Coccidioidomycosis of the eyelid

A 77-year-old woman presented with an ulcerated nodule on her right lower eyelid that was unresponsive to broad-spectrum antibiotics or incision and drainage. Coccidioidomycosis was suspected because of previous serologic testing and concurrent indurated cutaneous nodules. Although skin biopsies were not diagnostic, cultures from the eyelid were positive for Coccidioides immitis. The patient was initially treated with oral fluconazole, with resolution of the eyelid and skin lesions. She ultimately completed a 6-month course of oral azole therapy, and at 18-month follow-up she was symptom free. Few cases of granulomatous coccidioidomycosis of the eyelids have been reported. The clinical features of this infection are not specific, and the diagnosis is often difficult. Presentation can mimic bacterial infection or malignant neoplasm, leading to delayed or inappropriate treatment. We describe an unusual ulcerative lesion of the eyelid that led to a diagnosis of disseminated coccidioidomycosis.