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Case of the Month



Coccidioides immitis

The patient is a 68 year old gentleman who travels throughout the southwestern United States every winter in an attempt to keep up his golf game. He enjoys walking the course although the past few months has been struggling with shortness of breath. He finally takes a break to be seen by his physician who in turn orders a routine chest X-Ray. Imaging shows a somewhat irregular right lower lobe mass with hilar lymphadenopathy.

The patient is referred to a cardiothoracic surgeon for biopsy. A lung wedge with lymph node sampling shows necrotizing granulomatous inflammation in the lung with accompanying necrotizing lymphadenitis. AFB stain is negative for acid fast bacilli. PAS stain, however, reveals numerous endospores compatible with Coccidioides immitis. Coccidioidomycosis is highly infectious and may be an acute, self-limited respiratory disease or a chronic, malignant, sometimes fatal infection involving the skin, bone, joints, lymph nodes, adrenal gland(s), and central nervous system. It is endemic in the arid southwestern United States and in dry regions of Mexico, Central America, and South America.