Abstract
Coccidioides is a dimorphic fungus that causes coccidioidomycosis, also known as San Joaquin Valley Fever. The fungus is endemic to the southwestern United States, northern Mexico, and Central and South America. Infection is typically acquired through inhalation of dust particles that causes pulmonary infection. Direct cutaneous inoculation can occasionally occur.
We report a case of disseminated cutaneous coccidioidomycosis in a 21-year-old female from southern California with a remote history of Valley Fever years ago that resolved without treatment. She presented as a consult for a scar revision on the right inferior lateral neck at the site of a previous draining lymph node. Histology of the excision showed non-caseating granulomas in the deep dermis and subcutis beneath a dermal scar. Gomori methenamine silver stain highlights thick-walled spherules, predominantly 20-40 micrometers in diameter, some of which are filled with PAS positive endospores, within granulomas and multinucleated giant cells. Fite-faraco and Ziehl-Neelson stains were negative for acid-fast bacilli. The diagnosis of coccidioidomycosis was made based on histomorphology and patient’s clinical history.
This case is unique due to the remote nature of the patient’s original infection and unusual histopathologic findings. Cutaneous lesions of coccidioidomycosis typically show pseudoepitheliomatous hyperplasia with acute, suppurative granulomatous inflammation. Fungal organisms tend to be found more superficially and vary in density. Although non-caseating and sarcoidal granulomas have been described in late lesions of coccidioidomycosis, these tend to be in the upper two thirds of the dermis. The absence of pseudoepitheliomatous hyperplasia is also rare.
