Abstract Introduction Coccidioidomycosis (“Valley Fever”) is a fungal infection caused by Coccidioides spp., endemic to the southwestern United States. Most infections are mild, but severe pulmonary disease may occur in individuals with diabetes, immunosuppression, or high inoculum exposure. Radiographic findings range from focal consolidation to diffuse infiltrates or acute respiratory distress syndrome (ARDS).1 We report a case of severe coccidioidal pneumonia in a young adult with newly diagnosed diabetes mellitus complicated by diabetic ketoacidosis (DKA) and ARDS. Case Presentation A 26-year-old male with developmental delay presented with one week of worsening shortness of breath, cough, and fevers despite 1 week of amoxicillin therapy. On arrival, he was tachypneic, tachycardic, and hypoxic with SpO2 in the 80s on room air, requiring a non-rebreather mask. Laboratory testing revealed leukocytosis and hyperglycemia (glucose 313 mg/dL) with glucosuria, ketonuria, and an anion gap of 21, consistent with mild DKA. Chest radiograph showed right lung consolidation that worsened despite empiric ceftriaxone and doxycycline, later broadening to Vancomycin and Cefepime. His oxygenation declined, requiring high-flow oxygen and ICU transfer. Repeat imaging demonstrated multifocal right-sided consolidation with cavitary changes seen below. Serologic testing confirmed Coccidioides infection, while other infectious studies were negative.He developed severe ARDS (PaO2/FiO2 74) requiring intubation, neuromuscular blockade, and proning, with subsequent improvement. He was treated with liposomal amphotericin B for 5 days and, after clinical improvement, was transitioned to fluconazole. DKA resolved with insulin therapy. His course was complicated by amphotericin-related hypokalemia and hypernatremia, both corrected with repletion and hydration. The patient was extubated on day 6, transitioned to nasal cannula, and discharged on fluconazole, insulin glargine 40 units twice daily, and home oxygen. He was advised to have close follow-up for diabetes and his coccidioidal pneumonia. Discussion Severe coccidioidal pneumonia is uncommon in otherwise healthy individuals but can occur in patients with diabetes due to impaired immune function. Radiographic findings often mimic bacterial pneumonia but may progress rapidly to ARDS, making diagnosis challenging in severe cases. This case emphasizes the importance of early recognition of coccidioidomycosis in patients with community-acquired pneumonia unresponsive to antibiotics, particularly in endemic regions. Prompt antifungal therapy and supportive management are critical for favorable outcomes. CT Thorax showing bilateral consolidations most notable for prominant right sided consolidation suggestive of severe pneumonia References 1. Saubolle, M. A., McKellar, P. P., & Sussland, D. (2007). Epidemiologic, clinical, and diagnostic aspects of coccidioidomycosis. Journal of clinical microbiology, 45(1), 26-30. https://doi.org/10.1128/JCM.02230-06 This abstract is funded by: None
Sieck et al. (2026) studied this question.