Abstract 4373321: Coccidioidal Pericarditis: Clinical Presentation, Complications, and Outcomes in Disseminated Coccidioidomycosis

Background: Coccidioidomycosis is primarily found in the southwestern United States and endemic regions of Central and South America, typically manifesting as a mild respiratory illness. Extrapulmonary manifestations are rare, occurring in approximately 1% of cases. Among these, coccidioidal pericarditis represents an exceptionally uncommon but potentially life-threatening complication. This condition can lead to serious outcomes including pericardial effusion, cardiac tamponade, constrictive pericarditis, and heart failure. Methods: We conducted a comprehensive literature review using PubMed to identify relevant articles published from January 1950 to July 2024. The search terms used were "Coccidioides AND Pericarditis" and "Coccidioidomycosis AND Pericarditis." We further evaluated citations in included articles and reviews to identify additional studies and expanded our search to international literature from endemic regions. Description of Case: A 53-year-old immunocompetent African American male presented with a 4-month history of dyspnea, fever, and night sweats. CT imaging showed miliary lung infiltration, a pulmonary mass, and spinal lytic lesions. Initial echocardiography revealed mild pericardial effusion that progressed to cardiac tamponade within 48 hours, necessitating a surgical pericardial window. Pericardial fluid and biopsy confirmed Coccidioides infection. He was treated with amphotericin B followed by fluconazole. MRI two months post-discharge revealed spinal osteomyelitis, which was confirmed on biopsy. Results: Our review identified 37 reported cases of coccidioidal pericarditis between 1950 and 2024. Most were from the United States, particularly California and Arizona. Common presenting symptoms included dyspnea (67.6%), chest pain (48.6%), and cough (37.8%). Complications included cardiac tamponade (27.0%), constrictive pericarditis (27.0%), and heart failure (21.6%). Among 36 cases with outcome data, the mortality rate was 25.0%, with most deaths occurring in earlier reports. Conclusion: Coccidioidal pericarditis is a rare but serious complication of disseminated coccidioidomycosis. It can rapidly progress to cardiac tamponade or constriction and carries significant morbidity and mortality. Clinicians should maintain a high index of suspicion in patients from or with travel to endemic areas presenting with unexplained pericardial disease. Early diagnosis and multidisciplinary management are essential to improving patient outcomes.