Case Presentation: JT is a 26-year-old incarcerated male with no past medical history that presented to the hospital from a prison unit in Southwest Texas. He endorsed a 1-week history of dry cough, fever of 103F, chills, joint pain, and a painful rash on his legs. He denied any recent sick contacts, IV drug use, or new sexual encounters. Physical examination revealed clear lungs sounds bilaterally, profound symmetric joint swelling of the bilateral knees, ankles, wrists and hands with erythematous and painful indurated nodules on the bilateral pre-tibial region. Initial labs revealed a normal CBC and CMP with elevated CRP and ESR. CT imaging showed focal consolidation in the left lower lobe and reactive left hilar lymphadenopathy. X-rays of the affected joints were within normal limits. The patient was started on supportive medications, including acetaminophen and ibuprofen, which helped alleviate his rash and joint pain. Additional labs ordered included urine drug screen, HCV, HBV, HAV, HIV ANA, anti-smith, SSA, SSB, RNP, anti-CCP, RF, heterophile antibodies, coccidioides antibodies, QuantiFERON, syphilis screen, Histoplasma antibodies and anti-streptolysin titers. Testing was significant for positive levels of Anti-Coccidioides IgM and IgG antibodies and the patient was started on empiric daily oral fluconazole for acute pulmonary coccidioidomycosis. Confirmatory titers of complement fixation and immunodiffusion were obtained, and the patient was discharged on oral fluconazole 400mg daily for 8 weeks.
Discussion: Coccidioidomycosis, also known as Valley Fever or Desert Rheumatism, is an infection caused by the inhalation of either C. immitis or C. posadasii fungal spores. These spores are endemic to the southwestern regions of the United States, including California, Western Texas, New Mexico, Arizona and portions of northwestern Mexico. Immunocompetent patients are often asymptomatic, however clinical manifestations include flu-like symptoms, pneumonia, symmetric polyarthritis, and erythema nodosum. Joint findings are a frequently overlooked manifestation of acute infection. They commonly present as a symmetric polyarthritis in the ankles, knees, wrists, and hands that is self-resolving and does not signify dissemination. The differential can be broad and can include diseases such as early RA, HBV, parvovirus, rubella, or SLE. One study evaluated 36 patients with primary pulmonary coccidioidomycosis and showed 69% had joint complaints and 64% complained of rash. This rash can either be erythema nodosum (EN), erythema multiforme, or a generalized maculopapular exanthem. EN is the most common skin manifestation and may help guide diagnosis, especially if the patient is from an endemic area and presents with associated arthritis. Both the rash and arthritis typically resolve with supportive measures such as acetaminophen or ibuprofen without long term sequela. Treatment with antifungals have not been shown to assist with resolution of clinical symptoms. Diagnosis of coccidioidomycosis should be first demonstrated by positive EIA tests for IgM and IgG antibodies. Because IgM antibodies may be negative in the first week of illness, repeat testing must be done if clinical suspicion is high.
Conclusions: Flu-like symptoms associated with a symmetric polyarthritis and rash is a common presentation of acute pulmonary coccidioidomycosis. Clinical suspicion must be high in patient that has traveled to, or lives in endemic regions.