Case Presentation: A 61-year-old Indian man with past medical history of type 2 diabetes mellitus and dyslipidemia presented with a 3-month history of intermittent dry cough associated with fevers, chills, night sweats, and generalized weakness. He worked in California as an engineer doing home remodeling, never smoked, and had no sick contact, or animal exposure. Upon admission, he was found to be septic and have acute hypoxic respiratory failure. Physical examination revealed temperature of 103.3 degrees Farenheit, heart rate of 107 beats/min, a respiratory rate of 35 breaths/min, and oxygen saturation of 87% on 32% fraction of inspired oxygen. Diffused bilateral rales was present on lung auscultation. Pertinent laboratory findings revealed leukocytosis (WBC count 19.5k/uL) and elevated alkaline phosphatase of 325 U/L. Chest CT showed a left upper lobe subpleural mass with surrounding pulmonary infiltrate and scattered bilateral pulmonary nodules with associated lymphadenopathy. MRI of the abdomen showed multiple masses along the capsular surface of the right hepatic lobe and spleen. These findings were worrisome for malignancy. HIV Ag/Ab, T-Spot Tuberculosis, and Histoplasma antigen were negative. Serum Coccidioides IgM by ELISA was positive at 2.2 Index Value with a negative IgG. Coccidioides antibody by complement fixation was mildly elevated at 1:4. A bronchoscopy with transbronchial lung biopsy was performed but it failed to reveal evidence of malignancy though both bronchial washing and tissue cultures grew hyaline mould so a repeat bronchoscopy with biopsy was done. Pathology showed organizing pneumonia but bronchial washing culture eventually grew Coccidioides immitis. Therefore, the diagnosis of pulmonary coccidioidomycosis was confirmed. Unfortunately, the hepatic lesions could not be safely biopsied given their anatomical location so disseminated infection and malignancy cannot be entirely excluded. Patient was treated with intravenous liposomal amphotericin B and transitioned to high dose fluconazole with significant improvement of his symptoms and he would be followed up as an outpatient.
Discussion: Coccidioidomycosis was in fact the cause of this patient’s acute pulmonary findings, and it could possibly represent the hepatic and splenic masses. However, malignancy should always remain in a differential diagnosis in cases of suspected disseminated coccidioidomycosis as extrapulmonary coccidioidomycosis lesions are often indistinguishable from malignancy. Follow-up imaging studies of lesions should be performed. If there is no improvement in pulmonary and extrapulmonary lesions, further malignancy workup remains warranted. It is important to remember that one does not exclude the possibility of the other especially in a patient who is not known to be immunocompromised.
Conclusions: Coccidioidomycosis is an endemic and relatively common infection in the dry regions of the Southwestern United States. However, only about 1% of infected persons, with immunocompromised patients being more commonly affected, develop disseminated disease. In cases of suspected disseminated coccidioidomycosis, malignancy should always remain an important differential diagnosis.