Coccidioides immitis: A Rare Form of the Disease Process Presenting in an Even Rarer Location

Coccidioides immitis is a dimorphic fungus, growing as a fungus in the soil and as a yeast in the human body, that is geographically limited in the United States, being most commonly associated with the San Joaquin Valley and found in California and Arizona. In most individuals, infection with C. immitis causes an asymptomatic, self-limited pulmonary infection; however, in a small percentage of individuals, the infection is disseminated and can involve any organ. We present the case of a 50-year-old man who was found unresponsive in his home in the northern portion of the United States. Autopsy revealed a 2163-g spleen. The initial differential diagnosis for the splenomegaly was an infection or a neoplastic process, such as leukemia. Because of the geographic location where the body was found, C. immitis was not initially considered; however, microscopic examination confirmed the presence of C. immitis spherules, which were found in the spleen and other organs. Granulomatous inflammation, often associated with spherules, was also present in a kidney, the pancreas, the thyroid gland, a parathyroid gland, and the heart. Additional investigation after the autopsy revealed that the decedent had spent time in the past in California, which would have allowed for exposure to C. immitis. The decedent had a rare form of a disease process not normally associated with the geographic location in which he was found, which highlights the need for continued diligence in death investigation so as to not allow a first impression to impair the correct final determination.