SEPTIC SHOCK IN COCCIDIOIDOMYCOSIS

Objectives: To describe the clinical and laboratory parameters of pati ents with septic shock following infection with Coccidioides immitis, estimate the incidence of septic shock from coccidioidomycosis, and ou tline clues that may be helpful in early diagnosis of this syndrome. D esign: Retrospective, descriptive case series. Setting: A 250-bed gene ral public hospital in Kern County, CA. Patients: Eight patients diagn osed with septic shock from infection with C. immitis from September 1 991 to December 1993. Five were Hispanic, two were Filipino, and one w as African-American. The diagnosis of C. immitis was made by microscop ic examination and culture of the organism from sputum or other sites. Septic shock was diagnosed using criteria formulated by the American College of Chest Physicians Consensus Conference/Society of Critical C are Medicine. Measurements and Main Results: No patient had traditiona l immunocompromising conditions. All patients had pulmonary symptoms a nd were symptomatic for a mean duration of 19.4 +/- 19.8 days before a dmission. One patient presented with septic shock and the remaining se ven developed shock during their hospital course. Serology for coccidi oidomycosis was positive in six patients. The mean cardiac index was 5 .8 +/- 1.9 (SD) L/min/m(2), the mean arterial pressure was 71.0 +/- 16 .7 mm Hg, the mean pulmonary artery occlusion pressure was 16.9 +/- 3. 5 mm Hg, and the mean systemic volume resistance index was 846.6 +/- 2 24.1 dyne.sec/cm(5).m(2). All patients developed acute respiratory dis tress syndrome. Coccidioidomycosis was recognized or considered in onl y five of eight patients before they developed septic shock. Despite t herapy with amphotericin B, all patients died. One patient died of pro gressive pulmonary disease, two patients suffered an acute arrest, and five patients developed progressive multiple organ system failure and died with additional organ involvement. Conclusions: Septic shock fol lowing infection with C. immitis is an ominous yet underrecognized con dition. Hemodynamic parameters and cytokine concentrations were not si gnificantly differ ent from values seen in Gram-negative septic shock. Clinical clues to the diagnosis include duration of illness and consp icuous pulmonary involvement. Patient outcome in this series was poor but may improve with increased recognition of septic shock in infectio ns from C. immitis.