Case Presentation: A 48-year-old man with uncontrolled, insulin-dependent diabetes and hemodialysis-dependent ESRD living in southern New Mexico presented to the hospital with an 8-day history of pruritus, rash, chills, malaise and dry cough. He was initially afebrile and hypoxic to 87% oxygen saturation with left lower lobe rhonchi, a lace-like petechial rash on the right flank and scattered erythema with excoriation. Initial workup revealed left mid-lung consolidation on chest x-ray, mild eosinophilia, diabetic ketoacidosis and an A1C of 11.4%. Empiric antibiotics for pneumonia were initiated and his diabetic ketoacidosis resolved with protocolled management. After several days, the patient clinically deteriorated, becoming febrile to 38.8C with increased oxygen requirement to 6L by nasal cannula, worsening eosinophilia and evolving left lobar consolidation. Sera for coccidiomycosis antibodies and 1,3-beta D glucan were collected. He was negative for HIV and hepatitis. Over the next week, the patient had rapidly increasing eosinophilia and episodic fevers, despite modification of antibiotic therapy. A chest CT without contrast demonstrated consolidation in the left upper lobe, spiculated nodules, left hilar adenopathy and a sclerotic left humeral neck, raising concern for metastatic malignancy. PET-CT further revealed a left supraclavicular lymph node with hypermetabolic activity. On hospital day 9, the 1,3-beta D glucan resulted positive and coccidiomycosis serologies were nonreactive. Repeat serologic assessment of coccidiomycosis was performed. Bronchoscopic biopsy and brochoalveolar lavage revealed no evidence of malignancy or fungus. The patient then underwent a biopsy of the hypermetabolic supraclavicular lymph node. On hospital day 16, the biopsy resulted as granulomatous coccidiodal lymphadenitis, the repeated coccidiomycosis IgM titer resulted as reactive and his eosinophil count peaked at 50%. The patient was started on fluconazole and had subsequent improvement of hypoxia and eosinophilia and resolution of fever, pruritus and rash.
Discussion: Coccidiomycosis is a soil-borne fungus that causes a community-acquired pneumonia commonly known as Valley Fever and can rarely progress to disseminated infection. Uncontrolled diabetes and ESRD are common medical issues that lead to clinically significant, but frequently minimized, immune dysfunction. In the case of coccidiomycosis, these illnesses have been found to both increase the risk of invasive infection and decrease the value of serologic and bronchoscopic diagnostic tests.
Conclusions: Diagnosis in this case was challenging with initially negative serologies, a negative bronchoscopy and detection of extrathoracic sites of infection. As the population of patients with uncontrolled diabetes and ESRD continues to grow, their immune compromised status should be routinely considered to aid in the diagnosis of infections that may be otherwise of low clinical suspicion. This patient’s immune compromise and residence in an endemic region maintained a high pre-test probability and ultimately lead to the correct diagnosis.