This patient presents with pneumonia caused by coccidioidomycosis which appears as a spherule filled with endospores on histology as shown in Figure D.
Coccidioidomycosis, commonly referred to "San Joaquin Valley Fever," is a fungal infection endemic to the Southwestern United States and California. It can cause pneumonia and meningitis and has the ability to disseminate to bone and skin as well. Its incidence commonly increases following earthquakes as spores in dust are aerosolized by the earthquake and are inhaled to become spherules in the lung. On histology, it will appear as a spherule filled with endospores (Figure D, Answer 4). In regards to treatment, most cases with mild symptoms are self resolving and do not require therapy. Cases with severe symptoms will require treatment with antifungal treatment such as fluconazole or amphotericin B.
Crawford et al. review the risk factors and symptoms associated with coccidioidomycosis. They state risk factors include lower respiratory tract symptoms lasting longer than 14 days, chest pain, rash, having lived in endemic areas fewer than 10 years, and diabetes mellitus or immunosuppressive conditions. The most common signs and symptoms include cough (74%), fever (56%), night sweats (35%), pleuritic chest pain (33%), chills (28%), dyspnea (27%), weight loss (21%), and rash (14%).
DiCaudo reviews the dermatologic manifestations of coccidioidomycosis. She states coccidioidomycosis is frequently associated with striking cutaneous manifestations. Reactive, immunologically mediated eruptions include erythema nodosum, a generalized exanthema, and reactive granulomatous dermatitis. Less commonly, the skin can harbor the actual organisms as a result of dissemination from the lungs.
Figures are described in the incorrect answer choice explanations below.
Answer 1: Figure A demonstrates Candida albicans which is characterized by germ tubes at 37 deg C.
Answer 2: Figure B demonstrates Histoplasma capsulatum which is characterized by macrophages filled with H. capsulatam.
Answer 3: Figure C demonstrates Blastomyces dermatitidis which is characterized by broad based budding.
Answer 5: Figure E demonstrates Paracoccidioides brasiliensis which is characterized by budding yeast with the "captains wheel" formation.
Crawford P, Peterson T, Honeycutt D. Clinical inquiries: which risk factors and signs and symptoms are associated with coccidioidomycosis? J Fam Pract. 2014 Dec;63(12):747, 756. PubMed PMID:.
PMID:25486316 (Link to Abstract)
DiCaudo DJ. Coccidioidomycosis. Semin Cutan Med Surg. 2014 Sep;33(3):140-5. PubMed PMID:.
PMID:25577855 (Link to Abstract)