Coccidioidomycosis can manifest in acute, chronic, and disseminated forms, of which the latter is the most severe [1]. Overall, it is caused by airborne transmission of Coccidioides immitis spores. This endemic disease occurs in the southwestern region of the United States, Central America, and South America [2]. Coccidioidomycosis is more common during the summer time and late fall [1]. Risk factors for disseminated coccidioidomycosis include AIDS and other immunosuppressed states as a consequence of chronic steroid therapy, chemotherapy, diabetes, and lymphoma [2].

The majority of patients with coccidioidomycosis have a mild, self-limiting respiratory infection [3] [4]. Symptomatic patients with a primary disease may exhibit fever, cough, dyspnea, malaise, arthralgia, chest pain, chills, weight loss, night sweats, and erythema nodosum [5]. Susceptible patients are at risk for developing disseminated disease weeks or months following the initial infection, in which it spreads hematogenously from the lungs to the bone, joints, CNS, and skin [1]. Extrapulmonary dissemination may occur even after a year of primary infection or following therapy. Those affected with disseminated infection report fever, dyspnea, weight loss, and night sweats.

Disseminated coccidioidomycosis can affect any organ. Musculoskeletal involvement results in lytic or sclerotic bone lesions and arthritis. Additionally, meningitis develops in nearly half of all patients with disseminated disease, which is associated with morbidity and mortality frequency [6]. Specifically, meningitis is characterized by headaches, photophobia, and nuchal rigidity. Also, if present, increased intracranial pressure (ICP) leads to altered mental status and emesis. Patients may even develop cranial nerve palsies, seizures, and coma [7]. Skin features in primary infection are commonly notable for diffuse maculopapular rashes which may evolve into erythema nodosum. Spread to the heart, which is rare, causes pericardial effusions and even tamponade [8].

Poor prognosis is associated with immunocompromised states and untreated individuals [9]. Coccidioidal fungemia is a rare occurrence but involves spread to CNS, liver, and spleen. Acute respiratory distress syndrome (ARDS) and shock are other serious complications.

Patients could present with fever, splenomegaly, and lymphadenopathy. The clinical features will reflect affected organs or systems. Meningeal and other neurologic signs may be apparent. Also, skin infection may be remarkable for papules, plaques, or nodules. If present, pulmonary findings could include rales, rhonchi, and decreased breath sounds.

• Mediastinal Lymphadenopathy

  CT scan showed multiple bilateral focal opacities with hilar and mediastinal lymphadenopathy with no ductal dilation or gallbladder stones. [ncbi.nlm.nih.gov]

  The presence of paratracheal or mediastinal lymphadenopathy should suggest disseminated disease (Figure 10). [appliedradiology.com]

• Fever

  The patient was a 21-year-old, apparently immunocompetent, pregnant black woman who had fever of unknown origin for 6 weeks. She had recently moved from Arizona. [ncbi.nlm.nih.gov]

  Symptomatic patients with a primary disease may exhibit fever, cough, dyspnea, malaise, arthralgia, chest pain, chills, weight loss, night sweats, and erythema nodosum. [symptoma.com]

  The scientific name for Valley fever is “coccidioidomycosis,” and it’s also sometimes called “San Joaquin Valley fever” or “desert rheumatism.” [cdc.gov]

  The director of the University of Arizona Valley Fever Center for Excellence, John N. [deptmedicine.arizona.edu]

  Overview Valley fever is a fungal infection caused by coccidioides (kok-sid-e-OY-deze) organisms. It can cause fever, chest pain and coughing, among other signs and symptoms. Two species of coccidioides fungi cause valley fever. [mayoclinic.org]

• Weight Loss

  Symptomatic patients with a primary disease may exhibit fever, cough, dyspnea, malaise, arthralgia, chest pain, chills, weight loss, night sweats, and erythema nodosum. [symptoma.com]

  A 50-year-old man presented with a 2-3 month history of left lower quadrant abdominal pain, right periorbital headache, blurry vision, tinnitus, polydipsia, right elbow pain, and a 32 kg weight loss over the past year. [ncbi.nlm.nih.gov]

  Soon after the primary infection, dissemination (extrapulmonary spread) could be first suspected in those patients with a history of weight loss, prolonged duration of generalized symptoms (malaise, FULL TEXT [annals.org]

  Patients develop chronic productive cough, haemoptysis, weight loss and chest pains. [life-worldwide.org]

  Patients with disseminated coccidioidomycosis may present with: Altered mental status Lymph node enlargement Neck stiffness Swelling/stiffness of the joints Light sensitivity Unexplained weight loss. [dermnetnz.org]

• Chills

  Symptomatic patients with a primary disease may exhibit fever, cough, dyspnea, malaise, arthralgia, chest pain, chills, weight loss, night sweats, and erythema nodosum. [symptoma.com]

  The major signs and symptoms exhibited by Disseminated Coccidioidomycosis are fever and chills, cough, muscle stiffness and aches, altered mental status, and swelling of the joints. [dovemed.com]

  Patients with mild or self-limiting infections will present with: Low-grade fever with chills and night sweats Fatigue Pain (headaches, sore throat, chest pain) A cough, with possible sputum production and hemoptysis Lower limb/foot swelling Loss of appetite [dermnetnz.org]

  When the infection is in your lungs, it can cause flu-like symptoms, such as: a cough chest pain a fever chills night sweats fatigue joint aches a red, spotty rash shortness of breath This type of infection is commonly known as valley fever. [healthline.com]

  Other symptoms include night sweats, chest pain, chills, arthralgias, headaches, myalgias, wheezing, skin rashes, stiff neck, sore throat, weight loss, and hemoptysis. [clinicaladvisor.com]

• Malaise

  We report a case of disseminated coccidioidomycosis in an immunocompetent black male with cutaneous lesions, a flocculent neck mass, bilateral hilar adenopathy, persistent fever, night sweats and malaise. [ncbi.nlm.nih.gov]

  Soon after the primary infection, dissemination (extrapulmonary spread) could be first suspected in those patients with a history of weight loss, prolonged duration of generalized symptoms (malaise, FULL TEXT [annals.org]

  Symptomatic patients with a primary disease may exhibit fever, cough, dyspnea, malaise, arthralgia, chest pain, chills, weight loss, night sweats, and erythema nodosum. [symptoma.com]

  Primary infection is often complicated by prolonged cough, pleuritic chest pain, malaise, and fatigue, which can be prolonged and debilitating. [clinicaladvisor.com]

• Fever of Unknown Origin

  The patient was a 21-year-old, apparently immunocompetent, pregnant black woman who had fever of unknown origin for 6 weeks. She had recently moved from Arizona. [ncbi.nlm.nih.gov]

• Decreased Breath Sounds

  If present, pulmonary findings could include rales, rhonchi, and decreased breath sounds. [symptoma.com]

• Rales

  If present, pulmonary findings could include rales, rhonchi, and decreased breath sounds. [symptoma.com]

• Polydipsia

  A 50-year-old man presented with a 2-3 month history of left lower quadrant abdominal pain, right periorbital headache, blurry vision, tinnitus, polydipsia, right elbow pain, and a 32 kg weight loss over the past year. [ncbi.nlm.nih.gov]

  A 50-year-old man presented with a 2–3 month history of left lower quadrant abdominal pain, right periorbital headache, blurry vision, tinnitus, polydipsia, right elbow pain, and a 32 kg weight loss over the past year. [nature.com]

• Elbow Pain

  A 50-year-old man presented with a 2-3 month history of left lower quadrant abdominal pain, right periorbital headache, blurry vision, tinnitus, polydipsia, right elbow pain, and a 32 kg weight loss over the past year. [ncbi.nlm.nih.gov]

  A 50-year-old man presented with a 2–3 month history of left lower quadrant abdominal pain, right periorbital headache, blurry vision, tinnitus, polydipsia, right elbow pain, and a 32 kg weight loss over the past year. [nature.com]

• Neck Mass

  He subsequently developed a large neck mass and was found to have mediastinal and hilar adenopathy highly suspicious of a neoplastic process. Fine needle aspiration biopsy of the neck mass, followed by flexible bronchoscopy, was performed. [ncbi.nlm.nih.gov]

  There are case reports of neck masses due to cervical lymphadenopathy representing the only manifestation of disseminated disease. 37 Abdomen and pelvis The abdomen and pelvis are other potential sites for dissemination. [appliedradiology.com]

• Suggestibility

  The clinical illness and immunologic studies suggest subtle defects that may have existed antecedent to infection and, thus, provided an opportunity for widespread dissemination by these normally nonopportunistic organisms. [ncbi.nlm.nih.gov]

• Fear

  Corticosteroids have been avoided as adjunctive therapy to antifungals in the treatment of acute respiratory distress syndrome secondary to coccidioidomycosis because of the fear of enhancing fungal virulence, but they have been proven safe and effective [ncbi.nlm.nih.gov]

• Dark Urine

  A young man from California presented with acute onset of cough, fevers, night sweats and pruritus with dark urine. Laboratory studies were notable for moderate transaminitis with elevated bilirubin and eosinophilia. [ncbi.nlm.nih.gov]

• Headache

  Allogeneic epidural blood patches are an option for refractory dural puncture headaches when autologous blood may cause meningitis or malignant seeding of the central nervous system. [ncbi.nlm.nih.gov]

  If you have symptoms, they may include a flu-like illness, with fever, cough, headache, rash, and muscle aches. Most people get better within several weeks or months. A small number of people may develop a chronic lung or widespread infection. [icdlist.com]

  Specifically, meningitis is characterized by headaches, photophobia, and nuchal rigidity. Also, if present, increased intracranial pressure (ICP) leads to altered mental status and emesis. [symptoma.com]

  Symptomatic persons (40% of cases) usually present 1 to 3 weeks after exposure with fatigue, cough, dyspnea, headache, night sweats, myalgias, and rash. 1 – 3 Primary pulmonary disease is often self-limiting, but some patients fail to recover and develop [cdc.gov]

• Intracranial Hemorrhage

  Fatal intracranial hemorrhage is a rare complication of disseminated coccidioidomycosis. [ncbi.nlm.nih.gov]

  Fatal intracranial hemorrhage is rare and, to our knowledge, has been reported as occurring in only one patient (4). [ajnr.org]

The diagnosis is based on the clinical manifestations, history including risk factors such as a recent travel to endemic areas and the patient's immunocompetence, physical exam, and the appropriate studies.

Laboratory studies should include complete blood count (CBC), which may be normal or significant for elevated lymphocytes, eosinophils, and monocytes. Additionally, there is an increase in erythrocyte sedimentation rate (ESR).

Diagnostic studies include serologic testing such as IgM and IgG antibodies as well as complement fixation techniques for IgG. Polymerase chain reaction (PCR), skin testing, blood cultures, and the urine antigen test are all helpful. Also, visualization of the fungus in body fluids such as blood, sputum, urine, or cerebrospinal fluid (CSF) is beneficial.

Patients with disseminated coccidioidomycosis could exhibit hilar and mediastinal adenopathy as well as the miliary pattern on chest X-ray. Other findings may also be present. Computed tomography (CT) scan reveals the morphology of the lesions more effectively [10].

Patients with suspected meningitis or other neurologic manifestations warrant assessment with CT and magnetic resonance imaging (MRI) of the brain, with the latter demonstrating better sensitivity for coccidioidal meningitis. Frequently observed abnormalities include basilar meningitis, vascular occlusion, and hydrocephalus.

Fluorodeoxyglucose positron emission tomography (FDG-PET) scans demonstrate diffuse intake reflective of disseminated disease and active infection. Also, bone scans are indicated in patients with osteomyelitis or suspected bone disease [11]. MRI can also display affected bone and tissue.

Lumbar puncture is necessary for assessment of meningitis [12]. Common findings in the CSF include lymphocytic and eosinophilic pleocytosis, increased protein, and low glucose levels. Complement-fixating antibodies in the CSF typically reveal elevated titers, which confirms the diagnosis of coccidioidal meningitis.

• Bilateral Hilar Adenopathy

  We report a case of disseminated coccidioidomycosis in an immunocompetent black male with cutaneous lesions, a flocculent neck mass, bilateral hilar adenopathy, persistent fever, night sweats and malaise. [ncbi.nlm.nih.gov]

• Liver Biopsy

  The diagnosis is readily made with liver biopsy, and the outcome may be more favorable than other forms of dissemination. [ncbi.nlm.nih.gov]

  The test is generally used to diagnose a suspected respiratory tract infection A tissue biopsy may be performed to determine the site of disseminated disease and it may include: Bone marrow biopsy Liver biopsy Open lung biopsy Skin lesion biopsy Family [dovemed.com]

1. Cummings KC, McDowell A, Wheeler C, et al. Point-source outbreak of coccidioidomycosis in construction workers. Epidemiol Infect. 2010;138(4):507-511.
2. Kirkland TN, Fierer J Coccidioidomycosis: a reemerging infectious disease. Emerg Infect Dis. 1996;2(3):192–199.
3. Galgiani JN. Coccidioides Species. In: Mandell G, Bennett JE, eds. Principles and Practices of Infectious Diseases Vol 2. 6th ed. Philadelphia, PA: Elsevier; 2005:3040-3051.
4. Richardson MD, Warnock DW. Coccidioidomycosis. In: Fungal Infection Diagnosis and Management. Boston: MA: Blackwell Scientific Publication; 1993: 134-142.
5. Centers for Disease Control and Prevention (CDC). Increase in Coccidioidomycosis - California, 2000-2007. MMWR Morb Mortal Wkly Rep. 2009;58(5):105-109.
6. Blair JE, Mayer AP, Currier J, Files JA, Wu Q. Coccidioidomycosis in elderly persons. Clin Infect Dis. 2008; 47(12):1513-1518.
7. Blair JE. Coccidioidal meningitis: update on epidemiology, clinical features, diagnosis, and management. Curr Infect Dis Rep. 2009;11(4):289-295.
8. Arsura EL, Bobba RK, Reddy CM. Coccidioidal pericarditis: a case presentation and review of the literature. Int J Infect Dis. 2005;9(2):104-109.
9. Keckich DW, Blair JE, Vikram HR. Coccidioides fungemia in six patients, with a review of the literature. Mycopathologia. 2010;170(2):107-115.
10. Kim KI, Leung AN, Flint JD, Müller NL. Chronic pulmonary coccidioidomycosis: computed tomographic and pathologic findings in 18 patients. Can Assoc Radiol J. 1998;49(6):401-407.
11. Taljanovic MS, Adam RD. Musculoskeletal coccidioidomycosis. Semin Musculoskelet Radiol. 2011;15(5):511-526.
12. Adam RD, Elliott SP, Taljanovic MS. The spectrum and presentation of disseminated coccidioidomycosis. Am J Med. 2009; 122(8):770-777.