Case Presentation: A 50-year-old Hispanic male with osteoarthritis on chronic steroids of unknown dose from Mexico and type II diabetes mellitus was admitted to the hospital for generalized weakness and fall with questionable loss of consciousness. Physical examination revealed verrucous and nodular lesions on his right arm, posterior neck, and left thumb, but was otherwise unremarkable. Electrocardiogram revealed normal sinus rhythm. CT head and cervical spine revealed no acute intracranial abnormalities or spinal pathologies, and 30-minute electroencephalogram revealed no epileptiform discharges or electrographic seizures. CT chest revealed multiple bilateral cavitary lesions measuring up to 2 cm within the posterior left lower lobe and 5 mm within the right upper lobe concerning for infection. CT of the right knee was also performed due to the patient’s report of pain and revealed a moderate suprapatellar joint effusion. Infectious disease was consulted and recommended obtaining acid fast bacillus sputum samples to rule out tuberculosis, fungal workup, and arthrocentesis of the right knee. Dermatology was consulted for the patient’s skin findings and performed shave biopsy of the right arm lesion for pathology. The patient’s right knee was aspirated and revealed a white blood cell count of 27,000 cells/microliter with 84 percent neutrophils. Over the next several days, the patient’s labs resulted with positive Coccidioides immitis antibodies by immunodiffusion and his Coccidioides titer by complement fixation was found to be elevated to 1:256. Right knee fungal culture speciated with Coccidioides immitis and right arm shave biopsy revealed granulomatous dermatitis with verrucous and pseudoepitheliomatous squamous proliferation. Periodic Acid Schiff stain for fungus proved positive for organisms consistent with Coccidioides. Lumbar puncture was also performed but ruled out cerebrospinal fluid involvement. All other microbiological and fungal workup proved unremarkable. The patient was started on fluconazole 800 mg daily for his disseminated coccidiomycosis infection with plan to treat for a minimum of one year. He was also taken to the operating room for right knee arthrotomy with irrigation, debridement, and drainage for fungal septic arthritis. He tolerated the procedure well and was discharged to a skilled nursing facility.

Discussion: Coccidioides immitis is a soil-dwelling, dimorphic fungus endemic in the southwestern United States, northern Mexico, and Central and South America. Infection is acquired through inhalation of spores and occurs more commonly in immunocompromised individuals including those with HIV, diabetes, advanced age, pregnancy, and immunosuppressant use. Approximately 40 percent of individuals develop symptomatic pulmonary infections and 1 percent develop disseminated disease involving the skin, joints, bones, and central nervous system. The treatment for extrathoracic nonmeningeal disease is with itraconazole or fluconazole. Amphotericin B is given to patients with azole failure or to those with severe disease.

Conclusions: This patient’s Coccidioides immitis infection was attributed to his immunosuppression caused by chronic steroid use for his osteoarthritis and his type II diabetes mellitus. Thorough history and physical exam and a high degree of suspicion, particularly in immunocompromised patients is necessary to prevent morbidity and mortality from this infection.

IMAGE 1: Coronal View of CT Chest: 1.7 x 2 x 1.9 cm cavitary lesion in posterior left lower lobe

IMAGE 2: Axial View of CT Chest: 5 mm cavitary lesion in right upper lobe