Abstract

Endemic infections produce a spectrum of illness ranging from being subclinical to severe progressive disseminated diseases with Immuno compromised individuals being increased risk. In those with an apparently non-improving infection, a simultaneously occurring second infectious source should be considered. Our patient was a 56 year-old immune compromised male with a history of active CML (Chronic Myelocytic Leukemia) undergoing chemotherapy who was receiving doxycycline and fluconazole for actinomycosis and coccidioidomycosis during a recent hospitalization. He presented with persistent non-productive cough, generalized weakness and malaise. A Chest X-Ray suggested worsening reticulonodular opacities and thoracic CT scan exhibited increasing innumerable pulmonary nodules bilaterally with worsening hilar lymphadenopathy. An open lung biopsy by Video Assisted Thoracoscopic Surgery performed revealed suppurative necrotizing granulomas associated with acute organizing bronchopneumonia with fungal organisms consistent with Blastomyces though did not reveal actinomyces. Deeper biopsy sections revealed the presence of spherules both with and without endospores characteristic of Coccidioides immitis concurrently. The patient symptomatically improved with treatment change to amphotericin B from fluconazole. To our knowledge there are no documented instances of co-infection with these particular two organisms. This particular case highlights the need to keep simultaneous endemic infections high in the differential in susceptible individuals who present with unclear findings and an apparently non-improving infectious etiology. The diagnosis of mixed fungal pulmonary infections is a difficult task which requires a high index of suspicion. In the future, cases with questionable mixed fungal infection may be deciphered by techniques different from current diagnostics including broad-range PCR with sequencing and FISH (fluorescence in situ hybridization).

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