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Presentation

A 62-year-old male presents to the emergency department with complaints of fever, headache and altered mental status. The patient has a history of Type 2 Diabetes, hypertension, high cholesterol and had been treated a month prior for pneumonia and persistent cough. The patient is a construction worker in the Southern California area and spends the majority of the day outside. The patient was started empirically on anti-tuberculosis (TB) medicine due to symptoms and prior TB testing.

Lab Testing

Serology and fungal cultures were sent to rule out fungi such as Coccidioides (Cocci) and Cryptococcus. Serology for Coccidioides consist of enzyme immunoassay, immunodiffusion and complement fixation.  All serologies were positive for Coccidioides. The cultures were also positive from lung samples taken from the patient. Arthroconidia were seen microscopically in lactophenol cotton blue tease preps from the fungal culture in the laboratory.

Cause of Symptoms

The patient’s occupation as a construction worker exposed him to the environmental spores of Coccidioides. The patient was diagnosed with disseminated Coccidioides, Coccidioides pneumonia and Coccidioides meningitis. Coccidioides is the causative agent of Coccidioidomycosis, also known as Valley Fever, which gets its name from the San Joaquin Valley in California. The organism is a dimorphic fungus that exists in the soil. Spores are spread via perturbation of the soil via farming and wind. Spores are then inhaled into the lungs and form spherules. Acute infection can also lead to skin lesions and infection. The symptoms can resemble influenza symptoms like fever, cough, myalgia (muscle pain) and malaise (general feeling of discomfort). Many infections are asymptomatic.

Treatment

Mild to moderate disease is treated with either Fluconazole or Itraconazole. Severe disease (with rapid progression and/or infection of critical organs) is treated with Liposomal Amphotericin B. Other alternative therapies exist.