Beyond the superficial: Coccidioides immitis fungaemia in a man with fever, fatigue and skin nodules: a case of an emerging and evolving pathogen.

Coccidioidomycosis is an insidious fungal disease, endemic to arid regions of the Americas, which is becoming more frequently recognised worldwide. While most infections resemble a mild respiratory illness, a subset of cases progress to severe pneumonia or systemic dissemination. Here, we describe a case of disseminated coccidioidomycosis in a 54-year-old immunocompetent African-American man with geographic and demographic risk factors for Coccidiodes acquisition who presented with 2 months of fevers, fatigue, weight loss and painful skin lesions. Blood count and serum chemistry studies initially demonstrated leukocytosis, anaemia, hyponatraemia and acute renal failure. Chest imaging revealed numerous small pulmonary nodules and skin biopsy, serological studies and blood cultures eventually confirmed disseminated infection with Coccidioides immitis. This case highlights important features regarding the risk factors, spectrum of clinical findings, evaluation and treatment of coccidioidomycosis relevant to providers in endemic areas and throughout the world. 2014 BMJ Publishing Group Ltd.