Disseminated Coccidioidomycosis in an Immunocompetent Male Who Lived in an Endemic Region in the Remote Past: A Case Report.

Coccidioidomycosis is an endemic illness suspected in patients who live in or have recently traveled to an endemic area. Disseminated disease is less frequent and is almost always seen in the presence of risk factors such as immunosuppression. We present a case of disseminated coccidioidomycosis with a delayed presentation in a young immunocompetent male. The patient developed symptoms two years after migrating from the endemic region of Mexico. He presented with fever, cough, and shortness of breath for two weeks. Chest imaging revealed left-sided consolidation and pleural effusion. Empyema was ruled out by thoracentesis. The patient did not improve with antibiotics for community-acquired pneumonia. A comprehensive microbiological workup for bacterial, viral, mycobacterial, and fungal etiologies, including cultures of several specimens of sputum, pleural fluid, blood, bronchoalveolar lavage, serological tests (initial), and transbronchial lung biopsy, was nondiagnostic. The patient continued to have fever and shortness of breath despite the escalation of antibiotic coverage to broad-spectrum. The patient underwent an open surgical lung biopsy, and the diagnosis of coccidioidomycosis was ultimately established by histopathological examination of lung and pleural specimen which showed spherules of Coccidioides sp. The patient developed worsening headaches, a lumbar puncture was done and cerebrospinal fluid revealed coccidioidal antibody which confirmed meningeal dissemination. Human immunodeficiency virus/acquired immunodeficiency syndrome or other immunosuppressed state was not identified in the patient. Notably, the second set of antibody titers collected two weeks after the initial negative set of titers returned strongly positive. The patient was started on fluconazole but did not show clinical improvement and was switched to amphotericin B. Subsequently, the patient improved and was discharged on lifelong oral fluconazole with close outpatient clinical and serological monitoring. He has had no signs of relapse during the last 20 months.

Effect of Immunosuppressive Diseases and Rituximab Infusions on Allowing COVID-19 Infection to Relapse.

INTRODUCTION: Relapsing COVID-19 infections have been reported, but their etiology and severity are still unknown. In addition, there have been no cases in the literature that associate relapsing infection with immunosuppression, either from a disease course or medications. CASE PRESENTATION: This case series illustrates two patients who developed a relapsed infection, likely from recent rituximab infusions. In addition, both cases depicted a severe form of infection than the initial one. Laboratory investigations revealed these patients were unable to produce COVID-19 antibodies, even though one of the patients received convalescent plasma. CONCLUSION: Clinicians should be aware of the possibility of relapsing COVID-19, especially in immunosuppressed patients. Because rituximab induces B-cell depletion, it can also decrease the effectiveness of the COVID-19 vaccine. Therefore, these patients should receive the vaccine before their scheduled rituximab infusion.