Pulmonary Coccidiomycosis

54 yo Chinese lady had cough for 3-4 days and went to ER for check-up. She had no fever or chills, no CP or SOB.

PMH: negative
Medications: none
FMH: Her husband recently had a newly converted positive PPD and was treated with anti-TB drugs, his CXR was negative

SH: Smoker, 20 pck-yrs

What do you think is going on?
Simple bronchitis?
TB? Her husband is a recent PPD converter after all
Pneumonia?

Collect travel history:
She was in Arizona 2 months ago

What tests would you order?
CBCD, CMP, CXR

CXR shows LUL lesion and the radiologist recommended a CT scan of the chest.


There is a small nodule in the left upper lobe peripherally; Close-up of the nodule.

CXR report:
An ill-defined 2.5 to 3 cm nodular density overlies the left upper chest laterally. This may represent an infiltrate, but lung lesion/neoplasm is not excluded and further
evaluation by CT is recommended in this case. There is hyperinflation of the lungs with mild prominence of the perihilar markings, consistent with COPD.


The small 1 cm nodule is barely visible on the CT scan of the chest.


The nodule is seen better on the CT scan with lung windows.

CT chest with IV contrast:
1 cm thick walled cavitary mass in the posterior aspect of the left upper lobe with surrounding nodular infiltrative changes extending to the pleural surface.

"Is it cancer?" the patient was asking.

What is the next step?
Bronchoscopy.
The lesion is too peripheral to be accessed through a bronchoscope.

She had a VATS with lobectomy.

The mass turned out to contain granulomas and fungus elements characteristics of coccidiomycosis.


Lung biopsy shows coccidiomycosis; Negative Histoplasma urinary antigen

What happened next?
She had an uneventful recovery after surgery and was sent home. The ID consultant did not recommend antifungal treatment because the patient was asymptomatic.

Final diagnosis: Pulmonary coccidiomycosis

What did we learn from this case?
Always collect detailed travel history in ID cases. The clue to the diagnosis may lie in the travel history. Coccidiomycosis is endemic in California and Arizona.

In addition to inquiring about travel, also ask about any contact with pets, farm or wild animals