Pulmonary Infiltrates, Eosinophilia, and a Facial Skin Nodule: DISCUSSION part 2
The skin is the most commonly affected organ system in disseminated disease. Skin eruptions consist of verrucous granulomas, subcutaneous abscess, and indolent ulcers. Verricous lesions are commonly found on the face and nasolabial folds. Several lesions found together may suggest a more malignant course of disease. These lesions initially show epithelial thickenings and grow to resemble common warts. Occasionally, microabscesses form and caseating necrosis may occur. Spores are found in the tissue and in multinucleated giant cells. Abscesses are usually not tender, warm, or erythematous, and they are usually seen under the arm and on the back or hip. The abscesses usually have a necrotic center surrounded by a granulomatous infiltrate of lymphoid cells, plasma cells, epithelial cells, and giant cells. Fungal spores are abundant in these lesions. Chronic ulcers can form draining sinus tracts and are found over the joints of the foot, ankle, and hands. There are reports of skin as the only organ system affected. These cases are rare in occurrence and are thought to be due to direct innoculation of the skin in laboratory personnel.
Diagnosis is made by culture of sputum, skin lesions, visceral lesions, or urine, as well as with skin testing and serologic testing such as latex particle agglutination and complement fixation.
Primary coccidioidomycosis is self-limited and no treatment is usually necessary. Antifungal therapy, usually with amphotericin B, is required with progressive or disseminated disease. The toxicities of amphotericin В (local phlebitis, anemia, renal impairment, cardiovascular effects, and neurological symptoms) have led to attempts to resolve Coccidioides infections with other agents, such as ketoconazole and itraconazole.
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The prognosis of primary pulmonary coccidioidomycosis is excellent, with usual total resolution of disease, or, at worst, residual evidence on chest roentgenogram. Progressive pulmonary disease and disseminated disease have much more varied outcomes, ranging from total resolution to recurrent pneumonia-like episodes to rapid death (as with untreated meningitis).
Our patient showed no evidence of other extrapulmonary infection. He was treated effectively with 2.0 g of intravenous amphotericin В with complete resolution of all evidence of infection.
This patient presented with pulmonary coccidioidomycosis and an isolated skin lesion which was the sole manifestation of disseminated infection. This is unusual but has been reported. Close examination of the skin remains an invaluable tool in the initial assessment of the patient with pulmonary disease.
