Abstract Introduction Coccidiomycosis is typically subclinical or a self-limited illness in immunocompetent individuals. Progressive pulmonary disease is rare in the modern era of effective triazole antifungals but can still occur in diabetes mellitus with poor glucose control. Case report A 29-year-old man with diabetes mellitus was admitted with syncope while at altitude and found to have a new oxygen requirement. Eighteen months prior to presentation he was evaluated for chronic shortness of breath, night sweats, fatigue, and mild hemoptysis. Computed tomography of the chest at that time showed diffuse peribronchovascular thick-walled cavities and tree-in-bud nodules. A diagnosis of late presenting cystic fibrosis was considered, but he was lost to follow-up because of work and family responsibilities. Over the two years before presentation, he had 140 pounds of unintentional weight loss and two hospitalizations for diabetic ketoacidosis despite a diagnosis of type 2 diabetes. He was raised in the San Joaquin Valley of California, worked as a factory mechanic and had no travel history outside the southwestern United States. Computed tomography from his current admission showed marked progression of cavitary disease. Testing was negative for cystic fibrosis, vasculitis, immune deficiency, aspergillosis, or tuberculosis. Bronchoscopy was performed with alveolar lavage, endobronchial ultrasound and transbronchial forceps biopsies. Lung biopsies were notable only for loosely formed granulomas. Lymph node biopsies showed benign reactive lymph node tissue. Coccidioides antigen was negative by enzyme immunoassay (EIA). Coccidioides IgG was positive by EIA and immunodiffusion, and complement fixing titers were 1:256. Coccidioides IgM were negative by immunodiffusion. Sputum fungal cultures grew Coccidioides immitis/posadasii. Zinc transporter 8 autoantibodies were also positive, confirming the diagnosis of latent autoimmune diabetes in adults (LADA) and his hemoglobin A1C as 13.9%. He was discharged home with insulin and a plan for 1 year of fluconazole. Discussion Chronic fibrocavitary coccidioidal pneumonia should be considered in immunocompetent diabetics with poor glucose control, progressive respiratory symptoms, compatible imaging findings, and exposure to endemic areas. Coccidioides antibody titers above 1:32 by complement fixation are diagnostic, and Coccidioides antigen is frequently negative. Coccidiomycosis is common (up to 25% of community-acquired pneumonia) in endemic areas but is fairly rare elsewhere, so careful attention to travel history is necessary to identify cases that present outside endemic areas. Viable spherules may remain in pulmonary nodules for years and reactivate with immunosuppression or worsening glucose control. In the era of climate change, prolonged droughts are likely to increase the incidence of coccidiomycosis. This abstract is funded by: None
Donabedian et al. (Fri,) studied this question.