When should coccidioidomycosis be in the differential?

In a recent article in ASM Case Reports, Blomquist et al. (1:e00098-24, https://doi.org/10.1128/asmcr.00098-24) describe a young woman with several years of abdominal symptoms who subsequently was found to have peritoneal coccidioidomycosis. Her story calls into focus the value of considering this endemic disease, either in patients with typical or unusual manifestations. In this patient, eventually the concern for metastatic cancer led to a surgical procedure which established the true diagnosis. However, a simple serologic test, either done in the preceding years because of her chronic symptoms or shortly before her biopsy, would have improved her management. More generally, persons living in coccidioidal endemic regions who are diagnosed with community-acquired pneumonia, a common presentation of coccidioidomycosis, are often managed without being tested for this possibility. In addition, as with the patient described in the case report, many patients present with a variety of other syndromes, making it reasonable to include coccidioidomycosis in the differential diagnosis of a wider spectrum of illnesses where the exact diagnosis is not yet firmly established. These considerations are equally applicable to patients seen elsewhere with recent history of travel to Coccidioides-endemic locations.