Working Diagnosis:
Extrapulmonary disseminated Coccidioidomycosis involving the musculoskeletal system

Treatment:
IV Amphotericin B for 14 days followed by 12 months of Posaconazole. Physical Therapy for strength building.

Outcome:
Patient had improvement of range of motion and was able to return to drumming.

Author's Comments:
Coccidioides species are fungi common to southwestern United States and infect through aerosolization of spores. However, patients do not need to worry about person to person transmission for Coccidioidomycosis1. Coccidioidomycosis can cause a variety of symptoms which are usually self-resolving. Extrapulmonary involvement is rare and occurs in less than 1% of cases2,3. Our patient’s left shoulder pain was resistant to conservative management and had alarming systemic symptoms (chills, myalgias). Despite being immunocompetent, the patient was found to have moved recently for Arizona which was his only common risk factor4. Treatment includes long term antifungal therapy and surgical debridement. Practitioners evaluating patients from areas endemic for coccidioidomycosis should be wary of patients presenting with atypical musculoskeletal complaints.

Editor's Comments:
As mentioned by the authors, Coccidioides most commonly causes pneumonia. Extra-pulmonary systems are rare, and typically occur weeks to months after the initial exposure. Risk factors include immunocompromised states (advanced HIV, chronic immunosuppression therapy, and transplant recipients), pregnancy, and men of African or Pacific Island descent. However, an immunocompromising condition has only been found in about 30% of those presenting with more limited disseminated disease5. Musculoskeletal manifestation typically is a monoarticular arthritis (most typically the knee) or vertebral involvement. Isolation of the organism is the standard for diagnosis, but IgM and IgG antibodies can also be used. Itraconazole or fluconazole are the first line treatments. Amphotericin B is used for more severe disease, or those who have failed azole treatment. Treatment is usually 6 months to 1 year.
This case highlights the importance of asking about systemic systems, and reassessing if the clinical picture doesn’t make sense. Advanced imaging may be useful in such cases.

References:
(1) Diaz, J.H. (2018). Travel-related risk factors for coccidioidomycosis. Journal of Travel Medicine,25(1),tay027

(2) Ramanathan, D., Sahasrabudhe, N., and Kim, E. (2019). Disseminated Coccidioidomycosis to the Spine - Case series and review of literature. Brain sciences, 9(7),160.

(3)Benedict K., et al (2019). Surveillance for coccidioidomycosis- United States, 2011-2017. Morbidity and mortality weekly report. Surveillance summaries (Washington, D.C.: 2002), 68(7), 1-15

(4) Odio, C.D., Marcaino, B.R., Galgiani, J.N., and Holland, S.M. (2017). Risk Factors for Disseminated Coccidioidomycosis, United States. Emerging Infectious diseases, 23(2), 308-311.


(5) Adam RD, Elliott SP, Taljanovic MS. The spectrum and presentation of disseminated coccidioidomycosis. Am J Med. 2009 Aug;122(8):770-7. doi: 10.1016/j.amjmed.2008.12.024. PMID: 19635278.

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