Opportunistic Coccidioides Pulmonary Infection Following COVID-19 Pneumonia

Introduction: Co-infections in hospitalized patients are associated with higher mortality. The rate of co-infection in COVID-19 at the time of hospitalization is estimated at around 10%, but the long-term impact of SARS-CoV-2 on the immune system following the initial infectious period is unknown. Here we describe the case of a previously healthy patient hospitalized with coccidioides pulmonary infection following mild COVID-19 disease. Case: A 52-year-old man with no significant past medical history presented to the hospital with worsening non-productive cough, left-sided pleuritic chest pain, fevers, chills and sweats. Four weeks prior to presentation, he was diagnosed with COVID-19 pneumonia. He experienced respiratory symptoms for 7 days and then made a full recovery. Ten days later, he developed a new cough. He was found to have a new infiltrate on chest radiograph and was treated with two courses of oral antibiotics without improvement. CT chest was done and found to be concerning for a "fungal ball" and he subsequently presented to Jacobs Medical Center. He denied occupational exposures or smoking history. He was born in Ohio, and moved to California at age 3. Chest CT showed a left lower lobe mass-like consolidation with central necrosis, trace pleural effusion, and mediastinal lymphadenopathy. Initial laboratory evaluation revealed a leukocytosis to 17 that was neutrophil predominant. Over the next 5 days, his absolute eosinophil count climbed from 400 to 1100. COVID-19 PCR testing at the time of admission was negative. During bronchoscopy, there were two submucosal nodules in the distal trachea and left mainstem bronchus and bronchoalveolar lavage (BAL) was obtained from the left lower lobe. Cytopathic review of the BAL fluid revealed acute inflammation and spherules consistent with Coccidioides immitis. The BAL cell count revealed 21% eosinophils and fungal cultures grew coccidioides. Coccidioides IgM was positive, while IgG was negative. He was initiated on fluconazole therapy with rapid resolution of fevers and improvement in his cough and pleuritic chest pain. Discussion: This is a classic presentation of acute coccidioidomycosis infection involving a lobar necrotizing pneumonia, peripheral and BAL eosinophilia, bronchial submucosal nodules, positive serum IgM antibodies, fungal cultures, and cytopathologic exam. This case highlights the possibility that patients with COVID-19 infection are at increased risk of developing subsequent infections. It will be important for providers to remain vigilant for opportunistic infections at the time of presentation and in the period following COVID-19 infection.