Case Presentation: Disseminated Coccidioidomycosis is a rare fungal infection that can have various presentations in a hospitalized patient. Given the high mortality rate associated with delayed diagnosis, it is essential to keep this rare infection on the differential. A previously healthy 37-year-old Hispanic male presented with a one-month history of cough, high-grade fevers, night sweats, 15-pound weight loss, productive cough and one week of worsening headaches. He was seen in the ED a few weeks earlier for similar symptoms and was discharged with a course of levofloxacin for pneumonia based on a chest x-ray that showed right lower lobe consolidation. On exam, neck flexion produced pain with spinal radiation. Initial laboratory studies were notable for WBC count of 11.4 K/ul, negative HIV screen, and a positive quantiferon test. Head CT was unremarkable. CT thorax showed numerous scattered sub-pleural nodules suggestive of pulmonary miliaryTuberculosis(TB). He was started on empiric therapy for TB, however, lab studies revealed positive Coccidiodes IgG/IgM. In light of these findings and the patient’s worsening headaches, a lumbar puncture was performed and empiric treatment with fluconazole was started. MTB PCR, India Ink, cryptococcal antigen, and cocci complement fixation in the CSF were all negative. However, serum coccidiodes complementation subsequently revealed a titer of 1:32, indicative of disseminated infection. The patient clinically improved with treatment and was discharged on lifelong Fluconazole therapy.
Discussion: Differentiating between fungal, bacterial, and viral etiologies of concurrent meningitis and pneumonia is essential for guiding diagnosis and patient management. In this patient without significant past medical history and a positive quantiferon test, TB would appear to be the most likely culprit. However, initial diagnosis of disseminated pulmonary and CNS infection should include other fungal studies of species native to a particular region as well as bacterial or viral organisms. The definitive diagnosis of coccidioidomycosis infection is confirmed by positive Coccidioides Antigen in the serum and/or CSF, complement fixation of 1:8 or above in the serum and/or CSF, or positive Coccidiodes cultures. If the disease is detected in the early stages, as it was in this case, CSF findings might be falsely negative. Because the serum levels tend to rise more quickly, a significantly elevate cocci complement fixation titer of 1:32 or above is enough to confirm disseminated disease.
Conclusions: Although only 0.1% of all immunocompetent individuals will develop disseminated infection, it is important to keep this organism on the differential. Without prompt treatment, cocci meningitis has a 95% mortality rate but fluconazole treatment can allow patients to maintain a normal life expectancy.