Arthroconidia in coccidioidoma: case report and literature review.

Coccidioides immitis is a dimorphic fungus capable of causing a diverse spectrum of disease in humans. Although the diagnostic pathologic finding in tissue is a mature endosporulating spherule, hyphal structures can also be found in over 50% of pathologic specimens. This report presents a case of coccidioidomycosis in which there were no intact spherules, but characteristic barrel shaped arthrospores present in tissue and cultures positively identified the organism as C. immitis. This case was further complicated by presentation in a nonendemic area for the fungus. Coccidioides immitis is a soil fungus with two distinct phases: the saprophytic and the parasitic. This biphasic life cycle was first described by Ophöls,1 and more fully characterized by Baker and colleagues. The saprophytic stage occurs in the environment with the organism existing in a mycelial state. As the mold matures, barrel-shaped arthroconidia form and alternate with empty cells. The arthroconidia subsequently fracture from hyphae and are dispersed as an aerosol. The saprophytic cycle repeats itself upon infection of a new soil site. However, if the airborne arthroconidia are inhaled by a susceptible host, the parasitic phase is initiated. In the parasitic cycle, the arthrospore swells and becomes a rounded structure, known as a spherule. The protoplasm of the spherule divides to form large numbers of endospores. If the spherule ruptures, the endospores are released. Each endospore can develop into a new spherule, or, upon expulsion via contaminated secretions from the host, return to the environment where it transforms into its mycelial form. Although the characteristic histologic finding in coccidioidomycosis is the spherule with endospores, hyphal forms also can be found. The mycelial form of C. immitis cannot be definitively identified morphologically and requires confirmation by culture techniques or genetic probes. This report presents a pulmonary coccidioidoma in which arthroconidia were the predominant forms found in tissue.