PULMONARY COCCIDIOIDIOMYCOSIS IN AN INDIAN IMMUNOCOMPETENT PATIENT.

Introduction: coccidioidomycosis commonly known as ?valley fever? is a dimorphic soil dwelling fungus of genus coccidiodes and exists in two species c.immitis and c.posadasii.it is endemic to American continent including USA, mexico,brazil,argentina and Colombia. Case Details: A 33 years Indian male who is welder by occupation came from Mexico to our hospital with chief complaints high grade fever,persistent dry cough ,3 episodes of blood tinged sputum for about 10 days which increased in last 4 days.He developed all these symptoms there only and when not relieved with medication came back to India.There was no weight loss .No H/o TB/COPD/asthma. No pets exposure, No pallor/lymph nodes/cyanosis, No skin rash/arthralgia/urticarial No sneezing/headache Occasional H/o forest trekking was present.No relevant past history ,No occupational exposure of dust ,fumes.Vitals at the time of admission were , BP 110/80mm Hg,Pulse 78/min, Temp 100F, Spo2 99% room air. Positive findings on examination were bronchial sound with crackales on left side chest in infrascapular area. On investigations TLC 11600 esr 31 RBS 128,HBA1C 6.1 , HIV 1 & 2 negative ,mantoux test negative , chest x ray showed left lower zone consolidation with cavity .His sputum sample was not available because the patient is having persistent dry cough so CECT chest was done which showed left lower lobe cavity with paratracheal and subcarinal lymphadenopathy without necrosis and calcification,and mild thick walled cavitary lesion of 45 x 35 mm involving laterobasal segment of left lower lobe lung with associated ground glass haze and air spaces infiltrates ?findings consistent of infective etiology. Bronchoscopy showed normal anatomy on both sides.BAL fluid microscopy on cytospin smear showed reactive columnar and squamous epithelial cells ,alveolar macrophages ,few neutrophils,lymphocytes and mucoid cells and no frank malignant cell. His BAL culture ,AFB ,nocardia negative,gene expert and BAL fungal culture were negative, USG chest showed minimal left pleural effusion (non tappable). He was treated with iv antibiotics and other supportive measures and discharged when symptomatically better and followed regularly in OPD for 5-10 days. But patient was having persistent chest pain and left lower zone consolidation in chest x ray. So,In view of negative culture reports, CT guided lung biopsy was done and tissue sample was sent for HPE which showed coccidiomycosis in the lesion. He was again admitted for iv liposomal amphotericin B. After 7 days, lesions started resolving ,after 2 weeks cavity vanished and he was symptomatically better ,pain and cough decreased.Patient was discharged with fluconazole 200mg bd per orally and was improved. chest x ray cavity completely resolved. Conclusion: Coccidioidomycosis is commonly misdiagnosed as community acquired bacterial pneumonia .Health care providers should consider coccidioidomycosis when evaluating persons with pneumonia who live in or have travelled to endemic areas.