LAUSR

Introduction: Valley Fever (Coccidioidomycosis (CM)) is growing as a public health challenge with increasing incidence over the last 15 years. Due to its nonspecific presentation, diagnosis and treatment are often delayed. Here we present a pediatric patient with pulmonary CM presenting with life-threatening severe acute respiratory distress syndrome. Description: A 14-year-old Polynesian boy from Central Valley with severe obesity (BMI 33.3) was admitted with a oneweek history of cough, chest pain, shortness of breath, fatigue, and fever with bilateral chest x-ray infiltrates. Ceftriaxone and high flow oxygen were begun. CT of chest showed pulmonary nodules and bilateral extensive multifocal consolidations. His WBC count was 22.9 (18% eosinophils), Fungitell >500, CRP 25.3 mg/dL. Within 48 hours he decompensated, required intubation and high ventilator support with oxygenation index (OI) of 45. He was transferred to our institution for ECMO support. On arrival to PICU he was placed in prone position, sedated, pharmacologically paralyzed and managed with lungprotective ventilator strategy. He continued to be treated with broad-spectrum antimicrobial therapy; piperacillin-tazobactam, TMP-SMX, levofloxacin, fluconazole. Once serological tests confirmed Coccidioides infection (positive ELISA and IDTP assays), antimicrobials were narrowed to fluconazole and liposomal Amphotericin (L-Amb) 5mg/kg. Corticosteroids were initiated due to life-threating pulmonary disease (prednisone 40 mg oral q12 X 5d, 40 mg X 5d, 20 mg X 11d). Within 3 days, his oxygenation status gradually started improving. CSF studies were normal, and his CSF culture was sterile. He was extubated 10 days after PICU admission and discharged home on day 19 without any supplemental oxygen. He was sent home on oral fluconazole and prednisone taper. Discussion: We successfully treated a pediatric patient with severe ARDS secondary to pulmonary CM with L-AmB, corticosteroids and lung-protective ventilator strategy. Systemic corticosteroids can be an important adjunct to antifungal medications in the treatment of severe or complicated coccidioidal pneumonia. Coccidioidomycosis presentations can be severe and protean, timely diagnosis requires a high index of suspicion and could be lifesaving.