Disseminated Pulmonary Coccidioidomycosis Presenting as a Wedge-Shaped Necrotic Mass Mimicking Malignancy

Coccidioidomycosis is an endemic fungal infection of the southwestern United States that may rarely produce mass-like pulmonary abnormalities mimicking malignancy. We describe a 70-year-old Hispanic woman with poorly controlled type 2 diabetes mellitus (HbA1c >14%) who presented after three days of generalized weakness, nonproductive cough, abdominal pain, nausea, vomiting, and progressive difficulty ambulating. CT demonstrated a 7.3 × 5.4 cm wedge-shaped necrotic right middle lobe mass with multiple bilateral pulmonary nodules. CT-guided biopsy of the mass demonstrated granulomatous inflammation with fungal elements, while subsequent serologic testing and bronchoalveolar lavage PCR supported pulmonary coccidioidomycosis. Her hospitalization was complicated by acute respiratory distress syndrome requiring invasive mechanical ventilation, prone positioning, and neuromuscular blockade; non-liposomal amphotericin B-associated acute tubular necrosis requiring hemodialysis; ventilator-associated Klebsiella pneumoniae pneumonia; and persistent encephalopathy with multifocal MRI abnormalities highly suggestive of central nervous system dissemination despite nondiagnostic cerebrospinal fluid studies. This case highlights how pulmonary coccidioidomycosis can mimic malignancy. It illustrates the multifactorial deterioration that may occur in susceptible hosts, emphasizing early tissue diagnosis, careful interpretation of suspected dissemination, and individualized antifungal and critical care management.