercalcemia has been clarified, whereas in other granulomatous disorders, such as coccidioidomycosis, the mechanism is unclear. We present 13 patients with coccidioidomycosis and hypercalcemia to illustrate the clinical course and the mechanism of hypercalcemia. METHODS: We retrospectively reviewed all patients admitted to Kern Medical Center, a 270-bed public hospital, from 1990 through 1997 with coccidioidomycosis and a serum calcium level of greater than 10.5 mg/dL on at least 3 occasions. In addition, no other causes for hypercalcemia were identified. RESULTS: The mean highest serum calcium level was 12.7 +/- 1.8 mg/dL. All patients had disseminated disease. Six patients were nonambulatory and 4 had bone involvement. Of the 9 patients in whom parathyroid hormone was measured, it was normal in 6 and suppressed in 3. Of the 9 patients in whom 25-hydroxyvitamin D was measured, it was normal in 6, suppressed in 2, and elevated in 1. Of the 7 patients in whom 1,25-dihydroxyvitamin D was measured, it was normal in 3 and suppressed in 4. Urinary calcium was elevated in 2 patients, both of whom were ambulatory. Nonambulatory patients had significantly higher serum calcium levels (14.3 +/- 1.0 mg/dL) than ambulatory patients (11.3 +/- 0.46 mg/dL) (P<0.001). CONCLUSIONS: The mechanism of hypercalcemia in coccidioidomycosis is unrelated to increased production of 1,25-dihydroxyvitamin D. Nonambulatory status is associated with higher mean serum calcium.