Pulmonary Coccidioidomycosis :

Pictorial Review of Chest Radiographic

and CT Findings
 Coccidioidomycosis is a fungal The hyphal form  highly infectious
infection caused by inhalation of spores (anthroconidia)  inhalation
spores (anthroconidia ) from  spherules rupture  endospores
Coccidioides species (parasitic form)  inflammation

The lungs are the target organ in Risk factors

coccidioidomycosis are involved - HIV infection
in a wide spectrum of clinical - Immunosuppressive medications
Imaging manifestations  acute, - High-dose glucocorticoid
disseminated, or chronic disease administration
 Diagnosis
• Sputum, bronchoalveolar lavage fluid, smear from cutaneous lesions, or
tissue biopsy samples.
• Serologic test  Enzyme-linked immunoassays  immunoglobulin M and
immunoglobulin G antibodies
• Bronchoscopy (Bronchoscopy is a useful diagnostic procedure if sputum
evaluation or serologic testing is not diagnostic)
• Biopsy  transbronchial lung biopsy (bronkoskopi) and percutaneous
transthoracic needle biopsy with image guidance. Most biopsies are
currently performed with CT guidance.
 Pulmonary Manifestations of
Coccidioidal Infection
• Acute Disease
• Disseminated
• Chronic forms
 Acute Disease (primary coccidioidal infection)
Thoracic manifestations of acute coccidioidomycosis  pulmonary parenchymal
abnormalities, intrathoracic adenopathy, and pleural effusion.
1. Pulmonary parenchymal abnomalities  consolidation, nodules, cavities, and
peribronchial thickening
75%  consolidation, (manifasting as) solitary or multiple areas of segmental or lobar
opacification . Unilateral with perihilar and basilar.
• Parenchymal opacification (varies from)  a ground-glass appearance to
dense homogeneous consolidation
 bacterial pneumonia

• A migratory pattern of parenchymal disease  phantom infiltrates (in

which parenchymal consolidation) resolves at one site and reappears in a
different location
• 20%  nodular opacities  size or vary from 0.5 to 2.5 cm,
often multiple and well circumscribed, in the perihilar and
lower lung zones metastatic disease.
• Most nodules  multiple and bilateral, with ill-defined
borders, and ranged between 0.5 cm and 3 cm.

• Most acute parenchymal abnormalities seen at chest radiography resolve

within 6 weeks.
2. Intrathoracic Adenopathy
 Adenopathy results from regional spread of infection from pulmonary
parenchymal foci to hilar or mediastinal lymph nodes.
 Hilar or mediastial adenopathy (chest radiography)  ipsilateral
parenchymal consolidation, nodules, or peribronchial thickening

a. Frontal chest radiograph shows right hilar adenopathy (arrow).

b. Coronal CT image (soft-tissue window) shows extensive right hilar (white
arrow) and subcarinal (black arrow) adenopathy.
3. Pleural Effusion
 15%- 20% of patients with acute coccidioidomycosis
 Caused by contiguous spread of infection from adjacent parenchym
(pengaruh penyebaran infeksi dari parenkim paru).

Frontal chest radiograph shows a small right pleural effusion (arrowhead)

 Disseminated Disease
Diagnosed by  clinical symptoms, serologic findings, and tissue diagnosis.
Imaging of Disseminated fungemia and ARDS. Coccidioidomycosis
• miliary nodules caused by hematogenous spread
• Parenchymal consolidation
• Hilar and mediastinal adenopathy
• Extrapulmonary dissemination (occurs frequently and most commonly
involves the)  skin, lymph nodes, bones and joints, central nervous
system (vertebral disease) and hematogen.
• Patients with AIDS are at increased risk of fungemia and ARDS
• Diffuse or dependent lung opacities may be seen with ARDS
 Chronic Disease
 Persist beyond 6 weeks
 Imaging manifestations
• residual nodule,
• chronic cavity,
• persistent pneumonia with or without adenopathy,
• pleural effusion, and
• regressive changes.
Residual Pulmonary Nodule or Coccidioidoma
Chronic Coccidioidal Cavity
Differential diagnosis
 primary lung malignancy
 solitary metastasis
 other granulomatous infection