Diagnosis, treatment, and biosafety protection of imported highly pathogenic cutaneous fungal infection: a case-based study of cutaneous coccidioidomycosis.

Coccidioidomycosis is a significant fungal disease primarily endemic to the southern United States, northern Mexico, and South America. Coccidioidomycosis is non-endemic in China, with only approximately 47 cases reported over the past 63 years. Recognizing that increased global travel is altering regional disease epidemiology, the Chinese Health Commission has classified Coccidioides species as highly pathogenic pathogens. The diagnosis of coccidioidomycosis poses a major challenge in China for medical institutions without biosafety level 3 (BSL-3) laboratories. In November 2021, we diagnosed a case of imported cutaneous coccidioidomycosis caused by C. posadasii from the United States. Shortly after returning from Arizona, USA, the patient presented with pneumonia-like symptoms accompanied by erythematous skin rash. The diagnosis was confirmed by next-generation sequencing (NGS), direct microscopy, histopathological examination and fungal culture. The patient had fatty liver disease with elevated liver enzymes. During treatment with oral fluconazole (400 mg daily), liver enzyme levels fluctuated persistently, and the patient exhibited intolerance to liposomal amphotericin B. Following proactive weight reduction and lipid-lowering therapy, along with intermittent administration of fluconazole, the patient's liver enzymes normalized. In October 2025, a 2-week course of liposomal amphotericin B led to clinical improvement, although direct microscopy remained positive. The patient is currently continuing fluconazole treatment. This case suggests that infections caused by highly pathogenic fungi in non-endemic regions may represent a major public health challenge globally, encompassing limitations in diagnostic tools, lack of treatment experience, and biosafety concerns.