Coccidioides in lung transplant: case report

Area of Science:

• Medical Mycology
• Infectious Diseases
• Transplant Immunology

Background:

• A middle-aged woman with end-stage chronic obstructive pulmonary disease (COPD) due to alpha-1 antitrypsin deficiency underwent a double-lung transplant.
• She had a prolonged history of lung infection with Malbranchea spp., treated with itraconazole for 16 months.

Observation:

• Six weeks post-transplant, the patient presented with generalized, painful skin lesions.
• Initial skin biopsy revealed non-specific dermal inflammation, suspected to be a Malbranchea reactivation.
• Subsequent lymph node biopsy identified Coccidioides spp. (C. posadasii/C. immitis).

Findings:

• A review of the patient's travel history revealed a significant stay in Arizona during adolescence.
• Morphological similarities between Malbranchea spp. and Coccidioides spp. likely led to the initial misidentification.
• Immunosuppressive medication dosages were reduced, and antifungal therapy was switched from itraconazole to posaconazole.

Implications:

• This case underscores the critical need for accurate fungal identification in immunocompromised patients, especially transplant recipients.
• Reactivation or new infection with endemic fungi like Coccidioides can manifest with diverse dermatological symptoms.
• Prompt and correct diagnosis and management, including adjusting immunosuppression and optimizing antifungal therapy, are crucial for successful outcomes in transplant patients with fungal infections.