Today, we talked about a middle aged man presenting with acute onset of abdominal pain and weight loss, found to have a consolidation on chest imaging, low SAAG ascites, and a nodular omentum, work up revealing disseminated cocci! For more cases like this, check out http://www.humandx.org.  If you’d like to hear some expert diagnosticians take a crack at this case and learn from their reasoning, check out thecurbsiders.com.

Clinical Pearls: 

• Patients with immunosuppression, pregnancy, and DM2 are at risk of developing disseminated cocci.
• The most common manifestation of cocci is pneumonia which can be consolidative, nodular, or cavitary.  Other manifestations include the skin (erythema nodosum and erythema multiforme), joints (arthralgias, vertebra, osteo), meningitis, SSTI, and visceral organs (rare).
• Cocci should be on your differential of infections that can cause eosinophilia and a low SAAG ascites.

Approach to eosinophilia

• Neoplasm ⇒ hypereosinophilic syndrome, T cell lymphoma, hodgkins lymphoma, solid organs (cervical, ovarian, gastric, colon, and urothelial cell carcinoma)
• Allergies ⇒ atopy, medication induced 
• Adrenal insufficiency ⇒ rare cause
• Connective tissue disease ⇒ EGPA (formerly known as Churg Strauss), RA
• Parasites/infections
  • Parasites: strogyloides, toxocara, lymphatic filariasis, isospora, dientamaeoba, sarcocystis (note Giardia does NOT cause eosinophilia) 
  • Viruses: HTLV, HIV
  • Fungi: aspergillus (ABPA), cocci, paracocci, histo, crypto
• Primary eosinophilic syndromes (typically single organ involvement of eos, may not have blood eosinophilia) ⇒ eosinophilic fasciitis, eosinophilic cellulitis 

Differential for ascites based on SAAG

• <1.1
  • Peritoneal carcinomatosis
  • Infections (tuberculosis, bacteria, fungi including cocci, schistosomiasis)
  • Pancreatitis
  • Biliary ascites
  • Serositis
• >1.1
  • Portal HTN
    • Liver (cirrhosis, acute failure, alcoholic hepatitis, budd chiari, mets)
    • CHF

Coccidioidomycosis: Refer to this prior post on our blog for more details.

• Micro
  • Airborne fungal infection transmitted by cocci immitis and cocci posadasii
• Epi
  • Geographic distribution is southwest US and central valley
  • Most common time for transmission is summer and fall seasons
• Risk factors for developing severe disease
  • Immunosuppression (HIV with CD4 <250, steroids, chemo)
  • Pregnancy
  • DM2 (more likely to develop cavitary disease)
• Clinical manifestations
  • Incubation period is 7-21 days
  • Primary manifestation is CAP
  • Other manifestations
    • Skin: erythema nodosum and erythema multiforme
    • Joints: arthralgias (desert rheumatism), osteo of joints and vertebrae
    • Meningitis
    • SSTI
    • Visceral organs and omentum (rare)
• Testing:
  • Imaging (CXR can be normal in 50% of patients)
  • Serologies:
    • Cocci EIA to screen
    • Cocci immunodiffusion and complement fixation to confirm
• Treatment
  • Immunocompetent and minimal symptoms? No treatment, most resolve spontaneously
  • Severe disease/disseminated
    • First line is fluconazole or itraconazole
    • If no response, can try posaconazole
    • Last resort is amphotericin B
  • Duration of treatment can be up to a year
  • Repeat anti-coccidioidal Abs in 2-4 weeks after starting treatment to ensure treatment response