Cutaneous and Pulmonary Coccidioidomycosis

A 35-year-old Hispanic man presented with nonproductive cough; dyspnea; fever; and a painful, ulcerated, 1.5-cm, red-brown plaque on the left flank (A). He had had the lesion for 3 months and the symptoms for 1 week. The patient had grown up in Arizona, and he traveled there 4 months before the lesion arose. During the examination, diffuse rales were detected. A chest radiograph demonstrated bilateral, diffuse, reticulonodular infiltrates. Atypical pneumonia was diagnosed. The patient was admitted, and treatment with oral levofloxacin was started. LT Josephine C. Nguyen, MC, USN, of Burke, Va, and COL George W. Turiansky, MC, USA, of Silver Spring, Md, report that skin (B) and bronchial (C) biopsy specimens demonstrated Coccidioides spores (arrows). Cultures of a skin specimen and bronchoalveolar lavage were positive for Coccidioides immitis. Therapy was switched to amphotericin. Acute respiratory failure that required mechanical ventilation and acute renal failure secondary to amphotericin complicated the patient’s course. Because the chest radiograph findings were compatible with Pneumocystis pneumonia, HIV infection was considered in the differential. Results of a Western blot assay were positive for HIV-1 antibody. The patient’s CD4 cell count was 86/μL. Cutaneous and pulmonary disseminated coccidioidomycosis is an uncommon presentation of AIDS; moreover, it is rarely seen in this era of HAART. Treatment with oral fluconazole was initiated. Three weeks later, the patient’s skin ulcer and dyspnea had resolved, and he was discharged. HAART was started the following week.