A Unique Case of Disseminated Cutaneous Coccidioidomycosis Years After Initial Infection

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 disease. Direct cutaneous inoculation can occur but is rare. Histopathological examination of cutaneous lesions typically shows 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. In this report, we describe a case of disseminated cutaneous coccidioidomycosis in a 21-year-old female seen as a dermatology outpatient for scar revision with unique histopathological findings including deep dermal non-caseating granulomas and absence of pseudoepitheliomatous hyperplasia. With further investigation, a remote history of self-resolving Valley Fever years ago was revealed confirming the diagnosis of coccidioidomycosis. This case is unusual due to the delay in presentation from the patient's original infection and atypical histopathologic findings.