Case of Disseminated Coccidioidomycosis reported in NEJM

Dr Robert A. Myers and Monika T. Zmarlicka, at Maricopa Integrated Health System, Phoenix, A have reported a case of Disseminated Coccidioidomycosis. The case has appeared in NEJM.

Disseminated coccidioidomycosis is an airborne illness caused by the fungus Coccidioides immitis. When in the lungs, it’s known as valley fever and when it spreads from the lungs to other tissues, it’s known as disseminated coccidioidomycosis. Patients with C. immitis infection may have chronic pneumonia, fungemia, and extrapulmonary dissemination to the skin, bones, meninges, and other body sites. The clinical features of coccidioidomycosis may mimic those of melioidosis, penicilliosis marneffei, and tuberculosis.

According to history ,a 34-year-old man with a history of human immunodeficiency virus (HIV) infection presented to the emergency department with a 1-week history of headache, fever, and confusion. His temperature was 39.3°C, and on physical examination, a large, ulcerative lesion was noted on his tongue (Panel A). The patient’s CD4 count was 39 cells per cubic millimeter (reference range, 500 to 1450), and his HIV viral load was 197,000 copies per milliliter.

A chest radiograph showed patchy infiltrates in both lungs. IgG antibodies to coccidioides were detected in the blood and cerebrospinal fluid (CSF), and coccidioides antigen was detected in the blood, CSF, and urine and in fluid obtained on bronchoalveolar lavage. A biopsy specimen of the tongue lesion was obtained, and staining with hematoxylin and eosin revealed multiple fungal organisms consistent with coccidioides spherules (Panel B). Coccidioides was also noted in fungal cultures of fluid obtained on bronchoalveolar lavage.

Antifungal treatment was initiated; a combination of liposomal amphotericin B and fluconazole was administered for 2 weeks, followed by fluconazole monotherapy. HIV genotype testing revealed resistance to one of the medications the patient was taking, and the antiretroviral regimen was adjusted. At follow-up 3 months after presentation, the patient’s fever and headache had resolved, the tongue lesion had decreased in size, and the HIV viral load had become undetectable. He was subsequently lost to follow-up.