Introduction We present case series with three patients presenting at our institution within this past year with no significant past medical history and no history of immunocompromise presenting with reticuloendothelial involvement from coccidiodomycosis.
Case 1 A 24-year-old previously healthy, currently incarcerated African American man presented with a 2-month history of anorexia, 10 lb weight loss, and vomiting. There was no fever or chills. On examination he had hepatosplenomegaly, severe anemia, leukocytosis, and low platelets. CT of the abdomen showed marked splenomegaly. A bone marrow biopsy and culture showed focal granuloma with cocci. On day 14, he had exploratory laparotomy with splenectomy; the liver was enlarged and mottled. The specimens from the spleen and liver showed many cocci spherules. He developed refractory shock and died after 18 days.
Case 2 A 39-year-old incarcerated white male presented with fever, abdominal pain, and distention for 1 week. On examination he was febrile and tachycardic. He had ascites with no guarding or rigidity. CT scan of the abdomen showed large amount of ascites and infiltration of mesentery diffusely, with lymphadenopathy suggestive of malignancy. Peritoneal biopsies revealed granulomas and spherules of cocci. Two weeks into the hospital course he improved clinically.
Case 3 A previously healthy 31-year-old Hispanic presented with fever, generalized weakness, jaundice, abdominal pain, and 30 lb weight loss for 2 months. On examination she was a febrile and tachycardic. She had scleral icterus. Examination revealed a soft, diffusely tender abdomen with ascites, without rebound. Laboratory tests showed anemia, thrombocytopenia, and coagulopathy. Ferritin was 37,000. CT of the abdomen showed diffuse adenopathy, ascites, and hepatosplenomegaly. The patient expired on day 3.
Discussion There are some veterinary case reports of splenic involvement, but cocci affecting spleen giving rise to clinical symptoms has not been reported in the humans. Also, peritoneal infiltration and lymphadenopathy have been reported only once before. Such profound involvent of the reticuloendothelial system is not often described in the literature. This case report should make physicians aware that coccidiodomycosis should be considered in the differential diagnosis of obscure presentations in endemic regions, irrespective of race, immune status, or comorbid conditions.
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