A 50-year-old female smoker of 20 packs of cigarettes a year, of Peruvian nationality radiated in Chile.
With a history of cervical cancer treated with surgery and radiochemotherapy in clinical remission, insulin-requiring diabetes mellitus, dyslipidemia and a tuberculosis infection in childhood.
Patient was admitted to the emergency department with sudden onset of dyspnea associated with severe chest pain to chest X-ray 10/10.
Upon admission, tachycardic, eupneic, africa, with oximetry saturation of 96% breathing room air is described.
Pulmonary examination revealed tenuous crepitations at the base of the left hemithorax, with no limb edema or signs of deep venous thrombosis.
He had no cough or expectoration.
Laboratory tests were performed: blood count with 8,200 leukocytes, with 10% of bacilli, PCR 1.8 mg/dl (normal value < 1 mg/dl); normal cardiac enzymes and arterial gases; laboratory test D 800 ng/ml.
A chest X-ray showed consolidation of the sentinel node.
Pulmonary thromboembolism (PTE) was suspected and a chest CT angiography confirmed the diagnosis of consolidation, ruling out a diagnosis of pulmonary embolism.
A V/Q scan was also negative for malignancy.
An electrocardiogram showed sinus tachycardia.
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Empirical antimicrobial treatment with ceftriaxone and moxifloxacin i.v. was started with the diagnosis of CAP admission.
The etiological study of pneumonia using urinary antigen for Streptococcus pneumoniae and Legionella pneumophila, IgM for Mycoplasma pneumoniae, blood cultures and bronchial secretion culture was negative.
The patient was discharged home with fever from the second day of antimicrobial treatment, with progressive PCR, with a maximum value of 17 antimicrobials.Cefoxime increased clinically with cefoxime, CRP increased to 14 days after admission.
Two weeks after discharge, the patient persisted with intermittent fever and moderate exertional dyspnea appeared; oxygen saturation was 93%, breathing room air.
Among the control laboratory tests, the persistence of high CRP (12 mg/dl), erythrocyte sedimentation rate over 100 mmHg 1h, normal procalcitonin, normal leukocyte count with eosinophils stood out.
A new chest X-ray and computed axial tomography (CAT) showed an increase in the size of the lingular consolidation with air bronchogram and the appearance of multiple bilateral nodular infiltrates.
The patient was re-operated on, starting empirical antimicrobial treatment with clarithromycin and performing a fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsies.
The airway was normal with no secretions.
Biopsy samples were scarce so that no significant lesions could be demonstrated.
BAL fluid cultures were negative, as well as bacillicopies and FI cysticis jiroveci; fungal elements were not detected either.
The patient was admitted with intermittent fever and progressive deterioration of gas exchange for 10 days.
The radiological image showed an increase in the size of the lesions and loss of lung volume.
A surgical lung biopsy was performed by video-assisted thoracoscopy, which resulted in no incidents.
Bacteriological studies in lung tissue were negative (Gram and current culture, Ziehl Neelsen stain, Koch cultures).
A PCR for Mycobacterium spp. was also negative.
The pulmonary histopathological study showed non-caseating intraparenchymal and subpleural granulomas consisting of epithelioid histiocytes, few lymphocytes and focal necrosis.
Towards the periphery of the granulomas there was lymphocytic infiltrate and eosinophil granulocytes.
With Gomori-G staining, immature and mature spherules were observed, the latter with evident endometrium with Schiff periodic acid staining (PAS).
Gram, Warthin-Starry and Ziehl Neelsen stains showed no bacilli, cocacea or acid-fast bacilli resistant.
In two samples it was observed in the periphery of the granulomatous inflammatory process, loose connective tissue in alveoli and alveolar ducts.
The histological diagnosis concluded a coccidioidomycosis with granulomatous reaction and pattern of pneumonia in focal organization.
When the patient was re-interrupted, the antecedent of a recent trip to the north of Mexico, specifically to the city of Hermosillo (Sonora) and to the border of Mexico with E.U.A.
With this history and the presence of spherules with endosporas in histopathology, the diagnosis of coccidioidomycosis was confirmed.
Antibacterial treatment with itraconazole 200 mg twice daily for 12 months was resumed, achieving complete regression of pulmonary lesions and normalization of inflammatory parameters.
