Pulmonary coccidioidomycosis presenting as a fungal ball mimicking aspergilloma

A 49-year old female, known to have had an asymptomatic pulmonary cavity since 2015, presented in 2023 with hemoptysis. Radiology showed a mass suspected to be an aspergilloma. Due to persistent hemoptysis, lobectomy was performed. Pathological examination revealed fungal hyphae, and the cultured fungus was identified as a Coccidioides species by LSU sequencing. Microscopy, culture, and ITS sequencing at the national reference center confirmed the identification of Coccidioides posadasii. The patient's last visit to an endemic region was 13 years before the symptomatic disease.