Post-transplant pulmonary Coccidioidomycosis in a non-endemic area: Early diagnosis, the cornerstone for treatment of a life-threatening condition

Abstract

Coccidioidomycosis is an endemic mycosis in the southwest of the United States of America, northwestern Mexico and parts of Central and South America. Although this mycosis is infrequent outside the endemic zones and usually mild in immune competent individuals, it could be a lethal complication in the immunosuppressed patient. People who live in or travel to an endemic region can become infected and the time-frame for clinical appearance and severity correlates with the underlying immune status. In endemic regions, in which the levels of suspicion are high, this infection has been described after lung, kidney, heart and liver transplantation with an incidence of 1-7% and a concerning mortality rate of 20-50%. In non-endemic areas, the low level of suspicion is associated with a delay in the diagnosis and an even higher morbi-mortality. This work presents a case of early post-transplant pulmonary coccidioidomycosis in a renal recipient who was born and lives in a non-endemic zone, in which an aggressive diagnostic approach allowed an early diagnosis and biopsy-driven anti-mycotic treatment. This case highlights the changing landscape of traditionally well-delimited endemic areas and the need for a higher level of suspicion when transplant patients develop non-specific sings of a postoperative pulmonary infection.