CHSU Discovery

Abstract: 

Coccidioidomycosis, commonly known as Valley Fever, is a fungal infection endemic to the Central Valley, often manifesting as pneumonia. While disseminated forms of the disease are rare, they can present extra-pulmonary manifestations, including cutaneous involvement. Here, we present a unique case of disseminated Coccidioidomycosis in an 18-year-old male with history of pectus excavatum, currently residing on a ranch in the Central Valley. 

The patient presented to the Emergency Department with symptoms of shortness of breath, fevers, weight loss, productive cough, and night sweats over a month. Vital signs indicated tachycardia at 130 BPM and elevated temperature (Tmax 103.3° Fahrenheit). Laboratory findings revealed eosinophilia, band neutrophils, normocytic anemia, and mildly elevated liver enzymes, along with positive Coccidioidomycosis IgM and IgG, confirmed at UC Davis Coccidioidomycosis Serology Lab. Imaging studies demonstrated diffuse bilateral pulmonary nodules in a military pattern and hepatosplenomegaly. 

Initially, the patient was treated for community-acquired pneumonia with cefepime and azithromycin. Further investigations ruled out HIV, vasculitis, infectious hepatitis, and tuberculosis. A skin punch biopsy confirmed the presence of fungal spherules consistent with Coccidioidomycosis, highlighting the importance of considering this diagnosis in patients that live in, or have visited endemic regions. 
Cutaneous involvement in disseminated Coccidioidomycosis, occurring in 15 to 67% of cases, can mimic other diseases such as hepatitis, vasculitis, HIV, and TB. Lesions can vary in appearance, from nodules to ulcers, and diagnosis is confirmed through serology, histology, and biopsy. Histological findings typically reveal chronic granulomas, although organization levels vary. 

This case underscores the necessity of considering Coccidioidomycosis in patients residing in endemic areas presenting with cutaneous lesions, as it can masquerade as other diseases. With the increasing recognition of disseminated forms in immunocompetent individuals, it is crucial to include Coccidioidomycosis in the differential diagnosis, particularly in regions with high endemicity. This case serves as a valuable learning point, emphasizing the need for vigilance in diagnosing and managing fungal infections in at-risk populations.