A brother and sister with cough, low grade fever, and Erythema Multiforme. They had been with their cousins ten days before. One of the cousins had the same symptoms. I made the call of Mycoplasma pneumoniae causing the classic rash and treated them with Azithromycin and a five day steroid burst. They recovered nicely. I felt good about my clinical prowess.
Proverbs 18:12 “Before his downfall a man’s heart is proud, but humility comes before honor.”
Ten days later, the children developed intermittent fevers to 101F. Their eight year old cousin required hospitalization for right lower lobe pneumonia. Despite broad spectrum antibiotic coverage, his oxygen saturations deteriorated and his fevers soared. He was transferred to a children’s medical center.
I was on my cell phone discussing the case with the children’s momma. Mrs. Perez, the custodian, slipped in my office to empty the waste basket.
“Sounds like Valley Fever,” she whispered as she turned to leave.
I pretended not to hear her diagnosis.
“Valley Fever? In Harlingen, Texas? I don’t think so.” I pushed the idea out of my mind. Until the mother said: “I still say it all started when they were playing in that hole.”
“Excuse me?” I asked.
“It was during the Thanksgiving holiday. I sent my two and their three cousins outdoors to get some fresh air. Their uncle had dug a big hole for them to play in.”
“A big hole?”
“Sure. Uncle Perry used his backhoe to dig a fifteen foot deep hole with sloped walls…like a big ‘sandbox’. The five cousins jumped into the pit and spent hours digging, rolling, and wrestling about in the good south Texas dirt…”
Valley Fever. Coccidiodomycosis.
The spores of this fungus are endemic in Arizona and California and west Texas. In my 22 years in south Texas, we have not had a single case.
My patients both were afebrile at the time of their post-Azithromycin office visit. They both had a mild cough, but no arthralgias or malaise, except during febrile moments. The rash was gone. Pulse oximetry was 100% on room air. Their lungs were clear to auscultation. Their joints were normal.
Male 13 years old
- WBC: 6,600 with 13 % eosinophils
- Sed rate: 39 (0-30)
- CRP: 27.90 (normal <1.0)
- Coccidio complement fixation antibodies 1:8 (<1:2)
- Chest X-ray: normal
Female 11 years old
- WBC: 8100 with 3.4% eosinophils
- CRP: 51.80 (normal < 1.0)
- Cocciodio complement fixation antibodies: negative
- Chest X-ray: normal
I thought through the case: the children had hours of exposure to spores in a dirt pit in south Texas, 4/5 cousins with Erythema Multiforme, one with severe pneumonia, and two with positive Coccidiodomycosis antibody titres. I called a local infectious disease consultant and asked if it would be reasonable to treat my two patients with Fluconazole, 400mg daily for at least 3 months. He agreed. There are no randomized trials to determine if antifungal therapy shortens the course of illness or prevents long-term complications, but having received steroids for the Erythema Multiforme, and knowing that steroid use increases the risk of complications, I started treatment.
At two months both children are completely asymptomatic with normal sed rates, and positive Coccidio CFAb titres, hers at 1:1 and his decreased to 1:2. We will continue the anti-fungal agent for at least three months or until the titres are negative and three months beyond that time.
How did Mrs. Perez get the leg up on me on this diagnosis? I had rushed in with my CAP and treatment. She had seen ‘desert rheumatism’, ie, Valley Fever. She recognized the triad: fever, cough, rash (Erythema Multiforme or Erythema Nodosum). She was not thinking outside the sandbox…she was clear-thinking within the realm of experience and wisdom. I needed both. God supplied it through a humble lady.
Baddley,John: Geographic distribution of Endemic Fungal Infections Amoung Older Persons, United States; Emerging Infectious diseases 2011; 17; 1664-1669.
Galgiana, JN: Clinical Infectious Diseases 2016; 63; 112-146.