North Texas Research Forum 2024



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Medical City Fort Worth



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coccidioidomycosis, Coccidioides immitis


Bacterial Infections and Mycoses | Dermatology | Diagnosis | Medicine and Health Sciences


Introduction: Coccidioidomycosis is an infection caused by the organism Coccidioides immitis, a fungus endemic to the southwestern United States, Mexico, Central and South America. The presentation of coccidioidomycosis can range from symptoms resembling a simple upper respiratory infection, such as cough, to more severe systemic symptoms including fever, malaise, and chills. Cutaneous lesions of coccidioidomycosis demonstrate a large heterogeneity of clinical manifestations but are significant as they may be the presenting sign of disseminated disease. While usually confined to the lungs, extrapulmonary coccidioidomycosis can occur in about 1 in 200 patients, most commonly associated with immunocompromised status. Pregnancy is an often-overlooked immunocompromised status that is one risk factor for disseminated and severe coccidioidomycosis. A skin biopsy is a valuable diagnostic tool when evaluating a skin lesion with undiagnosed infection, especially in the immunocompromised population. Case report: We present a 22-year-old G1P0 female at 34 weeks with no significant past medical history who presented for headache, fever, photophobia, and neck pain for one week. She immigrated to Texas from Chihuahua, Mexico 1 year ago. Despite having prenatal care, a rapidly enlarging verrucous plaque on her forehead was left unevaluated for 2 months. The patient initially presented to obstetric triage 5 days prior to admission due to headache unresponsive to acetaminophen and decreased fetal movement. Labs showed no signs of systemic illness and was discharged. However, due to worsening symptoms, the patient later presented to the ED tachycardic, tachypneic, and febrile with temperature of 102.8F. Kernig’s sign was positive. CT head and chest x-ray were unremarkable. Lumbar puncture was negative for bacterial or viral organisms but revealed eosinophilia. Punch biopsy of the forehead skin demonstrated granulomatous inflammation and scattered foreign body giant cells. Within the granulomatous inflammation were spherules recognizable as coccidioidomycosis. Coccidioidomycosis serology by complement fixation of the remaining CSF fluid was later found positive. The patient was started on amphotericin B but experienced fetal heart decelerations and maternal hypoxia. She was subsequently switched to fluconazole. The patient demonstrated clinical improvement and was transitioned to daily oral fluconazole indefinitely. Several months later the patient delivered a healthy baby without complications. Learning points: A full body skin examination is recommended in patients with an unknown source of infection. Skin biopsies provide valuable diagnostic information in febrile, immunocompromised patients with skin lesions. Pregnancy is an often-overlooked immunocompromised status that has been recognized as a risk factor for disseminated and severe coccidioidomycosis with increasing rates of dissemination by trimester.

Original Publisher

HCA Healthcare Graduate Medical Education

Disseminated coccidioidomycosis discovered through skin biopsy in a pregnant patient from Mexico



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