CHEST Guidelines-A-62-Year-Old-Woman-With-Wheezing,-Respiratory-Fai

A-62-Year-Old-Woman-With-Wheezing,-Respiratory-Fai

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A 62-year-old woman with a history of travel to Arizona developed acute bronchospastic respiratory failure, leading to her intubation and transfer to the ICU. Initially diagnosed with community-acquired pneumonia, she had been partially treated with azithromycin but experienced worsening symptoms upon returning home. Subsequent hospital admission for unresolved pneumonia included treatment with levofloxacin, an inhaled beta agonist, and prednisone. Despite these interventions, her condition deteriorated, necessitating ICU care.<br /><br />Physical examination revealed labored breathing with bilateral wheezing. A CT scan and bronchoscopy highlighted diffuse opacities and significant mucosal inflammation, while laboratory findings indicated leukocytosis with pronounced eosinophilia. The diagnostic process involved bronchoalveolar lavage (BAL) showing elevated eosinophils, with negative bacterial and fungal cultures. Given the patient's regional travel history and symptoms, coccidioidomycosis was suspected. Further serologic testing later confirmed the diagnosis with positive IgM antibodies for Coccidioides species.<br /><br />Coccidioidomycosis, caused by inhalation of endemic fungal spores, predominantly presents as pneumonia but can manifest with endobronchial involvement and severe bronchospasm, although rare. Risk factors include immunocompromised states, older age, and dust exposure, as seen in this patient. Following diagnosis, treatment was updated to include fluconazole and cessation of azithromycin. Prednisone, administered earlier, improved her bronchospasm, and repeat bronchoscopy showed decreased eosinophilia.<br /><br />The clinical course emphasized the potential for systemic steroids to benefit immunocompetent individuals with such fungal infections, alongside antifungal therapy, without increased risk of dissemination. The patient was eventually discharged with a prednisone taper and continued fluconazole treatment, exemplifying cautious yet effective management of coccidioidomycosis-related respiratory failure.

Keywords

coccidioidomycosis

respiratory failure

eosinophilia

bronchospasm

ICU

fluconazole

Arizona travel

pneumonia

bronchoscopy

prednisone