Disseminated coccidioidomycosis in a patient managed with adalimumab for Crohn's disease.

BACKGROUND

A 50-year-old man presented with a 2-3 month history of left lower quadrant abdominal pain, right periorbital headache, blurry vision, tinnitus, polydipsia, right elbow pain, and a 32 kg weight loss over the past year. He had a 34-year history of complicated Crohn's disease that was notable for surgical stricture repair and partial colectomy for bowel perforation. The patient was receiving mesalazine and 6-mercaptopurine and, 2 months before admission, had stopped a 4-month therapy course with the biologic agent adalimumab for treatment of Crohn's disease.

INVESTIGATIONS: Physical examination, brain and elbow MRI scans, chest CT scan, routine blood analyses, assessment of coccidioidomycosis antibody levels, immunodiffusion and complement fixation studies in serum and cerebrospinal fluid, full-body technetium-99m nuclear bone scan, hematoxylin and eosin staining of resected tissue specimens.

DIAGNOSIS: Disseminated coccidioidomycosis with meningeal, bone, soft tissue and pulmonary involvement.

MANAGEMENT: The patient underwent treatment with amphotericin B liposomal complex and oral fluconazole and right elbow surgical debridement and irrigation. All immunosuppressive therapy was stopped.