ANSWER TO THE PHOTO QUIZ Anthony Amoroso, Section Editor
A 50-Year-Old Man With Dysuria (See page 251 for the Photo Quiz.)
Figure 2. Coccidioides immitis spherule (hematoxylin and eosin stain, ×40 magnification).
Diagnosis: Coccidioides immitis epididymitis. Pathology showed granulomatous epididymitis. Within granulomas, hematoxylin and eosin (H&E) stains (Figures 1 and 2) and Grocott methenamine silver stain showed thick-walled fungal spherules (approximately 75 µm in diameter) with variablesized daughter endospores consistent with Coccidioides immitis. Serum Coccidioides serology was positive for immunoglobulin G by immunodiffusion, with a complement fixation titer of 1:4. A screening chest radiograph was negative. Upon consultation in the infectious diseases clinic, he was started on fluconazole 600 mg daily. The patient had been an otherwise healthy tractor driver for a landscaping company in Fresno, California, for 12 years with frequent exposure to large amounts of dust. He presented to the hospital with disabling left testicular pain and dyspareunia, as well as hematuria and dysuria. He recalled being hospitalized 1 year prior for 3 weeks with an atypical pneumonia associated with dyspnea and night sweats, and was released without subsequent follow-up. Coccidioides species are dimorphic fungi that grow in soil as well as routine agar media as mycelia and are inhaled as airborne arthroconidia. Pulmonary symptoms begin within 7–21 days of
inhalation of arthroconidia, and patients seeking medical attention may receive empiric treatment for a bacterial communityacquired pneumonia that usually spontaneously resolves within 3 weeks. After entry into the lungs, arthroconidia remodel into thick-walled spherical cells between 60 µm and 100 µm in diameter. The spherule form ruptures and can release between 800 and 1000 endospores that can propagate in tissue and occasionally disseminate via the bloodstream or lymphatics to any organ system. Each endospore in turn matures into a new spherule, eliciting a local granulomatous reaction [1]. Coccidioides immitis is endemic to the San Joaquin Valley of California, and the most frequent method of diagnosis is by serologic testing with detection of complement-fixing antibodies. Direct detection of thick-walled endospore-containing spherules in tissue by H&E, Grocott methenamine silver, or periodic acid-Schiff stain, confirms the diagnosis. Nucleic acid amplification tests for coccidioidomycosis using polymerase chain reaction have been found to be both sensitive and specific and are increasingly being used [1]. Extrapulmonary coccidioidomycosis is observed in
A 50-Year-Old Man With Dysuria (See page 251 for the Photo Quiz.)
Figure 2. Coccidioides immitis spherule (hematoxylin and eosin stain, ×40 magnification).
Diagnosis: Coccidioides immitis epididymitis. Pathology showed granulomatous epididymitis. Within granulomas, hematoxylin and eosin (H&E) stains (Figures 1 and 2) and Grocott methenamine silver stain showed thick-walled fungal spherules (approximately 75 µm in diameter) with variablesized daughter endospores consistent with Coccidioides immitis. Serum Coccidioides serology was positive for immunoglobulin G by immunodiffusion, with a complement fixation titer of 1:4. A screening chest radiograph was negative. Upon consultation in the infectious diseases clinic, he was started on fluconazole 600 mg daily. The patient had been an otherwise healthy tractor driver for a landscaping company in Fresno, California, for 12 years with frequent exposure to large amounts of dust. He presented to the hospital with disabling left testicular pain and dyspareunia, as well as hematuria and dysuria. He recalled being hospitalized 1 year prior for 3 weeks with an atypical pneumonia associated with dyspnea and night sweats, and was released without subsequent follow-up. Coccidioides species are dimorphic fungi that grow in soil as well as routine agar media as mycelia and are inhaled as airborne arthroconidia. Pulmonary symptoms begin within 7–21 days of
inhalation of arthroconidia, and patients seeking medical attention may receive empiric treatment for a bacterial communityacquired pneumonia that usually spontaneously resolves within 3 weeks. After entry into the lungs, arthroconidia remodel into thick-walled spherical cells between 60 µm and 100 µm in diameter. The spherule form ruptures and can release between 800 and 1000 endospores that can propagate in tissue and occasionally disseminate via the bloodstream or lymphatics to any organ system. Each endospore in turn matures into a new spherule, eliciting a local granulomatous reaction [1]. Coccidioides immitis is endemic to the San Joaquin Valley of California, and the most frequent method of diagnosis is by serologic testing with detection of complement-fixing antibodies. Direct detection of thick-walled endospore-containing spherules in tissue by H&E, Grocott methenamine silver, or periodic acid-Schiff stain, confirms the diagnosis. Nucleic acid amplification tests for coccidioidomycosis using polymerase chain reaction have been found to be both sensitive and specific and are increasingly being used [1]. Extrapulmonary coccidioidomycosis is observed in
