Case notes

A 30-year-old Filipino woman was at approximately 14 weeks’ gestation in her first pregnancy when she presented to her obstetrician with a 1 week history of headaches, nausea, and vomiting. At that time, she was diagnosed with migraine headaches. About 2 weeks later, she visited the emergency department and reported unrelenting headaches, continued nausea and vomiting, joint pain, and fevers. Physical examination uncovered circular erythematous lesions on her right thumb and back. Lumbar puncture and cervical lymph node biopsy were performed.

Conclusions

The patient was given a diagnosis of disseminated coccidioidomycosis with meningitis, although she had not visited geographical areas traditionally known to be endemic for the infection, including California’s San Joaquin Valley. At 16 weeks’ gestation, she was transferred to our medical center and treated with intravenous amphotericin B, intrathecal amphotericin B, and intrathecal hydrocortisone. An obstetric ultrasound revealed an appropriately grown fetus. Both the anatomical survey and amniotic fluid volume were normal.

Approximately 10 days after beginning treatment, the patient had daily vaginal spotting for 3 days. Fetal heart tones were obtained via ultrasound. At 17 weeks’ gestation, she reported leakage of fluid, and a sterile speculum examination confirmed preterm premature rupture of membranes. The patient was counseled and chose termination of pregnancy. She delivered a nonviable female infant and an intact placenta. On review of placental pathology, the fetal portion showed evidence of infection with coccidioidomycosis ( Figure ). Gross examination of the fetus did not show any signs of infection.

The patient developed coccidioidomycosis meningitis during the second trimester of her first pregnancy. A pathology examination of her placenta revealed the presence of coccidioidal spherules.

Patel. Case of the sinister spores. Am J Obstet Gynecol 2013.

Coccidioidomycosis is caused by Coccidioides immitis or C posadasii , fungi endemic to the southwestern desert regions of the United States. Spores enter the body through the lungs. Although most people with coccidioidomycosis are asymptomatic, a wide range of symptoms can develop, depending on the extent of disease. Common early symptoms include cough, fever, and arthralgias. Disseminated disease can be marked by skin manifestations, such as erythema nodosum, and joint swelling and stiffness; the most serious development is coccidioidomycosis meningitis.

Immunocompromised individuals, such as those with diabetes, human immunodeficiency virus, cancer, or a history of organ transplant are at higher risk for developing a serious infection from Coccidioides species. Pregnant women are also at increased risk beginning in the second trimester, with the risk increasing throughout the remaining weeks of gestation. Certain groups, including African Americans, Filipinos, and Hispanics, are known to be at higher risk for more severe forms of infection. Our patient had 2 risk factors, making her more susceptible to dangerous disease.