INTRODUCTION: Disseminated coccidioidomycosis is seen in endemic areas. Here, we report a rare case of disseminated coccidioidomycosis in an immunocompetent patient from a non endemic area.
CASE PRESENTATION: 28-year-old Jamaican male with no significant medical history presented with hemoptysis, multiple skin nodules, fatigue, weight loss, intermittent fever, and chills. His symptoms began two months prior with a nonproductive cough which progressed to hemoptysis. He was treated with a course of azithromycin without relief. The patient emigrated from Jamaica to New Jersey four years ago. He denies any recent travel. He was a construction worker for two years and currently delivering packages for Fed Ex. On physical examination, multiple mobile, nodular lesions on the extremities and chest wall were appreciated. Lung sounds were clear. Laboratory values were unremarkable except for an elevated erythrocyte sedimentation rate of one hundred twenty nine. Computed tomography scan of the chest showed a large right upper lobe mass with diffuse right sided infiltrates. The patient underwent fiberoptic bronchoscopy with brush biopsy and washings which revealed mild edema and secretions with no endobronchial lesions. Initial bronchial washing cultures were negative. Biopsy of the chest wall nodule revealed coccidioidomycosis with granulamatous reaction and abscess formation. Three weeks later the bronchial washing cultures also grew coccidioidomycosis. The patient was started on liposomal Amphotericin B and discharged home with fluconazole.
DISCUSSIONS: Coccidioidomycosis is a primary pulmonary infection endemic in the southwest United States, acquired by the inhalation of arthroconidia. Primary infection is often asymptomatic in the immunocompetent patient. Those that become ill typically develop symptoms of pleurisy, cough, fever, marked fatigue and weight loss. Infiltrates that develop from primary pneumonia do not resolve in four percent of patients for months to years. Typically the lung lesions are solitary, peripheral and range several centimeters in diameter. The lung nodules are often impossible to distinguish from malignancy without biopsy. The risk of dissemination is higher in the immunocompromised, pregnancy, males, blacks, lower socioeconomic status and presence of diabetes mellitus.
CONCLUSION: To our knowledge this is the first case of disseminated coccidioidomycosis in an immunocompetent patient in a non endemic area. Our patient may have contracted coccidioidomycosis while handling packages at his work place.
DISCLOSURE: Fariborz Rezai, None.