Cutaneous coccidioidomycosis presenting as a facial rash

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Coccidioidomycosis is a fungal infection caused by the inhalation of Coccidioides immitis and Coccidioides posadasii spores. After inhalation, the infection can spread hematogenously or through lymphatics to any organ, so the clinical presentation of coccidioidomycosis can vary greatly. A 38-year-old man with obesity was referred to an infectious disease clinic due to a cutaneous coccidioidomycosis infection of his face. The patient initially presented to his primary care physician with symptoms of fatigue, knee pain, and a facial rash that had persisted for a couple of months. Initial treatment involved a course of oral antibiotics, yielding no improvement. Subsequently, the patient sought evaluation at a dermatologist's office for multiple lesions on his face and scalp. Another round of oral antibiotics and topical mupirocin ointment was prescribed. The lesions were biopsied, and a culture tested positive for Coccidioides immitis. He was then referred to infectious disease for management. The physical examination revealed a scaling, erythematous rash located on the right cheek, forehead, and scalp. Vital signs were normal. A chest computed tomography was positive for multiple pulmonary nodules consistent with a history of coccidioidomycosis infection. Laboratory results revealed a cocci IgM titer of 1.2, IgG titer of 8.8, and an antibody by complement fixation titer of 1:128. The patient was started on oral fluconazole 200 mg daily, which was later increased to 400 mg twice daily. The patient began to show improvement in his skin lesions. We report an unusual presentation of cutaneous coccidioidomycosis as a facial rash. Clinicians, especially in endemic areas, should be aware of the differing presentations of Coccidioides infections. Keywords: cutaneous coccidioidomycosis; Coccidioides immitis, fluconazole