CTICasesDisseminated Coccidioidomycosis with CNS Vasculitis and Necrotizing Lung Destruction
Imaging findings
In a patient with known biopsy-proven pulmonary sarcoidosis (fibrotic changes with eggshell-calcified nodal disease) who develops acute illness with a new neurologic presentation, serial chest CTs over a period of days show new, non-sarcoid-appearing focal and ground-glass opacities that rapidly evolve into extensive, irregular, large confluent cystic spaces with near-total destruction of the affected lung parenchyma over just two days. Concurrent brain imaging shows a low-attenuation lesion initially interpreted as ischemic stroke.
Key takeaways
Fulminant, rapidly progressive cavitary lung destruction developing over days, together with a new CNS lesion, proved to be disseminated coccidioidomycosis with CNS vasculitis (confirmed by positive coccidioidal antibodies in CSF and blood, plus a remote travel history to an endemic area) superimposed on the patient's baseline sarcoidosis -- a reminder that new, non-sarcoid-pattern opacities in a sarcoidosis patient warrant an aggressive search for a superimposed process, and that coccidioidomycosis can rarely cause dramatic, rapidly necrotizing lung destruction alongside CNS vasculitis mimicking stroke.
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