Disseminated Coccidioidomycosis Refractory to Multi-Drug Therapies in an Immunocompetent Patient

Abstract

Coccidioidomycosis is a fungal infection caused by Coccidioides immitis which thrives in dry desert climates such as the southwestern United States. Disseminated coccidioidomycosis is often seen in patients with an underlying immunodeficiency. Historically there have been few reported cases of opportunistic infections in the setting of low CD4+ count and no evidence of HIV infection. Coccidioidomycosis typically presents asymptomatically or as a minor respiratory illness in immunocompetent individuals. We report a case of disseminated coccidioidomycosis in a patient who is otherwise immunocompetent. Patient is a 24-year-old Hispanic male who presented with severe headache, fever, body pain, vomiting, and diarrhea for approximately 14 days. On admission, patient’s CD4+ count was 91 and CSF culture grew Coccidioides immitis, for which patient was started on fluconazole. Patient’s hospital stay was complicated by multiple bouts of altered mental status, fevers, hyponatremia, hydrocephalus, neurogenic bladder, new-onset Mobitz II heart arrhythmia, urinary tract infection, and sepsis. MRI studies revealed abnormal enhancement of leptomeninges, bilateral basal ganglia, thecal sac and cauda equina fibers, signifying disseminated disease. Patient’s serum Coccidioides complement fixation (IgG) titers remained elevated despite aggressive therapy with IV amphotericin B. After a total of six months of hospitalization, including treatment with intrathecal amphotericin B, patient’s last CD4+ count was 549, CSF IgG titers achieved