Coccidioidomycosis of the prostate: A determination of incidence, report of 4 cases, and treatment recommendations

Objective: To describe the incidence of Coccidioides immitis infection of the prostate gland in an endemic area, to describe four new cases discovered, and to propose treatment recommendations for this diagnosis. Methods: The pathology reports of all prostate tissue specimens collect ed at the Arizona Health Sciences Center from February 1, 1994 through January 1, 2000 and the Southern Arizona Veterans' Affairs Health Care System from January 1, 1990 through January 1, 2000 were reviewed. Results: A total of 3676 pathology reports were reviewed. Forty-four cases of granulomatous prostatitis were identified (incidence=1.2%). Among these, four cases of C. immitis prostatitis were identified (incidence of granulomatous prostatitis=10%; overall incidence=0.1%). Two cases were found at radical retropubic prostatectomy and two were found on prostate needle biopsy. Five months post-radical prostatectomy one man developed symptomatic coccidioidomycosis and died of complications despite treatment with amphotericin B. Another patient who underwent a radical retropubic prostatectomy was treated with oral fluconazole for 14 months immediately after surgery and had a good response. The remaining two patients received no anti-fungal therapy and are being observed. Conclusions: Coccidioidomycosis of the prostate is rare. However, when identified, the finding should not be ignored. Patients with symptomatic coccidioidomycosis require immediate anti-fungal therapy. When the diagnosis is an incidental finding and the patient does not manifest symptoms, the degree of tissue violation involved in making the diagnosis influences the need for treatment. Patients with minimal tissue violation (i.e. needle biopsy) can be observed whereas patients with more extensive tissue violation (i.e. prostatectomy) should receive anti-fungal therapy.