INTRODUCTION: Coccidioidomycosis is a dimorphic fungus endemic to the southwestern United States, Central and South America. Coccidioidomycosis, or “Valley Fever” has been called the “great imitator” as it can have a wide variety of clinical presentations. This case is unique as it represents an immunocompetent host with a posterior mediastinal mass which was due to disseminated coccidioidomycosis.
CASE PRESENTATION: A 31 year old African American female presented with dyspnea and a productive cough for about 3 days. Her initial course began 2 weeks prior to admission to our facility when she was admitted to another hospital for abdominal pain and underwent a cholecystectomy. She returned to the same hospital when she began having difficulty breathing. She had a past medical history significant for chronic back pain and asthma. A chest X-ray and subsequent CT scan showed a right perivertebral hypodensity with areas of erosion involving the T3, T4, T5, and T10 vertebrae and a left chest wall extra-pulmonary mass eroding the C4 rib as well as bilateral developing infiltrates. She was transferred to our hospital for diagnosis and evaluation. Her clinical condition rapidly declined so a bedside biopsy of the left chest wall lesion was obtained which was diagnostic for coccidioidomycosis. She developed respiratory failure, acute respiratory distress syndrome, profound hypoxia, disseminated intravascular coagulation, shock and complete heart block and died nine days after her second admission.
DISCUSSIONS: Coccidioidomycosisis is usually acquired via exposure to dust from soil containing spores. Coccidioides is a dimorphic fungus endemic to the southwestern United States as well as Central and South America. Disseminated coccidioidomycosis is a regional disease which has national importance. Disseminated disease is likely to be seen in certain populations; The infection and dissemination rate is much higher among Blacks and Filipinos. Males are infected more often than females, which may be exposure based, but may also be related to hormonal or genetic factors. Coccidioidomycosis can cause a range of presentations from asymptomatic disease, a mild self-limited respiratory disease to dissemination to multiple systems and organs. Dissemination can lead quickly to sepsis and death. The disseminated form of coccidioidomycosis may present with evidence of involvement of the skin, prostate gland, eye, bone, meninges, and liver but posterior mediastinal and anterior chest wall masses are extremely unusual for disseminated Coccidioidomycosis.
CONCLUSION: With appropriate exposure to endemic areas, clinicians should consider coccidioidomycosis in the differential diagnosis of a posterior mediastinal mass.
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