Coccidioides immitis

The donor was a 52-year-old African-American homeless woman who was found disoriented on the street and brought to a southern California hospital. She had a long-standing history of mental illness and did not have fever or focal neurological signs on admission. Head CT showed hydrocephalus with prominent lateral and third ventricles, MRI showed basilar artery infarcts, CSF analysis revealed protein of 25 mg/dL, glucose of 60 mg/dL, 40 WBCs/mm3(15% PMN, 62% lymphocytes, 22% monocytes, and 1% eosinophils), and 191 RBC. Repeat CSF showed similar parameters, but with lymphocytic predominance 8 days later. Donor was retrospectively tested for Coccidioides antibody complement fixation (CF), with a titer of 1:4. During procurement of the liver, a frozen section did not show abnormalities but a subsequent review revealed non-necrotizing granuloma in the portal tracts. The heart recipient was a Hispanic patient who developed shortness of breath and fever with leucocytosis on day +21. Chest x-ray with markedly enlarged cardiac silhouette; large pericardial effusion with evidence of tamponade, with cytology positive for organisms consistent with C. immitis. Mold grew in blood culture. Died on day +27 due to disseminated coccidioidomycosis without CNS involvement. Initial serology was negative. The kidney recipient was an Afro-American patient who presented on day +13 with fever, myalgia, leucocytosis and elevated AST and ALT. Blood culture grew a mold and respiratory secretions were positive for C. immits. He developed disseminated disease without CNS involvement and died on day +18. The liver and kidney recipient was a Mexican born Los Angeles resident; he developed fever on day +14 and chest CT showed small scattered bilateral pulmonary nodules and pleural effusions. Liver biopsy revealed non-caseating granulomas and endosporulating spherules consistent with C. immitis.