Granulomas on Granulomas: A Rare Case of Concurrent Coccidioidomycosis and Tuberculosis

Granulomatous diseases are a major cause of pulmonary pathology.Tuberculosis and coccidioidomycosis are two of the most prominent infective etiologies of pulmonary granulomas in the USA, occurring in approximately 0.0000028% and 0.0000426% of the population respectively.Here we present the rare case of a patient who was initially diagnosed with disseminated pulmonary coccidioidomycosis and was later found to have concurrent Mycobacterium Tuberculosis (MTB) infection.An 80 year old male with past medical history of hypertension and atrial fibrillation initially presented with one week of cough, shortness of breath, and chills.A chest CT was performed which revealed an 8cm right upper lobe lung mass and numerous sub centimeter bilateral pulmonary nodules, along with mediastinal and hilar lymphadenopathy.A PET scan was later performed which showed the mass and lymph nodes to be hypermetabolic.Given the radiological appearance, he was initially diagnosed with metastatic bronchogenic carcinoma.Eventually, the patient underwent CT guided biopsy of the lung mass.Pathology of the specimen revealed necrotizing granulomas, organizing pneumonia and thick walled spherules consistent with Coccidioides organisms.Confirmatory coccidioides immunodiffusion and complement fixation was positive.Due to concern for concurrent malignancy, given the radiological findings, patient underwent bronchoscopy and mediastinal lymph node biopsy.Fungus culture of this specimen grew coccidioides immitis.Interestingly, acid fast bacilli (AFB) smear of bronchoalveolar lavage fluid was positive for AFB and MTB PCR detected MTB DNA.Given the above findings, patient was referred to infectious diseases for treatment of both coccidioidomycosis and tuberculosis.Fungal and mycobacterial pneumonias are relatively rare in immunocompetent hosts.Coccidioidomycosis is a self resolving infection in most patients, with only 40% of those who are infected ever seeking medical attention.Mycobacterium tuberculosis infection is an important cause of pulmonary pathology in the developing world, but rates have been steadily falling within the USA.Risk factors for infection include immunocompromise, imprisonment and low socioeconomic status.Our patient had no history of recurrent childhood or adolescent infections, making a congenital immunodeficiency unlikely.HIV testing was negative and CBC was unremarkable except for eosinophilia.He did reside in Palm Springs, which is a desert area known to be endemic to both Coccidioides and MTB.However, he denied any recent travel history or imprisonment and was a Caucasian gentleman of upper middle class socioeconomic status.To date there have been no published case reports on PubMed which highlight a patient suffering from both of the above infections concurrently.