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Volume 29, Number 7—July 2023
Synopsis

Multicentric Case Series and Literature Review of Coccidioidal Otomastoiditis

Ilan S. SchwartzComments to Author , Caitlyn Marek, Harleen Sandhu, Ahmed Abdelmonem, Greti Petersen, Emma Dishner, Arash Heidari, and George R. Thompson
Author affiliations: Duke University School of Medicine, Durham, North Carolina, USA (I.S. Schwartz); Royal Inland Hospital, Kamloops, British Columbia, Canada (C. Marek); Kern Medical Center, Bakersfield, California, USA (H. Sandhu, G. Petersen, A. Heidari); Valley Fever Institute, Bakersfield (H. Sandhu, A. Heidari); Baylor University Medical Center, Dallas, Texas, USA (A. Abdelmonem, E. Dishner); UC-Davis Medical Center, Davis, California, USA (G.R. Thompson III)

Main Article

Table

Summary of cases of coccidioidomycosis involving the middle or outer ear or mastoid detected in multicentric case series of coccidioidal otomastoiditis, California, USA, and literature review of other cases*

Case Ref Age, y/sex; race/ethnicity Comorbidity Syndrome Symptoms Diagnosis Management Outcome
1
 (6)
 23/F; Hispanic
 Had been diagnosed with systemic lupus erythematosus 1 mo earlier on basis of fatigue, fever, arthralgias, proteinuria, and positive antinuclear antibodies, and treated with corticosteroids; in retrospect, sign/symptoms were probably caused by coccidioidomycosis.
Otitis externa → otitis media, mastoiditis
 L ear pain, fever.
After several months of antifungal therapy, partial L facial nerve paralysis developed.
 Middle ear fluid culture grew Coccidiodes. immitis; CF 1:8.
 Mastoid atticotomy, irrigation with amphotericin B (continued 3 weeks after final surgery); facial nerve decompression and temporal bone debridement, followed by IV amphotericin B for 5 d, followed by miconazole for at least 3 mo; irrigation of ear canal with amphotericin B (2 g) over 3 mo, including 3 weeks after final curettage
 Good clinical response, with return of function to facial nerve almost entirely in all branches. No relapse through 1 y of follow-up.
2
 (6)
 43/M; White
 None
 Pulmonary and lymph node disease initially; otomastoiditis 1.5 y later
 R ear pain and a “squishy” sensation
 Histologic diagnosis of coccidioidomycosis from lymph node; C. immitis cultured from middle ear fluid. Coccidioides CF 1:4.
 Tympanoplasty and mastoidectomy, myringotomy and revision tympanoplasty, grommet placement; local irrigation of mastoid with amphotericin B, systemic amphotericin B (267.5 mg IV for 7 d)
 Drainage subsided by 5 mo. No evidence of disease recurrence at 1 y.
3
 (7)
 20; Hispanic
 None
 Otitis externa
 Cutaneous lesion on external ear and periauricular skin
 Histopathologic examination of skin biopsy specimen demonstrated spherules of Coccidioides.
 Fluconazole (400 mg/d orally for unknown duration); frequent debridement of ear canal
 Unknown
4
 (8)
 4/F; unknown
 None
 Otomastoiditis; incidental left lower lobe lung cavity.
 6-mo history of R ear pain, mild hearing loss, intermittent fever; swelling behind R ear
 Histopathologic examination of mastoid biopsy demonstrated spherules of Coccidioides; biopsy of same grew C. immitis.
 Mastoidectomy; amphotericin B (IV) for 6 wk
 No recurrence (timeline not stated). Serial decrease in C. immitis antigens.
5
 This study (case 1)
 76/M; White
 None
 Otomastoiditis
 Cutaneous lesion over L tragus and cheek, L hearing loss
 C. immitis cultured from middle ear fluid.
 Fluconazole (400 mg/d orally for 3 mo); debridement; itraconazole (200 mg 2×/d orally for 6 mo)
 Persistent hearing loss after 6 mo of follow-up.
6
 This study (case 2)
 52/M; unknown
 None
 Mastoiditis
 Headache and jaw pain
 Histopathologic examination of mastoid biopsy demonstrated spherules of Coccidioides. CF titer 1:8; ID positive for IgG.
 Fluconazole (400 mg PO daily for 26 mo), then no longer available for follow-up
 Residual pain and ongoing radiographic evidence of mastoiditis after 26 mo of therapy.
7
 This study (case 3)
 42/M; White
 None
 Pneumonia, followed 18 mo later by otomastoiditis
 R ear fullness and tinnitus; later ipsilateral facial nerve palsy developed
 Coccidioides cultured from middle ear fluid. CF titer 1:4; ID positive for IgG
 Fluconazole (800 mg/d orally for 3 y)
 Resolution of ear effusion and tinnitus, partial resolution of facial palsy, radiographic improvement, CF titer decreased to undetectable. Well in follow-up with negative CF titers for 21 y.
8
 This study (case 4)
 22/M; Hispanic
 Diabetes mellitus type 1
 Pulmonary coccidioidomycosis →osteoarticular coccidioidomycosis→ otomastoiditis
 Left ear pain, purulent drainage, hearing loss, headache, nausea, and vomiting
 C. immitis cultured from mastoid biopsy. CF titer 1:256
 Otomastoiditis developed after poor adherence to fluconazole (800 mg); mastoidectomy and tympanoplasty, followed by liposomal amphotericin B (IV) for 6 wk, followed by posaconazole (400 mg/d orally) for several months before patient was no longer available for follow-up
 Clinical improvement. Gradual return of hearing. CF titer decreased to 1:8. Long-term follow-up data unavailable.
9 This study (case 5) 25/M; Hispanic Diabetes mellitus type II R otomastoiditis→R internal jugular vein thrombus and dural venous thrombus→ septic emboli R ear pain, purulent drainage, R mastoid tenderness and shortness of breath Coccidioides cultured from mastoid tissue (along with Staphylococcus aureus) and later a neck abscess. CF titers 1:32 Mastoidectomy and myringotomy tube placement, followed by liposomal amphotericin B (IV) and fluconazole (800 mg/d orally); heparin infusion for thrombosis Clinical improvement, pending follow-up imaging to determine regression of dural venous thrombus

*CF., complement fixation; ID, immunodiffusion; L, left; R, right; ref, reference.

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Page created: May 21, 2023
Page updated: June 21, 2023
Page reviewed: June 21, 2023
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