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Exophytic Laryngeal Mass

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 29-year-old Pakistani woman was referred to the otolaryngology clinic for increased postnasal drip, pharyngitis, odynophagia, cervicalgia, cervical lymphadenopathy, and right-sided otalgia that had persisted for more than a week. She was breastfeeding her 10-month-old, had no history of alcohol use, and had a remote history of hookah use. She was a Southern California native with travel history to Pakistan, Turkey, Jordan, Israel, Qatar, and Dubai 5 years prior to symptom onset. One month prior to onset, she drove from Los Angeles, California, to Houston, Texas. She denied recent unintentional weight loss, cough, fever, night sweats, chills, stridor, dyspnea, dysphonia, or rash.

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B. Coccidioidomycosis

Biopsy results with Grocott methenamine silver and periodic acid–Schiff stains highlighted fungal elements with features of Coccidioides species, specifically endospores within a spherule and background inflammation. The patient was then referred to an infectious disease specialist for further workup and management of her newly diagnosed coccidioidomycosis as well as for evaluation of potential disseminated disease. Chest radiography showed no evidence of disease, but the Coccidioides complement fixation (CF) returned strongly positive at 1:512, indicating disseminated disease. However, the patient did not exhibit any signs of disseminated disease, denying skin lesions, joint pains, headache, neck stiffness, visual or auditory symptoms, or cranial nerve weakness, and her bone scan did not show any evidence of bony dissemination. She was started on 400 mg of fluconazole, which was then decreased to 200 mg after 4 months when her CF was 1:8, with the plan of discontinuation when her CF was less than 1:2. Repeated office laryngoscopy after 8 months of therapy revealed interval improvement of epiglottic lesions, with normal-appearing laryngoscopy (Figure 2).

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Article Information

Corresponding Author: Anca M. Barbu, MD, Cedars-Sinai Medical Center, 8635 W Third St, West Medical Office Towers, Ste 590W, Los Angeles, CA 90048 (anca.barbu@cshs.org).

Published Online: July 28, 2022. doi:10.1001/jamaoto.2022.1990

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
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