Concurrent Pulmonary Coccidioidomycosis and IgA Vasculitis w
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A 58-year-old Caucasian male with history of untreated ankylosing spondylitis, presented with a one-week history of dry cough, mild fever, and painful skin lesions. At presentation, he was afebrile, hemodynamically stable, and mildly tachycardic (107 beats per minute). CT imaging of his chest demonstrated a 26 mm intrapulmonary abscess in the right upper lobe. Due to concern for necrotizing pneumonia, he was initiated on empiric antibiotics and admitted for further evaluation. On day 2 of his hospitalization, he developed severe colicky abdominal pain, with distention and obstipation. Abdominal CT imaging demonstrated dilated small bowel loops and distal small bowel wall thickening. He was transferred to tertiary hospital on the third day of admission for dedicated specialty evaluation.

Upon evaluation, skin examination revealed nonblanching palpable purpura and petechiae on his lower back, arms, and legs. From his proximal thighs, the palpable purpuric lesions coalesced distally into contiguous erythematous plaques with interspersing ecchymoses and ulcerations that were most prominent on his lower legs. Scattered upon this ecchymotic and erythematous base were numerous 1-3 cm tense red bullous lesions, actively draining sanguineous fluid. Dermatology was consulted for evaluation of his skin lesions.

A skin punch biopsy was obtained. The dermatopathology evaluation revealed extravasated red blood cells, neutrophilic infiltration, and fibrin deposition within vessel walls. Direct immunofluorescence discovered granular deposition of immunoglobulin A within the superficial cutaneous vessel walls.

An extensive infectious disease and rheumatology work-up was completed. Enzyme immunoassay serology tests for anti-coccidioidal IgM and IgG were positive. Percutaneous fine needle aspiration of the lung abscess yielded a specimen culture found to be positive for growth of Coccidioides spp without differentiating C. immitis or C. posadasii. Serum serology tests by indirect immunofluorescence reported positive for Legionella pneumophila serogroup 1 IgM titer of 1:256 and IgG titer of 1:1024.

The patient was initially treated empirically with piperacillin tazobactam and vancomycin for necrotizing pneumonia. Pending results of cultured lung lesion specimens, antimicrobial coverage was deescalated to doxycycline and fluconazole for legionella and coccidioidomycosis, respectively. He was started on high dose methylprednisolone for the small-vessel vasculitis and transitioned to an oral prednisone taper for one month. The lower extremity skin lesions were addressed with wound care.

Two weeks after discharge, CT showed that the lung lesion had decreased in size (17 mm) and adjacent micronodules had resolved. His lungs were otherwise clear, and 6 weeks post-discharge, he reported no respiratory symptoms. At 3 months post-discharge, chest CT demonstrates continued improvement. Fluconazole treatment continued for 5 months after discharge. Follow up renal function studies reported serum creatinine 0.8 mg/dL and no hematuria or proteinuria. He continues to follow up with infectious disease, rheumatology, and endocrinology for surveillance.