Coccidioidomycosis compounded by IRIS

coccy lung spherule.PNG

Dr. Kearney presented an interesting case of an individual with untreated HIV who presented with dyspnea found to have hypoxemic respiratory failure. The patient's history of a significant period of time off antiretroviral therapy (>3 years), the severity of the presentation of hypoxemic respiratory failure, and the severity of the lymphopenia (CD4# <35) data-preserve-html-node="true" raised suspicion for opportunistic infection. Sputum and blood cultures for fungus subsequently returned positive for Coccidioides immitis. Treatment had been started for coccidioidomycosis empirically with an azole and was subsequently increased to include amphotericin B once cultures returned positive. Highly active antiretroviral therapy was begun on admission as well. The patient's respiratory failure improved over the subsequent days, but unfortunately he developed recurrent hypoxemic respiratory failure and pseudosepsis concerning for IRIS.

The differential for dyspnea in the HIV+ patient is myriad. However, the CD4 count can offer a reliable indicator for the particular injuries for which the patient is at risk:

  Table courtesy of  HIV InSite &nbsp;(1)

Table courtesy of HIV InSite (1)

Prompt evaluation and a high index of suspicion for disseminated infection improved this patient's presenting syndrome. And while the patient subsequently developed IRIS after concomitant initiation of HAART, it is worth noting that it appears patients presenting with disseminated coccidioidomycosis do not appear to be at increased risk of developing IRIS with early HAART initiation per , though more study is needed.(1)

For more information on the immune reconstitution inflammatory syndrome, check out the review by Walker et al.(3)

References:

  1. Available at: http://hivinsite.ucsf.edu/InSite-KB-ref.jsp?page=kb-04-01-05&ref=kb-04-01-05-tb-04&no=4. Accessed February 8, 2018.
  2. Mu A, Shein TT, Jayachandran P, Paul S. Immune Reconstitution Inflammatory Syndrome in Patients with AIDS and Disseminated Coccidioidomycosis: A Case Series and Review of the Literature. J Int Assoc Provid AIDS Care. 2017;16(6):540-545.
  3. Walker NF, Scriven J, Meintjes G, Wilkinson RJ. Immune reconstitution inflammatory syndrome in HIV-infected patients. HIV AIDS (Auckl). 2015;7:49-64.