Rare in the Air: Disseminated Coccidiomycosis in an Immunocompetent Patient

Authors:
Allison Maxwell, Andrew Simms, Beverly Sha, Evan Anderson, Geoffrey Yang, Manish Bhojwani, Melisssa Gunchenko, Nicole Siparsky, Ziyi Sun

Body of Abstract:
Background: Coccidioidomycosis is a fungal infection endemic to the southwestern United States, often manifesting as a mild respiratory illness in immunocompetent individuals. Disseminated coccidioidomycosis occurs rarely (1%), typically in immunocompromised patients, involving extrapulmonary sites such as skin/soft tissue, bones, and the central nervous system (CNS). We present an unusual case of disseminated coccidioidomycosis with extensive multi-system involvement in an otherwise healthy young male, complicated by significant psychiatric and treatment adherence challenges.
Methods: We performed a retrospective case review after obtaining expedited Institutional Review Board approval by exemption, including notes, labs, imaging, culture data, and procedural reports.
Results: A 23-year-old male with asthma presented with an 8-month history of generalized pain, weight loss, intermittent chills, and limited ambulation due to right hip pain. Residential history included Arizona and the Great Lakes region with notable prior incarceration in Arizona. Examination revealed tachycardia (HR 120 beats per minute), lethargy, and tender swellings of the right thigh and left buttock. Labs demonstrated anemia (Hgb 7.9 g/dL), leukocytosis (13 × 10³/μL), elevated C reactive protein (165 mg/L), and hypoalbuminemia (2.5 g/dL). Imaging revealed a miliary pattern of pulmonary micronodules, cystic structures in multiple anatomical regions, and destructive bony lesions. Fine needle aspiration of a thigh lesion confirmed Coccidioides immitis. Cerebrospinal fluid sampling revealed WBC 0/uL, glucose 55 mg/dL, protein 28.9 mg/dL, and negative bacterial and fungal cultures. He was initially treated with fluconazole 400 mg daily. Subsequent admissions highlighted complications from poor medication adherence and worsening fungal burden despite increasing the fluconazole dose to 400 mg twice daily. Repeat imaging demonstrated extensive fluid collections and abscesses involving the pelvis, lumbar spine, and femoral regions. Psychiatry also noted psychotic features and cognitive decline, further complicating care. The antifungal regimen escalated to liposomal amphotericin B and voriconazole due to new neurologic involvement and significant disease progression. His course also included surgical drainage of a 22 cm buttock muscle abscess by skip-incision technique with insertion of four long-term surgical loop drains to prevent recurrence, as well as percutaneous drainage of deep space abscesses of the right thigh not amenable to simple drainage.
Conclusion: This case highlights the atypical presentation and challenges in managing disseminated coccidioidomycosis in an immunocompetent patient. Delayed diagnosis, medication nonadherence, and psychiatric comorbidities necessitated a multidisciplinary approach. Effective management required antifungal therapy escalation and surgical interventions. This case emphasizes the importance of early diagnosis and comprehensive care.