Coccidioidomycosis - the airborne assault continues: An unusual presentation with a review of the history, epidemiology, and military relevance

Despite remarkable advances in detection and therapy, coccidioidomycosis re mains a persistent threat to military troops deployed in endemic areas. Pre gnant women, immunocompromised hosts, and dark-skinned persons, particularl y those of Filipino, African, Hispanic or Asian ancestry, are at greatest r isk for disseminated coccidioidomycosis. The ethnically diverse military fo rces have susceptible active duty and reserve members stationed at or tempo rarily trained on bases located in endemic areas for Coccidioides immitis. Although the vast majority of infections with this organism are subclinical , unusual patterns of dissemination pose a diagnostic challenge. The milita ry physician may be tasked with recognizing acute non-specific symptoms as well as bizarre, occult manifestations of coccidioidomycosis. We present a case of disseminated coccidioidomycosis in an active duty Caucasian male wh o presented with a right shoulder mass. Our patient is atypical in that he had disseminated disease although immunocompetent and Caucasian. Another un usual feature is that the mass was not preceded or accompanied by any other symptoms. We could find only two other reported cases of coccidioidomycosi s presenting as a soft tissue mass, both in African-American patients. The epidemiology and history of coccidioidomycosis will be reviewed, with an em phasis on military populations. The insidious nature of coccidioidomycosis, the importance of early detection and treatment in decreasing morbidity an d mortality, and the presence of large numbers of military members in the e ndemic areas make the lessons of this case particularly relevant for all fl ight surgeons.