A case of disseminated coccidioidomycosis in a patient with a prolonged course of covid-19 pneumonia

Introduction: Coccidioides immitis is a dimorphic fungus endemic in California that primarily causes a pulmonary infection. It can become disseminated to any organ in immunocompromised individuals through hematogenous spread. Pathogenesis begins with inhalation of anthroconidia and development of symptoms within 7-21 days. We present a case of disseminated coccidioidomycosis in a patient immunocompromised by COVID-19 infection. Case Presentation: A 65-year-old male with history of type 2 diabetes and COVID-19 in July presented in October with 2 days of dyspnea and confusion. Since COVID-19 diagnosis, he was hospitalized twice for dyspnea, received steroids, and used 4L home oxygen. He arrived afebrile, HR 110, RR 37, BP 137/83. He was encephalopathic with increased work of breathing and diffuse crackles on pulmonary exam. Labs showed leukocytosis 16.3 K/cumm (88% neutrophils), procalcitonin 0.69 ng/mL, d-dimer 3.49 mcg/mL FEU, ferritin 1612 ng/mL, lactate dehydrogenase 271 U/L, and C-reactive protein 241.7 mg/L. Hypoxia improved with high flow oxygen but he remained confused. Chest radiograph showed marked increase in reticular opacities and peripheral nodularities. Chest CT angiogram showed no pulmonary embolism but revealed marked progression of a multifocal pneumonia with diffuse ground glass opacities, central consolidations, and innumerable small nodules. CT head without contrast was normal. He was admitted for COVID-19 progression, treated for pneumonia, ruled out for tuberculosis, and managed for delirium but was clinically unimproved with new fevers and rising inflammatory markers. An unremarkable lumbar puncture was performed and fungal studies sent to an outside facility. Due to tuberculosis concerns, he started treatment and was intubated for hypoxia and mentation. He developed punctate, maroon-pink skin lesions ≤ 1cm on his thighs which were biopsied. As he continued to clinically deteriorate and developed renal failure, the family chose comfort care and he passed. Afterwards, studies from serum, cerebrospinal fluid, and biopsy revealed disseminated coccidioidomycosis. Discussion: This patient was predisposed for disseminated coccidioidomycosis due to COVID-19, prior steroid use, and diabetes. Chest imaging shared similarities between advanced COVID- 19, miliary tuberculosis, and coccidioidomycosis, delaying diagnosis at the final admission and perhaps, even at prior presentations. Due to parenchymal lung damage from severe COVID-19, detection and treatment of superimposed infections is vital to improving survival. There have yet been no case reports of pulmonary or disseminated coccidioidomycosis in patients with COVID-19. Conclusion: As with other advanced pulmonary viral infections, in severe COVID-19, opportunistic fungal infections like coccidioidomycosis must be considered. Prompt initiation of antifungal therapy can improve mortality.