SHM Converge Scientific Abstract ePoster Gallery-Dressed to Deceive: An Atypical Presentation of Coccidiodomycosis

Pdf Summary

This case report describes a 66-year-old man in Arizona who initially presented with cough, dyspnea, night sweats, weight loss, and a left lower lobe pulmonary nodule. He was first treated as having community-acquired pneumonia with azithromycin, amoxicillin-clavulanate, and prednisone. When symptoms worsened, repeat imaging showed rapid enlargement of the lung lesion to a mass with new mediastinal and hilar adenopathy, raising concern for a serious underlying process.<br /><br />After starting piperacillin-tazobactam, he developed a pruritic rash, eosinophilia, and transaminitis within 48 hours, and was diagnosed with probable DRESS syndrome related to beta-lactam antibiotics. Antibiotics were stopped and corticosteroids were started, leading to rapid improvement. However, subsequent serology confirmed acute pulmonary coccidioidomycosis, and fluconazole was begun. Allergy testing later showed no evidence of penicillin hypersensitivity. Follow-up imaging demonstrated shrinkage of the pulmonary lesion and improvement in lymphadenopathy, with resolution of symptoms on antifungal therapy.<br /><br />The authors emphasize that coccidioidomycosis can trigger a systemic inflammatory response that closely mimics DRESS, including rash, eosinophilia, fever, and liver injury. In this case, the clinical picture initially suggested drug hypersensitivity, but the rapidly enlarging pulmonary findings, negative allergy work-up, and positive fungal serology supported infection as the true cause. The report highlights the importance of considering endemic fungal infections in patients from southwestern regions who present with DRESS-like features, especially when pulmonary abnormalities are present.<br /><br />Key lessons include obtaining early coccidioidal testing in endemic areas, avoiding premature antibiotic allergy labeling, and involving infectious disease and allergy specialists early to improve diagnostic accuracy.

Asset Subtitle

Victoria R. Ramirez

Meta Tag

Author List Victoria R. Ramirez, Yuan Zhou

Category Clinical Vignettes

Concept Coccidioidomycosis

Concept Drug Reaction with Eosinophilia and Systemic Symptoms

Concept Drug Hypersensitivity

Concept Coccidioidal serology

Concept Rash

Distinguished Non-Finalist

Presenter Organization University of Arizona College of Medicine - Phoenix

Presenting Author Victoria R. Ramirez

Track Adult

Keywords

coccidioidomycosis

DRESS syndrome

pulmonary nodule

eosinophilia

transaminitis

beta-lactam antibiotics

Arizona

fluconazole

mediastinal adenopathy

endemic fungal infection

Coccidioidomycosis

Drug Reaction with Eosinophilia and Systemic Symptoms

Drug Hypersensitivity

Coccidioidal serology

Rash