The reported patient is a 67-year-old female who resides in the southwestern United States with notable past medical history of asthma and asbestosis. Notably, there was no history of immunosuppression nor infectious diseases prior to the present episode. She underwent resection of a 11.2 x 7.5 cm well-differentiated liposarcoma of the abdominal wall in July 2018. At the time of initial evaluation at our center in February 2019, she was noted to have a 4.6 x 4.7 cm recurrent vs. residual focus of disease between the left internal oblique and left transversus abdominus muscles for which the patient remains in observation (Figure 1).
The patient has given informed consent for publication of this case.
In June 2020, the patient developed shortness of breath, increased fatigue and cough. No fever was documented or reported. An initial COVID-19 polymerase chain reaction test was obtained by the patient's local physician and was positive. No further laboratory or imaging evaluation was obtained at that time point. Multiple subsequent COVID-19 tests were negative, however, the patient's symptoms persisted.
A bronchoscopy was performed in July 2020 and the patient was diagnosed with an atypical mycobacterial infection (mycobacterium avium intracellulare) for which antibiotics were not recommended. At that time, the coccidioides serology was indeterminate for IgM, negative for IgG and antibody titers were negative.
In September 2020, symptoms persisted and computed tomography (CT) imaging revealed subcentimeter pulmonary nodules and small sclerotic bony lesions. As the lesions were too small to biopsy, close interval follow-up was recommended.
In November 2020, the patient palpated a new right chest wall mass. She reported pulmonary symptomatic improvement of prior respiratory symptoms and was without fever or systemic inflammatory symptoms. Follow-up CT imaging demonstrated new bilateral pulmonary nodules, a 4.8 x 2.7 cm right anterior chest mass extending from the pectoralis major muscle into the costochondral junction of the right third rib, areas of sclerotic foci in axial bones and a slow progression of the known left abdominal wall recurrent vs. residual liposarcoma measuring 5.5 x 5.1 cm (Figures 2A,C,E).
The appearance of new lung nodules, bone lesions and chest wall mass in this patient with liposarcoma was suspicious for distant metastatic lesions. The patient thus presented to our institution in advance of her usual surveillance visit for further evaluation. Although the radiographic features of these lesions were consistent with metastatic disease, well-differentiated liposarcomas are only rarely known to distantly metastasize. A biopsy was therefore recommended to confirm the diagnosis of metastatic liposarcoma prior to initiation of chemotherapy.
In December 2020, a core needle biopsy of the right chest wall mass was performed. The patient developed a right chest wall cellulitis post-biopsy which was treated and resolved with Doxycycline. The pathological examination found no evidence of malignant cells but revealed granulomatous inflammation with necrosis and rare spherical structures highlighted by Grocott's Methenamine Silver stain suggestive of fungal organisms (Figures 3A,B).
White blood cell count displayed a lymphopenia with a lymphocyte count of 430/mm3. Serology and antigen for cryptococcus were negative, as was the intra-dermal tuberculosis test.
Serological tests for coccidioidomycosis were negative for IgM and positive for IgG. Coccidioidomycosis complement fixation (CF) titer was 1:32.
Systemic anti-fungal treatment with oral fluconazole 400 mg daily was initiated with close follow-up and imaging. Patient remains under treatment with good tolerance. No other therapeutic intervention has been required.
In April 2021, patient reported persistent asthenia and shortness of breath but no cough. CT imaging showed decrease in lung nodules and chest wall mass which now measured 3.2 x 1.3 cm (Figures 2D,F). The sclerotic bony lesions were unchanged (Figure 2B). The residual abdominal wall liposarcoma was stable in size comparison to December 2020, with slight increase compared to postoperative imaging in February 2019. CF titer was 1:16. Lymphocyte count was 740/mm3.
The patient continues fluconazole treatment for an additional 6 months before repeat imaging and clinical follow-up.
Computed tomography images of disseminated coccidioidomycosis lesions. and a right lower lobe lung nodule in December 2020.